Neskirkja í Aðaldal
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The farewell portrait and a death certificate

“Hi doctor X! You’ve got free air in your abdomen.” Doctor X is a pediatrician, rotund and florid. He is rather excitable and has a vivid imagination. You often expect him to have a cerebral hemorrhage during a conversation (blow a gasket). He is a great story teller with artistic tendencies, and has good rapport with children and their parents. A bit unorthodox perhaps, but never boring. “I can sell this darling on the internet for you,” he said once when some parents were complaining about their son’s stomach. Well, the doctor had been seen by the surgeon on call, because of an abdominal pain, who had promptly ordered a CT scan because of his abdominal pain. After the examination he&the patient somehow got through the cracks and just went home. The surgeon on call came across the CT later in the day and there it was — free air in the abdominal cavity (which means there is a hole in a bowel somewhere). The surgeon immediately contacted Doctor X and ordered him to come post haste to the hospital. Understandably Doctor X got really scared, and with his imagination racing, thought his days were numbered. He was expected to return within the hour, but time dragged on, and finally he shows up obviously freshly shaven and sporting a new haircut! “Where the hell have you been?” was the first question. “I am certain that I am not going to make it,” came the retort — “that´s why I went to have a haircut and a shave.” Now the surgeon is incredulous “we fix this all the time you idiot” (is that how you talk to a pediatrician?). “No, I am a goner,” he continues, “to be on the safe side I also had my portrait taken by a professional photographer – in black and white for effect. Something for my family to remember me by.”

His treatment was uneventful, and he recovered. Since that time, he has a new found respect for surgeons and thinks we are miracle workers, nothing less. Doctors are a very difficult group to deal with as patients. Especially those who are cynical and meddle in their treatment plans. The only group that is worse is probably the clergy. “It is all in His hand” type of reasoning can get you to a boiling point. “Perhaps He put us here to take care of you” reasoning does not seem to enter their minds.

Neskirkja í Aðaldal

Neskirkja í Aðaldal

At the end of my training I used my vacation to do locum work at my first surgical department. I was a newly minted surgeon (licensed and all), and it was common for new specialists to do locum work in Iceland instead of taking a vacation. The family got to go home to all the relatives, and we got some brownie points for relieving the staff doctors. It was a bit like a dress rehearsal, where we could show just how good we were and also get a feel for working there for the future.

The atmosphere at the surgical department was jovial, and the morale good. The rhythm of the day was to present new patients at the morning meeting. The emergency patients were discussed, and any problems incurring during the last 24 hours were recounted. I had been on call, and we had admitted an old lady with a distended abdomen in the morning hours. She was emancipated and in dire straits, and the bowels were obstructed. What to do? Well, first off you discuss that with your patient. She understood that an operation was very risky, but by doing nothing she was going to die. She still enjoyed life she told me, and we decided on an operation as our only option. The staff surgeons were very negative about this endeavor. One of them of the “It is none of your damn business” fame (see my blog, https://everyjonahhasawhale.com/?p=1811) thought me mad. “Are you going to operate on that mummy?” He went on and on about it. Then there were the anesthetists! “The electrolytes are terrible, the kidney function impaired and my god that heart.”   Well, I honestly love anesthetists and I understand their plight. First, they have to anesthetize such a person, and then they have to deal with the surgeon – at the same time. So, the discussion with the anesthetists on the merits of such an operation, and the risks involved could be interesting. My central argument was always simple. The primary disease process causing all those abnormalities in the electrolytes, etc. was perhaps, and quite likely something that could be reversed. Our philosophy is, if the primary process can be fixed, the secondary problems have a chance of getting better. So, the patient will only survive the operation that fixes the primary problem. We must be very focused on that, and actually try to simplify things (some might call it tunnel vision). If you do not do that you will become mired in minutiae, and you can not do anything at all because it is all so terrible and rapidly getting worse. My arguments carried the day, and the anesthetists got the old lady ready for an operation. I was about to open her abdomen when the door of the operating room banged open, and the surgeon with his walrus mustache barged in.

