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While my guitar gently weeps

2015; Lippincott Williams & Wilkins; Volume: 80; Issue: 1 Linguagem: Inglês

10.1097/ta.0000000000000918

2163-0763

Thomas M. Scalea,

Optimism, Hope, and Well-being

John Lennon was born in Liverpool, England, on October 9, 1940. His outlet became rock and roll, and he talked his mother into buying him a guitar. As a young teenager, he formed his first band, the Quarrymen. He met Paul McCartney who joined the band. Paul was actually a better guitar player, particularly when he figured out how to play left handed. A friend of Paul, George Harrison, was mesmerized with John and also was a pretty fair guitar player. Stu Sutcliffe played bass. The first big break is an invitation to play in Hamburg. The Quarrymen have become the Silver Beatles. They drop the Silver, become the Beatles, and hire Pete Best as the drummer. They play at the Kaiserkeller, in the middle of the red light district. The boys play every night for hours, living on diet pills to stay awake and beer. There are other English bands in Hamburg, including Rory Storm and the Hurricanes with Richard Starkey as their drummer. According to a recent TV interview I saw with Paul, he impressed the Beatles. He wore a suit and hung at the bar smoking cigarettes and drinking real mixed drinks, not beer. He became Ringo Starr, Ringo for his rings and Starr so his solos could be announced as Starr Time. On October 18, 1960, John, Paul, and George record. Pete Best was in town buying drum sticks so they recruit Ringo to play, the first time that the Beatles would record together. The Beatles return to Liverpool. Stu stays with his girlfriend, Astrid Kirchherr, who suggested new haircuts. Ringo replaces Pete Best; George Martin, the Beatle’s manager, negotiates with EMI; and the Beatles record. Their first hit, “Love Me Do,” hits the charts in England in late 1963. On February 9, 1964, the Beatles play The Ed Sullivan Show. Seventy-three million people watch. During the performance, no crimes were committed by a teenager in New York. Even Billy Graham breaks away with tradition and watches television on a Sunday.1 “I Want to Hold Your Hand” is a number one hit 2 weeks later. The British invasion has started. Between 1964 and 1966, they tour and make two to three albums each year. Their new recording company, Capitol, thought the Beatles were a fad (John Scalea, personal communication). As their popularity grew, everything sold regardless of quality, so volume became the only goal. The Beatles play their last huge venue in Candlestick Park in August 1966. The audiences are so loud, no one can hear, including them; they stop touring. The first part of their career ends. The Beatles take control of their own music, and they make changes. In 1967, John meets Yoko Ono. The Beatles meet the Maharishi and Ravi Shanker and are exposed to new sounds. The sophistication advanced rapidly. They record Rubber Soul—in my mind, their greatest album. The Beatles made only one album per year. Sgt. Pepper’s Lonely Hearts Club Band is followed by the Magical Mystery Tour. The Beatles make movies instead of touring. The Beatles usher in the third and final phase of their career. John and Yoko have become inseparable, a source of irritation to the others. They get married. The Beatles are terrible businessmen and fight constantly. George Martin, who kept them organized, is gone. There is little or no collaboration; they actually record without being in the same room. John, Ringo, and George hire Alan Klein to manage Apple Records, and Paul responds by suing to break up the band. The last true album that the Beatles made was Abbey Road. Let It Be was released later, but it was a compilation of songs they had recorded earlier. On January 30, 1969, the Beatles reunite and play an impromptu concert on the roof of the Apple building, but it is too late. By 1970, the Beatles are finished. In six short years, they have changed history, made music that will live forever, and disbanded. The first album of their last phase simply entitled The Beatles becomes known as the White Album for obvious reasons. The best song on the White Album may be “Back in the USSR.” However, “While My Guitar Gently Weeps” stands out. It is written by George and is the first time that a non-Beatle plays with them. George’s pal, Eric Clapton, plays the guitar solo. The Beatles get back to their rock and roll roots. “While My Guitar Gently Weeps” is a beautiful song, the concept of gently weeping evokes emotion. It could be sad, but not necessarily. We weep tears of joy as well as tears of sorrow. We embrace, mourn, and come back together. Clapton’s guitar always takes me away. Why use this as a title for the Presidential Address? There are a number of parallels between the Beatles, our profession, and that song. We too have made great strides over a relatively small amount of time. We worked hard under less than ideal conditions and got better. I also believe we are at