Musings on my travels and experiences as a Zen practitioner, trauma surgeon, and citizen of the world.
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lessons from Florida wildlife
Walking along the road, I passed a hedgerow and heard a rusting in the underbrush. A small cottontail rabbit emerged onto the path in front of me, paused a moment, and darted back out of sight.
I was delighted at the brief encounter and smiled to myself.
As I continued on, I passed a carcass near the curb. I couldn't make out what it had been due to the degree of decomposition. There were bones and bits of fur flattened into the dirt by rain and ravaged by insects. The skeleton was small and had sharp teeth. A cat or opossum or skunk, perhaps. I was struck by the juxtaposition of the live rabbit I had just seen and these remains. But then it occurred to me that the two are not different. Death is part of life. Life is part of death. The cottontail will die one day. It will decay to bones and fur. The carcass was once alive. It breathed and ate and scurried across paths. They are the same.
I had taken a photo of the rabbit. I took one of the remains as well because one is no more beautiful than the other. One is no less valid or desirable or meaningful.
I bowed, grateful for the reminder.
Tuesday morning, February 12.
Somewhere in Florida.
“You made me promises promises
Knowing I’d believe
You knew you’d never keep...” plays over the loudspeaker.
The cashier’s name tag says “CINDY”. She sings along under breath, her feet and hips moving to the beat. I picture her dancing to the same song 35 younger, before the sun and cigarettes did their work.
She smiles at the man in line in front of us. Red hearts and “I Bless the Day God Led Me to You” embossed in gold adorn the black card in his hand. He sets it on the counter with a bottle of orange Gatorade and a box of instant potatoes. His dread locks extend beyond the hem of his chef’s coat.
“The nice thing about this job is you can just bring your own lunch, too. Anything microwaveable is generally good,” the older of the two men stocking the drink case tells the younger. He demonstrates how to carefully align the bottles with the labels all facing out.
Younger man nods, “Yeah.” Cuts open another case of Sprite.
Since leaving Facebook, I keep hearing from friends asking about where to find me. I’ve begun posting photo updates on Instagram as taggart_tracy and will be making regular entries here on this blog.
my wife and I moved to Florida at the end of last year, and life has changed a good deal for us. I’ll share stories and thoughts here as they arise.
Fog on the water.
Steam rises from my teacup
Two ducks on the pond
New Year’s Eve 2017
I woke up in a motel 75 miles from home, with a dead dog and a nasty head cold. I was on call for two hospitals that day, and there were eleven patients I had to see and some who would need surgery. I sat up in bed and nudged Lucy with my foot. “Time to get up, LazyBones.” She didn’t move. I reached down to shake her awake and felt how cold and stiff she was.
Lucy was old for a bulldog. We’d had nearly ten good years together, and I’d begun to fear she would die soon. I wrapped her in an old sheet I got from the housekeeper and placed her on the back seat of my Jeep then drove to the hospital. She lay there all morning as I rounded on inpatients, saw a new patient in the emergency room, and scheduled surgery for the day.
I took her to the crematory between operations. The gentleman who operates it out of his home in the country was kind, but not overly solicitous. He told me that the fee was based on weight, and took Lucy into the back of the shed which served as his office. Returning a moment later, he informed me the cost would be forty-two dollars.
I handed him my credit card, and burst into tears as he handed it back. He hugged me lightly and gave me a handful of tissues for the road.
An hour later, I was elbow-deep in the tangled intestines of an elderly woman who was suffering from acute ischemia of the gut. She was already gone in shock on arrival to the hospital, and without surgery would certainly have died.
It was a busy day. I removed a gallbladder full of stones and a rotten appendix. I inserted a chest tube into a pedestrian who’d been struck by a car, and drained an abscess resulting from intravenous drug abuse.
I met with the family of a very ill and severely debilitated man who were struggling with whether to place a feeding tube and keep him on a ventilator, or “let Nature take its course.” They felt he’d “had a good life” and decided not to continue aggressive treatment. The breathing tube was removed, medication supporting his blood pressure was stopped, and I sat with them as his heart ceased to beat.
I went back to the motel, put a frozen dinner in the microwave, and changed into sweats and a T-shirt that- like most of my clothes- were covered in dog hair. Exhausted as I was, it was hard to sleep without Lucy curled up at my feet.
