Dear CSA members,
We are fortunate to have so many talented members who are willing to share their lives and experiences with us. We will be publishing a series of three articles by Harrison Chow, MD, that are deeply personal and at times quite painful to read. I am in awe of his bravery and ability to so poignantly describe these experiences and his subsequent growth. I hope you l find value in these articles and join me in humbly thanking him for his contributions.
- Rita Agarwal, MD, FAAP, FASA
The tears flowed freely, the mind spinning to grasp hold of any anchor, to find any fixed point to make sense of a hazy personal world. A life in extreme shock.
Through the tears, I opened my eyes, seeking orientation, what do I see? What is happening?
I peered through the tears, my vision is salty and blurred, are those tears mine? I see a familiar dining room table, I see sandwiches piled high still in wrappers, an open bottle of red wine and a giant white box? No, it’s not a giant white box, it’s a stack of papers, whose papers are those? I recognized the table, it was my kitchen table. How did I get here?
“…you can sign the Power of Attorney statements in the morning with the Notary. We’ve enclosed your deeds and bank statements for reference”, said an eerily calm voice. I looked across table, past the sandwiches, past the glass of wine, and the phone book size stack of papers and saw a familiar face, a relative, my sister-in-law’s husband, a physician himself.
I recognized the scene now, I had just returned from the Good Samaritan Hospital, my wife Amy had just been diagnosed with terminal cancer. I hadn’t slept in 3 days. There I was with a pile of legal papers, sitting on the table where my sister-in-law “Cheryl” and her husband, “Mark” had sat for so many Thanksgiving and Christmas dinners. They had been apparently waiting for me. Where were my kids?, I thought.
“I’ll have an attorney look at these later,” I shook my head looking at the Mark, “there is so much to do”. I looked at my hands, they felt numb. I had been drinking.
Mark didn’t like the answer, “better to let us take this off of your plate, we can manage your finances”. I stared back but my mind was wandering. My relative was a family practice physician. What do you know about finances?
The mind in shock will not act linearly it will grasp onto any structure it knows, the experienced memories of an anesthesiologist in this case. I was in deep, deep crisis.
My mind drifted into a different but more familiar crisis one in the operating room. The memory became a crystalized foundation, a set of rules and subsequent actions, I could understand. The multi-colored lights flashing and alarms beeping, a patient dying. I could understand this. I had been trained for crisis management my whole life.
I remember a spine case gone wrong. An abdomen turning into a whirlpool of blood, filling up and spilling over onto the cold surgical floor. An OR in shock, a patient dying, a lifetime of clinical training, activated into action mode. Monitors all alarming. I looked to the general surgeon, “Artie”. What to do?
My mind drifted to a different time, a different place.“Artie, I have no oxygen saturation and no blood pressure, and the abdomen is filling up with blood and blood is dripping onto the ground. We need to do to something? “What to do?
Artie peered up from behind the drapes both hands covered in blood, buoyant intestines now floating in a bloody pool, eyes wide and searching in shock, “help me?”.
My mind floated again then. Back to endless days of trauma call at UCSF and San Francisco General Hospital trauma call. Stab wounds, gunshot wounds, buoyant intestines floating in blood. What to do?
I remember complaining to my residency director at UCSF, Dr. Rosen at time. Why so much call, why so much long days, why so much abuse?
Dr. Rosen had one of the most meaningful and profound answers, in retrospect of my entire life.
“Harrison (as a resident anesthesiologist) we train you so hard because we, as a Department and as faculty, want you to able to develop the experience, the brain and muscle memory, to function clinically without sleep and in an emergency. It will become reflex to you”, he said then. In my haze I could remember those words.
As Dr. Rosen shooed me out of his San Francisco Parnassus office, I remembered his final words “You will be able to function as a high capacity anesthesiologist in moments of sleep-deprivation and shock because you will remember your training”.
I was a talented UCSF anesthesiology resident at those times with a doubtful, prickly attitude, at best, I believe. But those words never rang so true. Dr. Rosen, the wise man he was, was so very, very, very right.
“Artie, I need you to reach into the abdomen and cross-clamp the aorta above the kidneys and do it now please.” I said back then in a calm voice, remembering a training script from decades ago.
“The kidneys will die if I do that Harrison”, Artie said then, “I need time to fix this.”
“The kidneys will die in 2- 4 hours Artie,” l looked at the flatlining monitors save the EKG which was now in V-fib, continuing to recite a decades old training script, “the patient’s brain is going to die in 5 minutes, cross-clamp the aorta now, PLEASE.” During this 1-minute conversation an aortic clamp had fully appeared on the instrument table. Artie wordlessly clamped the aorta then.
My mind faded back to my pseudo relative Mark still pushing telephone book pile of legal papers to me. Maybe I hadn’t heard him clearly enough? he must have thought, he persisted. “This will save you a lot of time and effort later”, he pressured, pushing the papers across my kitchen table to my chest. “Please take this to the Notary tomorrow and have this signed”. Where were my kids? My mind floated back the that OR. All I could think of was “cross-clamp the aorta”, but now what? And Mark, seriously, what do you know about finances?
The OR nursing director back then, “Stephanie”, had been quietly overhearing our conversation between Artie and I, had quietly ordered the aortic cross clamp, units of blood and the code cart.“Dr. Chow, what can I do?”. I could hear my training talking. Always use the BEST resources you have available with the time you have. But always have a Plan.