a critical juncture, and we gently weep. My reference will be my career. This will be a compilation of discussions with colleagues. This is our story. I just happen to be on the podium. Organized trauma care has only existed for 50 years. In 1966, the National Academy of Sciences released Accidental Death and Disability in the United States: The Neglected Disease of Modern Society.2 The findings were broad and, sadly, still relevant today (Table 1). Their solutions, conducting national conferences on trauma care from injury to rehabilitation, establishing a national trauma association, formation of community councils on EMS, and a national council on accident prevention and creating a National Institute of Trauma in NIGMS [National Institute of General Medical Sciences], seem familiar.TABLE 1: Accidental Death and DisabilityOrganized trauma care received a huge boost early with several studies by Don Trunkey and colleagues.3–5 In one, Trunkey, West, and Lim compared Orange County, a place with no trauma center, against San Francisco county, which had San Francisco General Hospital as a trauma center.3 There was a highly statistically significant advantage to being injured in San Francisco. In 1957, Gerry Shaftan established the first organized trauma service at Kings County Hospital in Brooklyn. In a recent telephone conversation, Dr. Shaftan recounted that Clarence Dennis, his chairman, asked him to start a trauma service after a conversation with Owen Wangensteen who had just returned from Europe. The Kings County general surgeons fixed fractures at that time as they did in Europe, so this seemed logical. In Maryland, R Adams Cowley recognized injury as a disease, and the clock started clicking at the time of impact, the Golden Hour. The clerk for one of the heads of the House of Delegates was injured in Frederick, Maryland, and was transferred to a hospital in Hagerstown. He continued to worsen, and he called his boss and said, “Please do not let me die here” (Gov. Marvin Mandel, personal communication). His boss called the governor, who had heard of Dr. Cowley. RA had a US Army grant with a laboratory in the basement known as the “death lab,” trying to understand shock. Dr. Cowley borrowed a helicopter from the army, landed on the grounds of the Hagerstown hospital, brought him to the University of Maryland, and saved his life. In gratitude, Governor Mandel gave Dr. Cowley a small gift that established organized trauma care in Maryland. He later created MIEMSS [Maryland Institute for Emergency Medical Services Systems], which many people consider now the model trauma system. Our profession started evolving. The first great trauma group was at San Francisco General with Bill Blasdell as chief, supported by Don Trunkey, Art Thomas, Muriel Steele, Frank Lewis George Shelton, and Bob Lim. Trauma and critical care emerged as a real specialty with the establishment of fellowships. Centers sprung up, such as those at Penn, Memphis, Vanderbilt, San Diego, Baylor, Harborview, Shock Trauma, and others. In New York City, it was Rao Ivatury’s group at Lincoln, Leon Pachter at Bellevue, and our group at Kings County. Those centers not began training the next generation of trauma surgeons and developed concentrated interest and expertise in trauma care. In the late 1980s, the crack wars produced unprecedented violence. Stab wounds or low-velocity gunshot wounds became multiple multicavitary high-velocity injuries. We operated nonstop. Standard therapy failed, and clinical investigation rapidly escalated.6 A better understanding of shock and resuscitation led us to concepts like damage control.7,8 The link between trauma and critical care led to a renewed interest in this specialty as a career for surgical residents.9 This concentration of expertise and need to modify old practices, combined with a group of mostly young, eager trauma surgeons, produced huge advances in the care of badly injured patients (Table 2). These advances were described over a short period. We developed the first generation of surgeons that cared for critically ill and injured patients for their entire career. Previously, trauma care was provided by young surgeons who covered emergency departments (EDs) until they could build a practice.TABLE 2: Major Recent Advances in Trauma CareIn his book, The Greatest Generation, Tom Brokaw details stories of the men that fought World War II.10 Mr. Brokaw writes, “As I walked the beaches with American veterans, men in their 60s and 70s, and listened to their stories, I was deeply moved and profoundly grateful for all they had done. Years later, I returned to Normandy, and by then, I had come to understand what this generation of Americans meant. It is, I believe, the greatest generation that we have ever produced.” Mr. Brokaw remarks how they answered the call and were mature beyond their years. They were disciplined by training and sacrifice and stayed true to their values of personable responsibility, duty, honor, and faith. They made the greatest