My mother has OCD. And 12 cats. This combination was responsible for the nightly ritual known as “counting cats”. We were a family of five in a standard three-bedroom ranch style home in El Paso, Tx. My two sisters and I dreaded bedtime. I, for one, had been known to slink off to bed early just to avoid participating. Before you judge, let me describe the scene to you:
”Bedtime!” my mother announces. We all know what that means. My sisters and I crowd into the one full bathroom in the house to brush teeth, wash faces, apply moisturizer, and whatever else our toilette entails. The cats, of course, scatter to the four winds.
Everyone changes into pajamas, and it begins.... each cat must be located, it’s location reported and confirmed. Don’t even try to pretend you’d found one when you hadn’t. If your veracity was at all in question, someone would be sent to verify your claim. Woe be to the prevaricator! Not only would they be punished (lying was the greatest evil in my mother’s mind), but when the cat you said was inside was actually left out all night, suffering a cruel death at the mercy of the elements and/or the coyotes, upon your shoulders is where the blame would firmly rest.
Those of you who know cats will understand when I say I’m convinced they took sadistic glee in finding impossible hideaways at this time of night. The cat who sat on your homework all evening, the one continuously howling for cream in the kitchen, the one snoozing peacefully on the sofa, the one biting your toes under the dinner table, the one who’s so old and fat it lays in the same spot in the hallway twenty-three hours a day- all disappear.
“None in my room!” cries Tammy, the middle sister. Her room is neat and tidy- nothing out of place. A cat could not go unnoticed in there, even under the bed or in the closet (Standard Search Protocol).
”I found Juby in my room!” reports Tara, the youngest. She and Juby have a special bond. They’re each the youngest and the smallest of their litter. Make of that what you will.
“Prince is in the bathroom,” says my mom. Prince, an affectionate, languid, long-haired Persian mix who’s favorite hiding place is the towel closet, is the reason every time I get out of the shower and dry myself, I’m covered in fur.
Four cats down, eight to go. The search continues.
“I’ll check the laundry room,” I announce. Just then, Katie, a shy calico we found living in the woodshed with her newborn kittens (whom we obviously took in), leaps down from the shelf above the washer, narrowly missing my head, and darts past me. “Katie’s here!”.
The only kitten of Katie’s we were unable to find another home for was Marilyn. Now a full-grown, cotton-haired white cat whom we suspect is deaf, and who is perpetually covered in mats due to an aversion to self-grooming, resides primarily under my bed. She’s called Marilyn in honor of Miss Monroe, due to her lush white fur and habit of lounging about and gazing provocatively at anyone who passes. Don’t try and touch her though; she bites. I spot her (without touching her) lying in the far corner under my bed.
Someone has located Kelly, a large, fluffy, motherly calico, asleep amongst the couch cushions. That leaves only “The Boys”, who are likely outside.
Once my mother is convinced every room has been thoroughly scoured, she heads for the front door to round up the stragglers.
“Heeeeeerrrrre KittyKittyKittyKittyKittyKitty!” she calls.
And again. “Heeeeeerrrrre KittyKittyKittyKittyKittyKitty!”
Nermal comes sauntering in. He heads directly to the kitchen, expecting a treat. Tara obliges him with a saucer of milk.
My mother continues to call for several minutes, then enlists me to take over.
Reasoning that perhaps they simply couldn’t hear her well enough from the doorway, I venture out onto the porch. Standing under the porch light, I begin to call.
“Heeeeeerrrrre KittyKittyKittyKittyK.....AAAAAHHH! Stupid bugs! Heeeeerree KittykittykittyKITTY! Help!!!”
The porch light has attracted the usual array of moths and June bugs, and now there’s a June bug entangled in my hair, buzzing frantically near my right ear, its creepy little legs crawling on my scalp. I’m generally considered the least squeamish and the boldest of the family, but June bugs are my Kryptonite. As I dance around yelling for help, Keaton ducks past me and scratches at the front door. Tammy opens the door and he runs in. She manages to get the bug untangled from my hair and takes over the cat calling.
Back in the kitchen, I trip over Nala. “Where did you come from?” I ask him. He mewls at me, indicating the empty milk dish.
“All right,” says my mother as she comes into the kitchen. “Who’s not here?”
I run down the list with her: Juby, Sugar, Pepper, Prince, Kelly, Katie, Marilyn, Nermal, Keaton, Nala. Only two missing.
Momentarily, Tammy opens the door for Shadow. “Just Cowboy left to go”, she reports.