Dánarvottorð

Dánarvottorð – Death certificate

He was in fine spirits and was holding a pen in one hand and a death certificate in the other  hand (those forms were the only ones we used on yellow paper.) Then he bellows – “When you start cutting – I will start writing!” He really was a lovable scoundrel.

There you go – what an auspicious start to an operation. By that time, I was getting to know him and I suspected that he was only “weighing my cojones,” so I did not get too rattled. All this black humor is a coping mechanism in a stressful environment. The operation was easy, and I found the suspected incarcerated femoral hernia, which was easy to fix. This lady recovered nicely and was duly discharged.

I sit here alone on the banks of the river

The lonesome wind blows and water runs high

I can hear a voice call from out there in the darkness

But I sit here alone too lonesome to cry

The Lonesome River – Bob Dylan

For doctors the river is constantly there. Our lives are lived on the banks of the river. Sometimes our toil is to prevent early departures and sometimes it is to help people to navigate across. We might as well fish it while we are at it!

 

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“It is none of your damn business!” — And a reason for fly fishing

My first rounds

I graduated from med school 1977. My class was required to do internships in various departments to fulfill a certain standard (Europe adheres to this system). When the standard was met, we could embark on studies in our chosen fields. This system is not used here in the States. Here you graduate and go directly into a specialty without going through the main departments of medicine and surgery. Young doctors, in the European system, can sniff various branches of medicine, so it helps them to choose right. It is amazing how similar personalities aggregate in the same specialty. Think about the orthopedic surgeons you have met – and my case is proven. There are even some medical idiot savants who can tell the speciality of male doctors just by looking at their ties. I think the European system has the edge, as it exposes young doctors to more varied scenarios, but it takes a year, and time is expensive.

It is known that surgeons can be a handful. They can get a very bad case of the “God complex,” and the cardio-thoracic ones tend to be severely afflicted, with neurosurgeons, who are a close second. Society has some blame here, as witnessed by this rendering on a stamp of one of the pioneers of modern surgery, Professor Theodore Billroth.

Theodor Billroth

Theodor Billroth

This could easily be Jesus with his disciples, right? I, however, am the most humble surgeon that I know.

My first day as an intern was at the Department of Orthopedics, and I was eager to learn proper bedside manners and how to conduct the morning rounds. The Chief of Orthopedics was a big personality. He was a bit under average height, but compactly built, and a former gymnast. His hair was black, combed straight back – he wore black glasses. He was always very neatly attired, and brought his own white gowns to work, which were starched to perfection. I discovered quickly that the attending doctors at that time had two faces. First was the “inside face” for the medical and nursing staff, then there was the “outside face” for the ´patients. He was very charming and funny in his own way, and I grew to like him a lot. However, he could be brusque, and small talk was not his forte. Professionally, he had his opinions and he made them known. I never detected any meanness in him.

Hip replacement

Hip replacement – painless!

Well, I will get to the morning round now. We set off from the nursing station, in a big posse, The Chief, his attending ortopods, the head nurse, and finally I, trailing behind. We got through the first patients, and nothing special occurred, and I was picking up pointers, drinking it all in. Then we entered a room where yesterday´s patients were located. Lying there were four elderly ladies who had undergone hip replacement surgery the day before. The method used by the Chief was called the Charnley´s operation. Charnley pioneered the so-called plastic and steel concept. The part of the hip joint that is the pelvis was replaced with a steel cup that was lined by plastic. The other part of the hip joint, the femoral head, was summarily cut off by slicing through the femoral neck. This part was then replaced with a metallic prostheses with a ball part that fitted the plastic cup.  So, all in all it is a considerable operation with a long incision and severing of a bone. The Chief bursts into the room and asks the first patient about her status. “Doctor, I am in pain” said the first lady, and this turned out to be the answer du jour for the four ladies operated on. The Chief did not answer the first lady, just moved on to the next lady, asks his question, does not respond, and moves on, etc. Wow, I was impressed by the compassion and tenderness of the spectacle. Now the Chief heads for the exit and turns around and says, “You ladies cannot have any pain in steel and plastic,” and he was gone. It was an absolutely correct statement, and I begin to think – I need be to toughen up some for this specialty.