investment in higher education of any society. They were not perfect. They resisted the societal and political upheaval during the 60s. They allowed McCarthyism and racism to exist way too long, did not embrace women in the work place, and failed to realize that the Vietnam War was different from their war. Those characteristics also describe the men and women who I would arbitrarily say are in their mid-50s and older. Mature, disciplined by training, willing to sacrifice, responsible, honorable, and called to duty describe a group I will call the greatest generation to practice trauma. I was recently at a meeting to select the publisher of our new journal. Grace Rozycki leaned over and said, “We are doing this, but 10 years ago, it would not have been us, it would have been others.” That is true, and 10 years from now, it again will not be us, it will be others, some sitting in the audience. Our careers, while not yet over, are coming to an end. When and how we quit are issues many of us have not fully contemplated, and there are precious little data to guide us. “How long are you going to do this?” is a frequent question. Seventy years seems to be a fairly consistent answer. Twenty years ago, Lazer Greenfield surveyed 882 members of the American Surgical Association to determine attitudes and practices with respect to retirement.11 Seventy-five percent of people responded, impressive for a survey. The questions were short, but open ended. Across all ages, nearly 70% had no plan or minimal retirement plan. This was true in 152 (72%) of 211 surgeons between 60 years and 70 years of age and even 53 (32%) of 164 of these older than 70 years. Only 17% had a detailed plan. Sixty percent thought that elimination of mandatory retirement age was a good idea. Interestingly, this was a prevalent opinion, with between 54% and 64% agreeing across the age categories. The age 70 years seems to coincide with neurophysiologic testing, which demonstrates a more rapid decline after 65 years of age, with physicians doing better than the general public, but the curves come together by age 75 years. Advances in primary care and preventative health have improved health and may have allowed Americans to live and stay active longer.12 The age when we should quit may now be higher, but there still is a ceiling. It just is unclear where the ceiling should be. Dr. Michael DeBakey commented that he “would not mind being operated on by a surgeon of 91 years”; of course, Dr. DeBakey was 91 years old at the time and still operating.13 There has been great variability in how the members of my generation have dealt with this. Some have remained at the top of their game as the years pass, a minority of people. Some of us simply go until they fall. Most of the rest of us are still working on it. None of us wants to age. We do not want to lose our hands or cognition, but it is inevitable. We need to quit, we want to do it at the top of our game and want to be relevant through our entire careers. Knowing how and when to do it is more complicated. The balance of youth versus experience in surgery is critical. Residents now learn skills that were not available when we trained. They are better at these than we are. However, the ability to anticipate and/or to get out of trouble when in it is not a skill that most young surgeons possess. It can only be refined by getting into and hopefully out of trouble, and that comes only with experience and volume. Recently, I was called in to help care for a patient with a devastating injury to the head of his pancreas and duodenum. We did a Whipple and a colon resection with a primary anastomosis in just less than 5 hours. None other than me had done a Whipple for trauma. We inkwelled the pancreatojejunostomy; none of them had ever done that. No one other than me actually knew what an inkwell was. I pointed out the potential pitfalls with each step and guided my young faculty member and fellow. They put every stitch in, but I watched each one. I had to wear loupes; they did not. That my eyes are not what they were 20 years ago did not matter. Things would not have gone as well, had I not been there. I know this happens in every center. Who will take our place? It is hard to know, but it is time to create a plan. The greatest generation to practice trauma has always had poor life-work balance. As Deb Stein once remarked, “It is hard to have life-work balance when you have no life.” While I may be an extreme example, all of us have made innumerable sacrifices. We missed baseball games, did not come home for dinner, or left to go back to the hospital and took too much call. Who knew you could get paid for call? Many of us still work more than the house staff and continue to take call and work the day after. To a large extent, our work has been our life. This does not mean that we have not had families or close relationships. There are innumerable relationships that have stood the test of time. How? While I am sure it is individual, I believe it