Cowboy is a rogue and a rambler: a large, lanky, orange tabby who prowls the neighborhood from dawn to Last Call. There have been a few nights we finally gave up and let him stay outside (against my mother’s better judgment and ability to sleep). When he does come inside, he sleeps in my bed- curled up on my pillow just like when he was a tiny kitten. I feel a particular fondness and a responsibility for him, so I volunteer to brave the porch again, thinking maybe he’ll come for me if no one else. This time, though, I avoid the June bugs by turning off the light. Cats can see in the dark anyway, right?
After another twenty minutes of calling with varying tones, pitches, and ululations, he appears. I scoop him up in my arms, kissing his head and scolding him for causing so much worry.
My mother announces it’s now truly time for bed. All is well. Until tomorrow night......
The pager went off at 6:42 pm. "Full Trauma -- ED 6"
I hurried down the stairs and into the Trauma Bay. Several team members were assembled around the room
"What have we got?", I asked.
"24 year-old male, GSW to the chest. CPR in progress". (GSW = Gun Shot Wound)
"Get the thoracotomy tray. Have we called Blood Bank?"
"A box of blood is on the way. EMS three minutes out."
We heard the stretcher coming down the hall. A moment later, the unconscious patient was lifted onto the gurney. Nurses and techs went into action: placing EKG leads, starting additional IVs, stripping off blood-soaked clothing.
"What has he had?", I asked the medic.
"This is liters two and three of lactated ringer's. We've given epinephrine twice. He's in PEA."
I felt for a pulse at the carotid artery and there was none.
The monitor showed an electrical rhythm but there was no pulse, likely because there was insufficient blood in the vascular system to generate an adequate blood pressure.
"Rapid infuser is ready," said the trauma nurse. "How much blood do you want?"
"Hang a unit of cells and keep it coming, alternating with plasma every two units."
Meanwhile, I had opened the surgical tray and grabbed the scalpel. With one long, smooth stroke, I made an incision along the upper edge of the fifth rib from sternum to armpit, slicing through skin and fat down to muscle. I traded the scalpel for scissors, cutting the muscle between the ribs to enter the chest cavity. I could see pink lung tissue inflating and deflating with every squeeze of the AMBU bag.
The chest compressions were obscuring my view of the pericardium, the tough sac that contains the heart. When they stopped, I could see it was distended with blood which was crowding out the heart so it could not fill and pump. I cut a hole in the pericardium with the scissors and blood rushed out- over the lung, out of the chest, off the gurney, and into my shoe. There was clearly a large hole in the heart or one of the large vessels associated with it.
"More blood! Keep it coming!”
I took up the scalpel again and extended the incision across the sternum and onto the right side, an exposure known as a "clam shell". I now had access to the entire chest cavity, which was held open by a Medieval-looking instrument called a "rib-spreader".
The heart was not beating, and it was flaccid and flat- EMPTY. Blood was pouring out of a hole at the junction of the inferior vena cava and the right atrium. I put a finger over the hole. The heart filled and began to beat weakly.
With my left index finger on the hole, I took the suture in my right hand and started sewing. Meanwhile, the nurses continued pumping warmed blood into the veins. As I completed closing the hole, the heart began to beat more strongly. The monitor showed a rapid but normal rhythm. Blood pressure rose. A sigh of relief went around the room.
"Call the OR- we'll have to take him down and get him closed. Do we have an ICU bed ready? Let's get a set of labs. Warm blankets, please. He'll need a Foley catheter and a nasogastric tube."
We'd done it. Life saved.
"Family is in the consultation room," said the Chaplain.
I looked down at myself. I was a mess: arms smeared with blood to my elbows, scrubs soaked with blood from chest to knees.
"I'll have to change before I talk with them."
Someone ran to get me a clean set of scrubs and I set about washing up at the sink.
"Pressure is falling again!", announced the trauma nurse.
I turned from the sink.
“Check for a pulse. Give epinephrine. How much blood has he gotten? Do we have labs yet?"
The respiratory therapist read off the numbers. They indicated sufficient blood volume and oxygenation, acceptable acid/base balance and electrolyte levels.
I looked back at the heart. The sutures were intact and there was no bleeding. The heart was full, but barely beating. I began rhythmically squeezing the heart between my hands to augment its contractions. Soon, they ceased. Medications to stimulate heart activity were administered, I kept pumping, and we spent another twenty minutes working with no recovery of spontaneous heart function.
"We've lost him.", I said.