Charnley´s hip prostheses

Charnley´s hip prostheses

At that time, we did not have any ultrasound, computed tomograms (CT) or magnetic resonance imaging (MRI). Understandably, diagnostics were really difficult. The hospitals had their fair share of people who had all kinds of complaints, mostly rooted in some neurosis or other. How to sort it all out was a challenge. We were doing all kinds of investigations and taking all kinds of tests on these patients. Patients lingered in their beds as this waltz was being performed. Next I became an intern at the department of Surgery at the City Hospital. Our hero is now a crusty general surgeon with a walrus mustache, a small beer belly, and outsized personality. He is one of the most charming persons I have ever met, and a superb conversationalist. Full of humor and mischief. We were discussing a difficult case where we were coming up empty in test after test. It was becoming apparent that there was malingering behind this. Come the morning rounds next day and we found ourselves at this patient´s bedside. Our surgeon recounts the negative results of all our testing. The patient is whining and whining and whining (you know, honestly, they can do that) and our hero was becoming irritated and fed up of all the b.s. going on. Finally, our patient laments “Then what is wrong with me doctor?” — to which he immediately answers “It is none of you damn business.” That response was truly one for the ages!

It could be very hard to discharge this type of a patient. However, we had an ace up our sleeve! You know when all else fails – we suggested the Air Encephalogram. That was done by tapping a little bit of cerebrospinal fluid via lumbar puncture, and replacing the fluid with air. The air rose into the skull, and then x-rays were done. This usually was a quite a painful procedure and the clientele was aware of this. This suggestion usually worked to get them check out of the hospital.

Did this behavior influence us young men and women at the beginning of our careers? Sure, it did up to a point. Society was changing fast at that time, and iconoclasts were hard at redefining professional roles in society, and pretty much the whole of society.

After that I found myself in an ER setting, fresh from graduating and probably pretty full of myself. I was asked to see an old man whom I had not encountered before. However, I immediately recognized his name (which is magnificent – but cannot be divulged). I had read about him in a contemporary novel describing the diverse and often colorful characters on our national scene years prior. He had led a tragic hard life of addiction, and was well known in the ER setting, and now he was there old, burnt out, with withdrawal symptoms, and generally in a bad way. Despite all that, he had a presence of serenity, and was still in possession of his dignity. His speech was immaculate, the voice was clear, and he was very courteous. It started badly. He, in his calm courteous voice listed the drugs he needed to counter the withdrawal symptoms – then he said he needed to be admitted to his usual ward. He had quite the experience with this situation. I was young, inexperienced, cocky and stupid, took umbrage at the patient telling me what to do. I delivered a mini rant of sorts for a while. He just looks at me with a sad expression on his face and experienced eyes, and he obviously pitied me. Jonas, he asks me “Are YOU really going to become one of those?” It was like being hit with a sledgehammer. Was I in jeopardy of becoming a stereotype? Well, I cannot have that. Since that day, I have tried to be just me. So, I sobered up and pretty much followed his plan of action, and off he went to his ward. What are the chances that you can “cure” such a person?  Well, nonexistent really.

The Kanagawa wave

The Kanagawa wave

I am sure that all these patients and my interactions with them, and a host of colorful specialists shaped my personality.  Sometimes it felt being like drowned by a great Kanagawa wave.

After my surgical training, on return to Iceland, I realized that I would need a hobby to stay sane. The constant barrage of sick patients, and the pressure cooker of the hospital environment is stressful, and I needed something to get away from all that. Then there were the meetings! My Lord, those were the worst of all. Imagine being trained to make decisions on the spot, and then acting on those decisions. Then you have to suffer through meetings where no decisions are ever taken. And to boot, the people at those meetings really did not want a decision, as it would risk scrapping some future meetings (coffee and danish is good remember). Is it any wonder that I choose the solitary and quite sport of fly fishing?

