Resilience as a Metaphor

Forces that threaten to negate life must be challenged by courage, which is the power of life to affirm itself in spite of life’s ambiguities.
Martin Luther King Jr

If I am not for myself, who will be for me? If I am not for others, what am I? And if not now, when?
Rabbi Hillel

Imagine you are a freestyle skier executing an aerial maneuver. You are sixty feet in the air, having launched yourself on an impossibly steep trajectory. Somewhere between the glorious rise and certain fall of take off and landing a tiny seed of doubt germinates as you analyze your speed, balance and body position. In that microsecond of awareness you know, that on this day, disaster and landing walk hand in hand.  Your thoracic spine crushes on impact. Doctors use the word paraplegia and you know that means a wheelchair. Can you visualize it? Some may not relate to this scenario, it will not resonate as a potential scene in their life because, after all, they would never consider freestyle skiing in the first place!

Lets try a different scenario. Now imagine you are a successful, athletic businessman who embraces life at full speed. Others whisper with both awe and envy that you are lucky, you have it all, but at 45 your physician informs you that you have a rare cancer. Your only chance for survival involves removal of the liver you cannot do without. You must find a compatible living donor – a friend or relative who will give you a portion of their liver, undergo risky transplant surgery and, should you survive the complications, you will require potent anti rejection drugs every 12 hours just to stay alive.

Or this. On an otherwise ordinary day your only child is killed in a motor vehicle accident. You must weather the confusion, fear, guilt, anger and loss. The world grinds to a halt as you try to recall every detail of your last interaction with your child. It is your job to make sense from senselessness. You take one more breath and one more step to survive this day and try to comprehend the eternity that follows.

If any of the above stories were yours, how would you cope? How would you fare if life had dealt you such a hand?  The fact is, none of the above are stories, they are events from the lives of real people that I have come to know. All of these individuals actively contribute to the rich tapestry that is the community in which I live. Soon the freestyle skier will compete in the Sochi Para Olympics (with a silver medal from the Vancouver Olympics in his pocket). He is a motivational speaker whose brilliant career is the substance of a recent Ted Talk (and the above video, The Freedom Chair) . The businessman has just returned from 14 days of wilderness trekking in the Himalaya. He lives everyday in the present moment and takes life as it comes. The child was an organ donor for many others and she lives on as a part of them each and every day. A scholarship for other youth with similar goals and aspirations has been set up in her name so that they may venture where she once did. The parents continue to do the activities they shared with their child, and find comfort and continuity in this. They have established meaningful relationships with her friends and together they keep alive the memories that are the rich legacy of a short life shared.

What all of these extraordinary people have in common is resilience. Psychologists define resilience as the ability to bounce back from hardship and to carry on. It is a priceless commodity, for those individuals who possess it are rich beyond measure while those who do not remain poor in the face of material wealth. Tragedy, accident and disease form a community of souls and at some time or another we will all gain citizenship. How we fare in this new community will largely depend on our individual resilience.

Fortunately, one does not have to be extraordinary to be resilient. Without question it is the ordinary citizen, the one who does not let hardship define them, that I admire most. These individuals are not known beyond their circle of family or friends but they fully participate in life in spite of great odds. Some days in the office I will see in tandem individuals from both ends of the resilience spectrum. I recall a patient suffering from a soft tissue disorder unable to carry out many of the activities of daily life. Their  appointment was planned to discuss a long-term disability application, as the patient was unable to work. During the visit I was asked to take a telephone call. On the line was a dentist, seeking medical advice. After answering his questions he informed me he would soon be away for a holiday. He and a friend (who was confined to a wheelchair following a mountain bike accident) were off to kite ski. As I made my way back to the patient’s room, I was shaken by the conundrum before me. Why such a vast difference between how each individual deals with adversity? Why does one individual feel totally disabled by a medical condition while another individual feels a wheelchair is not an impediment to kite skiing?  More frightening was the question, Where in the spectrum would I stand if these hardships were mine? The answer of course, depends on the resilience of the individual, and you will never know the answer until it is your turn.

My next thought was, “What constitutes a resilient person”, and  “Am I resilient”?

Resilient individuals have the capacity to rise above, even flourish in the life that follows misfortune. If they were the clay of a future vessel, adversity molds them but resilience is the kiln that fires who they become. They come through the fire of hardship transformed, never defeated. They maintain a positive outlook, adapt to crises and moved on. Their misfortune does not come to define them but remains a paragraph in the story of their transformation. Such individuals serve as role models for how we would hope to see ourselves under similar circumstances.