is based on realistic expectations, which included the knowledge that work is important. My generation embraced each other. My closest relationships are with people in this room. We have been open. I remember Bill Schwab’s Eastern Association for the Surgery of Trauma (EAST) Presidential Address as he barely kept his composure describing violence in Philadelphia.14 Anyone who heard Jerry Jurkovich’s Western Trauma Association (WTA) Presidential Address, “Paint the Ceiling,” where he told the story of being treated for lymphoma––a patient in his own health system––left moved.15 Last year at the WTA, David Livingston did the same, and Grace Rozycki presented an abstract about coping with her husband David’s life-threatening bout of acute pancreatitis.16 She detailed how the trauma community came to her side and how grateful she was for the support. When tragedy has taken friends or people close to our friends, we have rallied. While I look forward to the science at meetings, as I age, I look forward more to seeing the people. A martini with friends is time well spent. I love sitting at dinner listening to and/or telling the stories about the old days and planning the new. The conversations and camaraderie with American Association for the Surgery of Trauma (AAST) members from my generation are the memories that stick. Some say your children do not read your CV, but I do not think that is true. I am sure that they do not read your papers (some may), but that does not mean that they are not watching. A few years ago at the WTA, three young men, including my nephew, Joe, presented. All had fathers or uncles as senior members with poor work-life balance, the next generation of the WTA. Apparently, those three had valuable family role models. Joe lived with us for a year. He went to medical school and did his residency at the University of Maryland. He was at dinner many nights and saw our sacrifices. We often talk shop at dinner, discussing cases, philosophy on training, ethics, and the future of health care. It was no surprise when Joe became a surgeon. It was furthermore no surprise when I saw our dinner conversations in his practice as he progressed through his residency. Apparently, he had read our “life” CVs and took them to heart. Fifteen years ago, I was leaving for home after I had been at the hospital too long. I was dog-tired and thus dismayed when someone knocked on my door. There was a visiting Italian surgeon who said, “My name is Osvaldo Chiara, and I have an appointment to speak with you.” I really wanted to tell him to go away. I was just too tired. As I started, I heard my mother and ducked as she went to hit me in the back of the head. Instead, I asked him to please come in and asked if he would like some coffee. It turned out that Osvaldo was Professor Chiara, and he had autopsy data on all trauma deaths in Milan in the last 2 years. We talked for hours. As we finished, I remarked that he had not touched his coffee and asked him if it was okay. He said for the first but not the last time, “This is not coffee, this is dirty water.” Coffee means espresso. We convened a panel of experts and reviewed his data. Forty-three percent of the deaths were either definitely or potentially preventable.17 In response, the city of Milan established a trauma center at Oespidale Niguruarda that looked a lot like Shock Trauma. With some help from me and others, Osvaldo has established a trauma system that links the hospitals in and around Milan with both ground and helicopter transport. The preventable death rate dropped to approximately 3%.18 This is trauma systems development and prevention at its finest. Thousands of people who would have died lived. Every December, I travel to Milan, participate in their annual congress, see their progress, complete my Christmas shopping, and on occasion, we even operate together. None of this would have happened if I had gone home that evening. He was leaving to return to Milan the next day. We have become close friends, colleagues, and collaborators. Another victory for poor life-work balance. All relationships matter. The ones with patients and families are often short but close. Injury is unscheduled tragedy. It disrupts patient lives and those of their families. We are responsible for both. Nonmedical people often ask me, “Why do you do what you do, and do you not want relationships like primary care providers that last for years?” Some years ago, I was out to dinner, and a woman approached asking me if I remembered her. I did not. She was the mother of a patient I had treated, and we saved her daughter’s life. She told me that every night when she prayed; she thanked God for me and the people around me. Not many people say that about their primary care providers. The relationships that we have with our staff are important. Many of us recently attended Norman McSwain’s memorial service. The room was full of nonphysicians, nurses, and prehospital people who came to say goodbye. It seemed so appropriate. Baltimore