One thing I have learned on the way. Old doctors are the worst cynics you will ever encounter.

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Ruby Throated Female

Return of Hummingbirds and schadenfreude

“Whoa – what was that”? It is late February early March in Texas. Something just whistled past me as I was gardening. This UFO was small, the size of a big bumblebee or a big moth. No way I could identify it, such was the speed. I rewound the memory spool, and yes there was some sound too. Could it be? I had never in my life seen hummingbirds, but knew they existed in the Americas. My interest was piqued and I did some googling. Yes – it very well could be a hummingbird. I discovered that they will drink a sugar solution if available to them. Now next step was to procure a feeder which I did. The mix is one part sugar dissolved in three parts water. Then you just hang the feeder in a place where the birds can easily access it and feel secure (think like a bird eh?). Now the wait and after a little while I was rewarded when this exquisite creature came to the feeder.

Ruby Throated Female

Ruby Throated Female

 

I was so overjoyed by seeing this bird for the first time that I felt like a little kid. (Those of us who are not grownups by fifty do not have to.)  I must put a disclaimer here. These birds move so fast that it is very hard to get sharp pictures and some of mine could be better. However I use them since they are mine, and if you are interested, go to the net and enjoy their colossal beauty in professional photos.

https://www.google.com/search?q=hummingbird+facts&client=safari&rls=en&biw=1313&bih=1131&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiv1PD8xa7SAhWDRiYKHblbD_cQ_AUICigD

Ruby Throated male on his property

Ruby Throated male on his property

Why do I find them so special? First off they are the smallest birds there are, from 3-5 grams. They can hover in the air, go up and down, sideways and even back. They can cross the Gulf Of Mexico in a 20 hour flight, losing half their body weight enroute. It is very tedious to list all their factoids, so I put a facts website here. What really sets them apart is their rapid metabolism. Heart rate per minute is 500 bpm at rest and 1200 on the wing! I guess it could be called delirium cordis?

http://www.worldofhummingbirds.com/facts.php

They eat insects for protein, and then they hunt for flowers to drink their nectar, which supplies their energy. The plants need pollinators and will provide just enough nectar to keep them flying, doing their job. I already have mentioned my Bottlebrush in a previous post and how the Monarchs love that plant. The butterflies like their nectar a bit fermented explaining their erratic flight! The Hummers just love the Bottlebrush too, and the nectar it provides. Late summer there are probably up to a hundred of these birds in my trees.

Monarch

Monarch sampling the Bottle Brush

They are solitary birds and the males are surprisingly aggressive and territorial. When a male has located the feeder, it is his property, and magnificent aerial battles are fought over the right to have a sip. Of course a male will allow a female to drink from his feeder. I suspect the motivations  are somewhat less than pure, but what the heck, I understand. If the number of males gets to be too much to defend against, they change strategy and all are friends and drink the sugar solution together.

Ruby Throated males in aerial battle

Ruby Throated males in aerial battle

 

In Iceland the migratory birds are the harbingers of spring. Here I have chosen the hummingbird for that task.

It is with perverse joy I write this since today in Iceland there is 2-3´of snow and here there is this glorious spring. It only proves the article of Swedish faith that the only real lasting joy in this world is schadenfreude.

https://en.wikipedia.org/wiki/Hummingbird

https://en.wikipedia.org/wiki/Schadenfreude

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Cartagena Colombia

Cartagena – Colombia

Cartagena is a walled city in Colombia on the Caribbean coast. It is renowned for its well preserved architecture. This post is going to be just pictures all taken by Drifa Freysdottir. There is nothing to add, the pictures say it all.

https://en.wikipedia.org/wiki/Cartagena,_Colombia

 

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The choice, the sun and Icelandic crepes