Psychologists have found personality traits that correlate to high levels of resilience; a positive attitude, flexibility, an openness to change -what psychologist call an internal locus of control (the ability to affect the outcome of an event by personal action). Resilient people identify more with the survivor role than the victim role. They have strong problem solving skills and strong interpersonal networks. They are able to seek and accept help. Such individuals experience the setbacks of life as acutely as anyone else; feel stress just as intensely, but they move on to find solutions because, after all, setbacks are part of life and one can always move the goal posts and start again.

Fortunately resilience can be learned and the learning can come from such simple things as setting goals, addressing problems, nurturing and respecting your body, focusing on your strengths rather than your weaknesses, cultivating and feeding your friendships and realizing that, above all, each of us plays an active part in our destiny. The single action of stepping up to the plate, acknowledging that this life is yours to live, will vastly increase personal resilience. In the face of hardship when adversity comes calling, it will always be more successfully handled from the driver’s seat.

Understanding a concept such as resilience does not make it so and as a result the question remains – How will you do and how will I when misfortune comes to call? Lets hope we both have high resilience.

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History shows that for better or worse, Alabama was the birth place and slavery the mother, of modern gynecology.

If building the great pyramids had required the physical labor of women, gynecology would have been invented thousands of years ago. Instead, the birth of gynecology would have to wait centuries, for a prime time in history when women and men were equally subjected to punishing labor, to a time when one less bended back in the field meant cotton unpicked and money unearned, to a time when early and frequent slave pregnancy provided a master with more able bodies to be worked or sold, to a time when women unavailable for the field due to childbirth and its complications lowered productivity, to a time when the enterprising capitalist gentlemen of the antebellum south felt enough of a squeeze in the pocketbook to look into what could be done to combat those pesky women’s problems. History shows that for better or worse, Alabama was the birthplace and slavery the mother, of modern gynecology.

For the slave states it was good economics to minimize the complications of childbirth. After 1808, the US Congress forbade further importation of slaves to the US and as a result the only new blood for the system arose from the reproductive capacity of those already in bondage. Without access to new slaves from abroad, reproduction was the sole means of maintaining both the slave labor pool and the southern way of life. For their owners slave women were doubly valuable as laborers and as breeding stock. A doctor would often contract with a slaveholder to provide medical care for indentured women thus ensuring both slave fertility and the slaveholder’s profits. One such doctor was Marion Sims. Practicing in Alabama in the 1840’s, Sims was nothing if not innovative. Today, when a patient is positioned for a rectal examination they assume the Sims position, a left lateral position with the right knee drawn up and flexed. When a vaginal or cervical examination is performed on a female in 2013, the speculum used is not dissimilar from the Sims prototype devised from 2 bent spoons. When a patient has a wound sutured the principle of using a sterilized silver suture comes from Sims. All of these techniques have their origin in the experiments Sims performed on slave women suffering from the complications of labor.

The conundrum associated with medical advancements under such circumstances is that they were achieved disregarding the principles of beneficence and autonomy, that is, indentured women had no choice. For example, while refining the technique for a new procedure (incontinence repair) Sims operated on one particular woman on 30 occasions (He purchased a number of his slave patients from their slave holders for easier access.) over a 3-year period. Although ether was available, its use was not considered necessary for slaves although it was regularly used for the same procedures on white women of “a better class”. By today’s standards the ethics of Sims’ advancements in the field of gynecology leave much to be desired. Nevertheless, if you are interested, you will find a statue of Marion Sims near Central Park, NYC as well as in Alabama and South Carolina.

Until Marion Sims, women and their obstetrical/gynecologic problems were largely ignored. The Romans took interest for a time, creating an obstetrical treatise entitled (I’m not kidding) Soranus. Civilized societies used this same manual for all things female for the next 14 centuries. True, that it was updated in 1540 to become The Byrthe of Mankynde, but that was pretty much it until Sims came along. There are, however, a few important updates that have occurred over the centuries that are worth mentioning. These include the forceps delivery (pioneered by Peter Chamberlen (1560-1631) and then kept secret by his descendants for the next 125 years), and the discovery that hand washing between vaginal examinations proved to be an effective way to reduce infection complications (fetal and maternal death) in obstetrical patients.

History shows that female circumcision was also advocated in 19th century Western liberal democracies in the form of clitoridectomies. Victorian physicians proposed removal of the clitoris as a cure for “female hysteria, nymphomania and the dangers of female masturbation”. In 1858, British physician Isaac Baker-Brown, championed removal of the clitoris stating: “intractable women become wives; rebellious teenage girls settle back into the bosom of their families and married women formerly averse to sexual duties become pregnant”. Medical textbooks discontinued such recommendations, but shockingly, not before 1937.