“Stephanie, when Artie cross clamps the aorta we are going to get half our blood volume back, we need to jumpstart the heart to get our blood pressure back. We are going to need to defibrillate the heart and do chest compressions to refill the coronary arteries, got it?” The words rolled out of me from a brain-muscle memory, just like a voice recording playback.
As Artie (a general surgeon) cross-clamped the clamp aorta, as the gushing blood stopped, I ordered the defibrillation. V-fib converted to sinus tachycardia. And like an ON switch the arterial line and the pulse oximetry began the sinusoidal beats in red and blue. We are alive! The patient is alive.
Stephanie nudged my arm, “Dr. Chow now what?”. “Artie,” I suggested, “Can we get a vascular surgeon in here?”. Artie refused because he needed more time. Stephanie looked at me, rolled her eyes behind the mask. Surgeon pride.
“Stephanie, please call any available vascular surgeon to the OR now, I whispered.” A few minutes later Stephanie came back. “Dr. Chow vascular surgeons A, B and C are not available within 30 minutes but who can I call?” Always use the BEST resources you have available with the time you have. But always have a Plan.
But there was Robert! I just went to his retirement party two weeks ago I thought, I bet he is still in his office across the street, cleaning up! “Stephanie what about Robert, he still has privileges!”, I almost yelled then. Stephanie made a call from the OR, “Robert” is coming across the street and will be here in 10 minutes” she giddily blurted out loud. The entire OR including the overwhelmed Artie seemed to breathe a giant sigh of relief. Help, the right help, was coming.
Mark was still clearly unhappy, he and Cheryl will be back in the morning to help my family and take me to the Notary. They would take care of me in my moment of distress, my moment of need. That’s what family does. “Yes Harrison, just get these signed in the morning”, chimed in Cheryl like a chorus. I looked at Mark, he a family practice physician and myself an anesthesiologist. His eyes were cold. My wife Amy had been hospital 3 days now from a life-threatening pulmonary embolism (a common symptom of undiagnosed advanced cancer), he had yet to visit. The crucial thought came in “what do you know about finances and estate law and - why have you not visited her?”
I called my good friend when they had left that very next morning, an old middle and high school basketball teammate and friend, “Noah “ from Florida. Noah had gone on to become a high-end estate and trust attorney for the Manhattan elite. After our sobbing over the phone, he asked me about my financial and estate situation. I explained the strong arm pressure from my in-laws, the pile of papers to be signed and finally the “no need to see an attorney just notarize the signed paperwork.”
Noah laughed aloud for a bit then catching himself recognizing the personal gravity of the situation. “That’s some low rent trailer trash stuff there,” he explained “stupid greed. Nothing is legally binding in Estate court under duress. No judge would sign off and approve that crap paperwork. Now here’s what we are going do." And just like that we created our own paperwork our own estate plan. And a plan to defend our estate from Mark and Cheryl. For the vulture thieves had already arrived.
I remember Robert arriving and saving the patient from a surgeon in denial back then. This time it was Noah arrived and helped save the Chow (my) family from a greedy relative perpetrating an ongoing scam, literally the cliched hospital room power move. Robert and Noah were competent and reputable people who could fix what they were trained to do. As could I.
But I ultimately had to make the decision to bring them in. Crisis management. I knew what to do when the fog lifted because it was in my muscle-brain memory. I could trust my eyes and my decision-making because it was what I was trained to do. Always use the BEST resources you have available with the time you have. But always have a Plan.
A colleague’s wife once told me that the life outside of an operating room is the time to take off the OR cap. This is mostly true. Our controlled and regulated OR environment does not replicate outside the surgical facility and hospital walls. People make mistakes, act with immorality and frankly are unable to perform and the pressured consistency that we take for granted in our work environment.
Whether dealing with petulant children, a spouse taking forever to put on nice clothes for a theater show or a fast food cashier, they nor the process implemented by them will even remotely function like the OR environment. Our health care world is an extraordinarily reproducible world remarkably free of major mistakes and we should be proud, but we will be disappointed by trying to enforce our OCD culture on our loved ones or the waiter taking the food order.
Where my colleague’s wife analogy was wrong though when life is in crisis. What better human being, other than perhaps an airline pilot, can organize their thoughts into action than an anesthesiologist? It’s in our educational blood, it’s in our training, it’s who we are. It is our job not to crash the plane, even in peril, and land the plane safely. We do this every day in the OR, in management, administration and in a million little ways. Just wait, if you don’t know already, you have some kickass crisis skills.
In crisis (personal or professional), take a deep breath. You can solve the problem, it’s in your training and experience. I speak from that experience, having undergone a personal ordeal unlike any other. An ordeal that frankly would have crushed the weak, the inexperienced, the untested. But I was trained for crisis management as are you. Trust your eyes and your training if or when you are in crisis mode. You are special, if you didn’t know it already. You were trained for this. You are an anesthesiologist.
Next – Part II – One Nation Under Anesthesia
Harrison Chow, MD, is a practicing anesthesiologist at Vituity Anesthesia Medical Group and is formerly was the Specialty delegate to the CMA and Chair of the CMA Hospital-Based Practice Forum and Chair of CSA’s Legislative Affairs. Amy, his wife of 27 years, passed away from complications related to lung cancer this past summer. This part one of a 3-part series of articles special to the CSA.