I continued manually pumping the heart while verbally running down the list of what had been done so far, what the current status was, then polled the room.
"Is there anything more we can do? Can anyone think of anything we've missed?"
No one could.
"I believe we have reached the limits of what we can do, so I propose we discontinue resuscitative efforts. Are there any objections?"
There were none.
"Time of Death: 7:51 pm.”
"No Theatre today."
"What do you mean? We have six cases scheduled." I was standing in front of the scheduling board with Farada Ali, the intern who would be operating with me that day. Samuel, our anaesthetist, had just joined us.
"No Theatre today."
Samuel pointed to the pole that held the power lines to the small building that housed the operating rooms. The pole had fallen over during the night--its complete collapse prevented by the water tower. There were two men busily digging around the base of the power pole, and I was assured they should have the problem solved by the next morning.
The next task for me was to determine how to reschedule the two semi-urgent operations and the four outpatient procedures we had planned for the day. I was most concerned about a nine year old boy who had been admitted during the night with appendicitis. He looked rather ill, and I feared he would be far worse by morning.
As we puzzled over the particulars and possibilities, Husnity, the intern assigned to Casualty for the day, came running up to us.
"Dr. Tracy, you must come to Casualty immediately!"
Casualty is what we in the U.S. would call the Emergency Department. We all followed him at a jog across the courtyard, through the crowd of roughly sixty people who had queued up in hopes of seeing a doctor that day.
Casualty was a ten-by-twelve foot room equipped with a rickety stretcher covered with a torn sheet, a small metal table on which sat a half box of gauze and a stethoscope missing an earpiece, and a wooden chair. The nurse on duty was standing over the stretcher where a nine month old baby girl lay. She was semi-conscious, covered in dirt and scrapes. Her mother stood nearby, wringing her hands. She explained they had been on a motorcycle taxi and there was an accident on the main road just outside the hospital.
The infant's left foot had been amputated completely at the ankle. The resourceful intern had tied a latex glove around the baby's calf as a tourniquet to prevent blood loss, and in doing so probably saved her life. There was nothing more he could do then but come find me, as she would certainly require surgery.
Though barely conscious, the baby's heart rate and breathing were normal, so I was a bit reassured. I examined the wound, complimented the intern on his quick thinking and actions, and turned to Samuel.
"I'm going to need to tie off the vessels, debride the wound, and apply a dressing", I told him.
"No power to the Theatre."
"Yes, I am aware. But I can do this without power. It will take less than ten minutes. Can you give her a sedative and we'll just get it done? She'll need a formal amputation and wound closure, but that can wait until tomorrow."
"OK", he conceded.
Samuel started an IV, and we took her to the operating room. I removed the tourniquet, ligated the major veins and arteries, trimmed away some dirt and damaged tissue, cleansed the wound, and applied a dressing.
The next morning, I was delighted to learn that power was restored, and we could proceed with surgery as planned for the day. My first priority was the nine year old boy with appendicitis. He had indeed worsened overnight, with high fever, chills, vomiting, and severe abdominal pain. I was sure his appendix had ruptured and that he was developing peritonitis and sepsis. He needed surgery right away.
As the nurses prepped him, I went to see the baby girl from the day before and was pleased to find her actin more like a normal baby and nursing from her mother. As the intern interpreted for me in Swahili, I explained to the mother that more surgery would be needed. I would amputate higher up on the leg in order to provide good closure of muscle and skin over the end of the bone. We agreed to do that the next day, as the present day was already full of cases we'd postponed from the day before. Some of the outpatients had walked for hours to the hospital the previous day, only to be turned away due to the power outage. They had been instructed to return today.
We performed the appendectomy, and as expected there was widespread infection in the abdomen. With several days of antibiotics, the boy recovered and was able to return home.
The following day, we returned to surgery for amputation of the infant's leg. It's customary to immobilize the leg after surgery, so I asked for plaster to make a splint. None was available. I was told by the intern that such materials must be purchased by the patient or their family from a pharmacy, and he assured me he would write the prescription for the mother to take to the pharmacy. I instructed him to apply the splint as soon as the plaster arrived.
When we made rounds the next day, there was no splint. The baby's mother explained to me that she had no money for the plaster, the cost of which amounted to less than $2 US.
I later gave the money to the intern, he went to the pharmacy and purchased the plaster, and we applied a splint. The next day, the child went home with her mother.
Musings on my travels and experiences as a Zen practitioner, trauma surgeon, and citizen of the world.