When women look back on the medical history surrounding their sexuality and “female problems”, they will discover it is a troubling history at best. Upon reflection, we all must quietly remember and give thanks to the exploited slave women who suffered for our benefit. Much progress has been made in the field of women’s reproductive health but it would not be unrealistic to admit that for most of history, women and their issues have been both ignored and misunderstood.

Anesthesia- From Life or Death to a Dining Experience?

Aside

The Ether dome, first anesthesia

Massachusetts General Hospital, 1846. The first anesthesia.

It is over: she is dressed, steps gently and decently down from the table, looks for James; then turning to the surgeon and the students, she curtsies- and in a low, clear voice, begs their pardon if she has behaved ill. The students- all of us- wept like children; the surgeon happed her up.

 John Brown describing a 19th century mastectomy (taken from The Emperor of All Maladies by Siddhartha Mukherjee).

I have 9 toes.  I was born with 10 but along the way I lost one due to the complications of frostbite and finally, the surgeon’s knife. There are perks ( cheaper,quicker pedicures ) and drawbacks ( no flip-flops) to the revised me, but I have no regrets. In retrospect, sacrificing a digit was a small price to pay for freedom from for the daily pain of a seemingly incurable osteomyelitis (bone infection).

The surgery was uneventful. I walked into the hospital with 10 toes and left with 9. In between I had a pleasant conversation with the surgeon and the anesthesiologist and a really good sleep. I have had other operations in the past and I can say that I have never had a bad experience. Although general anesthesia should never be undertaken unnecessarily, and never should it be employed in Michael Jackson style as a drug for sleep, modern-day anesthesia for the healthy patient is relatively straightforward thanks to better anesthetic agents and the expertise of anesthesiologists.

As much as one may take elective surgery and general anesthesia for granted today, the process has not always been so uneventful. For most of history, surgeries were performed cold, that is, conscious, without the benefit of anesthesia. Early physicians employed various agents to induce sleep or dissociate the patient from the pain of the procedure and to this end combinations of opium, marijuana, belladonna, cocaine, alcohol, mandrake or jimsonweed were all tried with variable success and significant toxicity.  None of these agents worked especially well or for very long and as a result the decision to undergo surgery was a daunting one, made only by the courageous patient on the threshold of life and death. Under such primitive conditions one can only imagine with pity and horror the fates of young men centuries past who, when wounded on the battlefield, underwent amputation with the appallingly inadequate combination of a bottle of liquor, opium and a saw,

Under such circumstances it is not surprising that the reputation of a 19th century surgeon was built upon the speed of his surgery. In the 1840s Robert Liston ( a distant cousin of my husband) was considered a skilled surgeon because he could perform an amputation in 2 and ½ minutes. For additional speed he would hold his surgical knife between his teeth freeing up both hands for the procedure. As the germ theory of disease would not be recognized until 1865, fifty percent of surgical patients succumbed to postoperative infection and died.

In 1846, an event occurred that would propel the field of surgery into the future. In the packed medical amphitheater of Massachusetts General, a Mr. Gilbert Allen was the ground zero patient for effective anesthesia. While a gallery of surgeons watched, ether rendered him unconscious and amnesic and a lump was swiftly removed from Mr. Allen’s jaw. This historic breakthrough in the field of anesthesia occurred just in time to be made available to the 50,000 men who underwent amputation on the battlefields of the American Civil War (Chloroform was discovered around the same time but tended to cause fatal cardiac rhythms).

Civil War OR

Surgeries were performed without sterile technique.

The advancements in anesthesia in the past 167 years are miraculous and the process of going under has gone from a harrowing ordeal to an experience that, for the healthy patient, more resembles a dinner of several courses (albeit a horizontal one). At the risk of being facetious, let me explain.  Start by thinking of the OR as the restaurant of choice. A reservation is made beforehand and you are taken to the appropriate table. The experience commences with a starter of oxygen, propafol (induces anesthesia) and rocuronium (paralyzing agent). Feeling a little dry?  The IV fluids will help. Then the general anesthesia, desflourane or a similar agent, would be your main course as it keeps you under for the duration of your stay. Having a little discomfort from the surgery? A little analgesic via your IV will help.  Any individual needs that arise during your stay will be immediately addressed by staff as you are the only customer. In this restaurant, dessert is included. It comes in the form of the reversal agents, to wake you up. The procedure is over and it’s off to the post op recovery room and time for the staff to prepare the next setting. The whole experience was not to your liking? Relax, you won’t remember a thing but when you are recovered, think of how anesthesia is just one more reason to feel  lucky to be living in this time and place.