was rocked with civil unrest following the death of Freddie Gray. The riots that followed devastated the city. This followed a murder-suicide that involved two of our young intensive care unit (ICU) nurses the week before. Emotions were fragile, to say the least. I was scheduled to go to London but canceled the trip and spent a week in the house during the curfew. I told myself it was because I needed to be instantly available but later realized that I needed to be with my people. I had a cup of coffee with the nurses at 3:00 AM, sat in the operating room lounge and talked football with the technicians and asked the housekeepers if they were okay. I put my arm around people and hugged them without saying a word. They all hugged me back. Many thanked me for just being there. It was important for them and me. In the period after the riots, the clinical demands were immense. That has not changed. We were really busy. The telephone rang, and a mountain of food, pizza, pasta, and all of the things that truly fuel health care arrived, a gift from our colleagues at San Francisco General Hospital. It was a wonderful thing to do. A few dollars, a great sentiment, a memory that will last forever. Several years ago, I went to Afghanistan for an American College of Surgeons’ trauma systems evaluation. Our group became tight. There was not much to do other than to talk. I had the opportunity to get to know everybody, but Mike Rotondo particularly well. Mike and I grew up not far from each other in Rochester. We had many things in common. For instance, we are both recent inductees into our high school’s hall of fame. Not many of you know, Mike was a professional drummer playing in the Chuck Mangione Band as a teenager. I am sure I saw him play, as I saw Chuck’s band play all the time. It made us closer and cemented our relationship. It was a great trip for many reasons, but that alone was enough. These are just a few examples of why our work families and friends must be important too. We must make time for them. We must renew our commitment to responsibility. I fully recognize that the 80-hour work week fundamentally changed the way we train and practice. Working 120 hours was perhaps never a good idea. However, now I wonder who actually is the patients’ doctor? Any patient can be admitted to a team with someone on call, but then, care is assumed by a different person in the morning. If that patient becomes ill two nights later, care is provided by the on-call person. Faculty rotate by the week. Some now do shifts. Residents rotate by the day or 12-hour block. I recognize no one can be there all of the time. However, responsibility can become elusive. Responsibility is personal. It does not belong to a group. About a year ago, I took care of a terribly injured young man. We worked on him nonstop for 2 days or 3 days, but then he died. I had spent a huge amount of time with his family, and then, I got to tell them he was dead. It was awful. It really hurt. I returned to the office shaken, obviously quite upset. Stevie came up and put her arm around me and said, “You are not God; you cannot save everybody. If I was a mother and my child died and I saw how upset you were and how hard you had tried to save them, I would feel better. It would still be lousy, but I would feel better knowing how much you cared.” I appreciated her comforting me. Later, it occurred to me, it was supposed to be that bad. When a group takes care of a patient, it just does not hurt enough when someone dies. It is supposed to suck, and we should cry when the family cries. That bond is fundamental, and we must not lose it. We must commit to humanistic care. We communicate now via text messaging, not speaking. We are all being pushed to produce at a higher and higher level. When all we talk about is RVUs, ICD-10, EPIC rollouts, and compliance, we forget why we are here. We make rounds via computers, not in the room. We order CT scans without a physical examination. On rounds, only my NPs, PA, and I have a stethoscope. I could not practice without one. We need to touch patients. It is good for them and good for us. I actually practiced medicine before the day of CT scanning. Shockingly, not everyone died. I make rounds every evening to discuss concepts and talk with the residents and fellows and patients and their families about clinical care, but other issues too. This is simply my everyday routine. Recently, we had an EM3 rotate in the ICU. A week after he left, I was called to the medical ICU to see a patient who had a mitral valve replacement, on Coumadin, and who had a huge retained right hemothorax. I walked in, and it was him. He obviously needed a redo right thoracotomy, evacuation, and decortication. He was tachycardic and on the ropes but awake. I told him I would call the new chief of thoracic surgery. He reached up and grabbed my hand and said, “No, I want you.” I stepped away and took a deep breath. The room was full of his fellow residents, his chairman, my faculty, and senior