After graduating Med School I worked for six months as a general practitioner during the coming winter. At that time it was a requirement for obtaining a license as a doctor before you could embark on your chosen speciality. I took a post in a small village in the countryside where I was the sole doctor. It was remote from Reykjavik. The villages around Iceland are mostly coastal with fishing interests and service to what is left of the farming community around. The movement of people from the country to the towns and villages had already depleted areas that once were thriving communities. Where I was posted the fjords are deep and the mountains are layered up to a flat tabletop. The mountain sides are steep and they will block the sun if the village is so located. These fjords are ringed by mountains where the foothills run into the sea with limited lowland. Some places the mountains cascade into the sea with vertical cliffs and the surf pounding the walls. The ocean is a part of the allure sometimes flat and other times raging and cold it is. These fjords are barren devoid of trees, mostly stones and tundra but exceptionally beautiful even majestic.

The preceding summer I worked as an intern in one of the hospitals where I got to know a young patient in her twenties. She was battling a cancer. She was from the rural area where I became posted and her only wish was to live in there. South of the mountains in the next fjord she lived with her husband on a farm in a valley where there were no other inhabitants. Mountains both sides and then a bay with yes you guessed it more mountains. There were no lights from any other settlements to be seen from where she lived.  When the snow started in the fall it became impossible to to get there driving. There was a an airstrip at villages north and south of her but if you can not get there it is useless. The lady had a relapsing condition and after each treatment and actually from the first treatment she absolutely refused to be in Reykjavik extended periods for follow up and such. She could not stand the city and would go back to her farm immediately after the chemo. She had had a number of relapses and then recovered. This lady was very intelligent and understood well her predicament. However living on her farm was the only thing she would accept despite the consequences.

In these fjords the mountains are so high they will block off the winter sun that only manages to get up over the horizon some few degrees in the wintertime. It takes for ever for the sun to rise and it sets slowly. Some villages do not get any direct sun at all for a while. You can see the mountain tops across the fjord illuminated and you track when the rays are creeping lower as the sun rises after the winter solstice.  So winter at these latitudes is prolonged periods of dusk little bit of sun but mostly pitch dark. To not feel the sun on your skin for an extended period of time is depressing and you long for the caress of the sun again. The feeling of the sun on your skin after this period of deprivation is indescribable even wonderful. The day will come that the sun manages to get over the mountains blocking it and shine on our village and that day is understandably a very special day. This day we have the sólarkaffi (sun coffee). We bake what is locally called pönnukökur (pancakes) but the rest of the world calls crepes (we think everyone else has it wrong). We do not care so pönnukökur (or pönnsur a nickname) it is. We bake them on flat round crepe pans that must not ever be washed and are not used for anything else. These pans become heirlooms. My sisters wondered what became of momma’s pan but I know. There are many recipes and I for instance put a little bit of coffee in the batter to get a better color, I actually prefer instant coffee if it is to be had. We like them thin and roll them up warm with sugar brown or white or we we put whipped cream and fruit jam on top and fold them twice so they look like a padded quarter circle. This is a great tradition as we indulge in crepes and the revitalizing rays of the sun. This is the best celebration I have experienced in my life.

The winter I was working there I took some blood samples which were sent to follow up on her condition. The winter was uneventful and I returned to the City and soldiered on. Next year in the fall I learned that the lady was getting weaker again. She understood the situation and as she was snowed in the Coast Guard was summoned to help out. Before that she in her weakened state hiked up the mountain and sat down on a stone and awaited the return of the sun. When the sun reached her she sat there and soaked it up and then hiked back to the farm. Pönnukökur  were baked and she enjoyed her sólarkaffi (sun coffee). Now she was ready and the Coast Guard got her out of the isolation and she had to return to the hospital. She did not make it back alive. I am certain that her spirit, if there is such a thing, is there in these barren isolated majestic valleys. The memory of her certainly is.

That damn fireplace is smoking again irritating my eyes so I have to fix that.

Pictures Drifa Freysdottir

 

 

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