people from the department of medicine. This was not a great opportunity. We reversed his coagulopathy, took him to the operating room, and did his case. He did well. I later asked why me? He said he knew he needed a technically competent surgeon but wanted a good doctor and someone who would really care about him and his family. I hope I am competent but know I take good care of patients and families. We must correct our errors, and the greatest generation to practice trauma has made its share. We failed to be politically active enough. While the burn association and orthopedics garnered huge numbers of federal research dollars, we were absent. We responded by establishing the Coalition for National Trauma Research, a joint venture of the AAST and the National Trauma Institute. We took too long to establish acute care surgery as its own discipline and define a training program for it. The AAST took responsibility. Popularity has skyrocketed. This year, 187 people have registered for the match (Fig. 1). The quality of the applicants is at an all-time high. With the CV I had when I was a chief resident, I would not be able to get an interview at a decent training program.Figure 1: Surgical critical care match results.We have not sufficiently integrated the AAST internationally. We are signing a memorandum of understanding with the Pan American Trauma Society, so American College of Surgeons fellows may see ultra-high volumes of penetrating injury. With the European Society for Trauma and Emergency Surgery, we have formed an emergency general surgery course. We must reinstitute rigor, which has all but disappeared in training. I go to M&M and hear chief residents or fellows present, and they are not able to tell us what operation they actually did, particularly if there was a complication. The faculty then rescues them. While I recognize that they may not have been present for the treatment of the postoperative complication, one would think that they would then interrogate those present to understand what happened and how it was treated. They should be able to explain it. It is what my faculty does. How else can we improve? Rigor need not be harsh. I recently had a discussion with one of our young fellows who, in my opinion, had made judgment errors. The patient had a 95% plus mortality; thus, it is not clear to me if a different course would have mattered. I spent 30 minutes going over the decision making step by step and pointed out what I considered two or three judgment errors. As I looked up, the fellow, visibly upset, said, “It is as important to me as it is to you to do this well. Thank you for taking the time to do this with me.” We must take the time to do this. Medical students have become passive visitors. They barely see patients and leave for lectures every day. I recently finished a tracheostomy, and I gave the suture to the third-year medical student and asked her to sew the trach in. She looked stunned and then said she preferred not to because she did not want to hurt the patient. I asked her if she knew how to instrument tie; she did. I then said, “This is not a spectator sport,” and handed her back the suture, took my gloves off, and walked away. The trach got sewn in. The next generation will not be responsible until we make them responsible. We must commit to our core values. We operate a service, largely staffed with faculty and nurse practitioners run by Sharon Henry, that often operates late into the evening or night. On-call residents just want to do the cases with her. They have no interest in seeing the patients postoperatively. Asking her if she needs help is certain to precipitate a rapid negative response. Saying, “Dr. Henry, would it be okay if I scrub with you, and I promise to follow the patient with you as long as they are in the hospital,” generally produces a favorable response. They better then follow the patient. We say we do not want to train itinerant surgeons, but we do. We must do a better job of inspiring those who will follow us. We recently interviewed one of our PGY-5s for our fellowship. He later sent me a note that said, “I remember a young man who survived an ED thoracotomy but came back with cardiac arrhythmias from a pericardial infection. We were back in his left chest with Deb Stein, with his heart exposed peeling chunks of rind off his pericardium. You stood back and said, ‘Isn’t this great? Who else gets to do stuff like this?’ It stuck in my mind for several reasons. First, it was an amazing case; it is not in many places that this patient would survive and have acute care surgeons able to handle this complication. It also helped me recharge my enthusiasm for surgery training during a time when residency seemed like an endless stream of scut and not enough operating time. You reminded me of the light at the end of the tunnel, and I have never told you how helpful that was to me.” He now wants to be like us. I frankly do not remember this case. They are all listening even when we do not realize it.