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July 13, 2011

Prescription to Love blog post

I can tell when a patient wants to get out of my office. It was Marsha’s first appointment, and she wasn’t making eye contact, her eyes kept flicking to the door, and she was answering all my questions with mumbles.

Most people don’t like going to the doctor – especially the gynecologist – but Marsha seemed particularly, almost pathologically, nervous. She had come to me for a second opinion. Her original surgeon had recommended removing her uterus and ovaries for the severe pelvic pain she suffered. This represents a drastic approach for a childless woman in her early thirties.

Marsha made it clear to me she didn’t want another examination from a male doctor. Now, I do what I can to make my patients comfortable, but a gender change is not on the table. I alerted Marsha that there are plenty of wonderful woman physicians she might like to see.

After some hemming and hawing, Marsha elected to let me take care of her, and a few weeks later, I took her into surgery. Just one look inside revealed that her pelvic organs were virtually glued together with scar tissue. Instead of removing the uterus and ovaries, I cleaned out the scar tissue that seemed likely to be the cause of her pain. The surgery went well. Marsha’s pain dissipated almost entirely.

Pain That No Surgery Can Cure

Yet during the coming months, it became obvious in the follow-up appointments that Marsha suffered from a problem that went beyond a surgical diagnosis and cure. She was in her mid-thirties – living alone, estranged from family, and with almost no social contact beyond work and trips to the grocery store. Marsha chose to be virtually alone in the world. As her trust for me grew, Marsha’s story gradually came together, revealed in bits and pieces.

It wasn’t totally unexpected that sexual abuse played a part in Marsha’s past. What was uncommon, however, was the degree and amount of abuse she had experienced. For as long as she could remember, Marsha’s male relatives – including her father and her brothers – had enforced sexual relations upon her. It had begun when she was five years old, and had continued until she was fifteen – old enough to finally fight them off, and shortly afterward, to move out of the house forever.

Removing scar tissue from the human body is technically difficult. But it’s a simple job compared to removing the scars of childhood abuse. When you excise abnormal tissue, the remaining healthy tissue comes together and heals. But how do you remove the unholy, festering memories? Marsha was physically healed, but far from resuming the act of living. I couldn’t see how Marsha could learn to love other people, when those who should have given her those first lessons were the source of her earliest injuries.

I pondered these questions in thought and in prayer. To Marsha, I recommended counseling, the church, volunteer work…but my suggestions were met with an unyielding resistance born out of deep mistrust for all people. Truthfully, it made me sad to have Marsha as a patient. It’s difficult to see a patient whom you’re not able to help.

A Life-Changing Prescription

Then one day, a simple solution presented itself. I decided to write Marsha a new prescription. On my pad I wrote: Do one good thing for someone else today. Write down what it was. Repeat daily.

I told Marsha it didn’t matter what she did, or when she did it, or who she did it for: just keep the love in her heart, and search for the opportunity to share it with someone else in need. Once a day.

I had no idea what Marsha would do with her “prescription.” Throw it in the nearest trash can, I suspected. I just knew she needed a different kind of medicine – the kind that isn’t manufactured by any pharmaceutical company. Healing of the body can only go so far: it is the health of our soul that makes us truly alive.

Two months later Marsha returned for her next appointment. I was pleasantly surprised to hear that she had made a friend. She had simply helped someone at the store with her groceries. She attributed it to her new prescription, and promised she would continue to follow it every day. Six months later, I learned she had made some more friends. She had even joined a book club and was attending a local church.

And a year later she went on her first date. Ever.

Over the past several years, Marsha’s health has improved so much that now I only see her from time to time. Recently she sent me a card. She wanted to let me know she was getting married. And across the bottom of the card, in a small and hopeful postscript, was a note that she was hoping to have a baby.

I have no idea why Marsha decided to take her “prescription” seriously. Maybe it was the fact that it was written on an official pad. Or maybe she could feel the desperation in my last ditch effort to help her.But perhaps it’s simply that Marsha recognized the truth. I believe that we are hard wired to recognize the truth when we see it, and the truth is this: Love is the necessary ingredient for a healthy life, and it is not always the love we receive that heals.

More often, it’s the Love that we give.

-Dr. Mike Litrel

July 12, 2011

family-litrel-272h

Disagreement between a husband and a wife occurs even in the best of marriages. Sometimes this manifests as open argument. But other times, marital conflict can be more subtle, an unspoken tension permeating the relationship for years like an uncomfortable humidity.

I met Ann when I was a sophomore at Wesleyan University in Connecticut. I was visiting my brother at University of Michigan, where Ann was enrolled a year ahead of me. We met at a fraternity Halloween party. She was dressed as Aphrodite, in a skimpy toga no father would have permitted his daughter to wear in public.

I fell in love.

Our entire three year courtship was a long distance relationship. Ann and I grew to know each other through letters and the periodic visits my budget would allow. She finished her degree a year before I did and moved to Atlanta. After my graduation we married.

There has been nothing in my life I have looked forward to more than finally living with my beloved. My attraction to Ann was more than just her physical beauty; I admired her intelligence, her kindness, her discipline, her many talents.

I still admire her. But after twenty plus years of marriage, I have to admit that the intelligence- discipline thing sometimes gets on my nerves.

Conservation vs. Comfort

Ann has tendencies towards frugality that do honor to her Scottish heritage. She also endeavors to be environmentally aware. These two qualities are evinced in the temperature settings Ann prefers for the household thermostat. During the hot Georgia summer the air conditioning is set at 85. During the cold of winter the heat is set at 60. In January when I am cold, Ann tells me to put on a sweater. In July when I am hot, Ann tells me to take my sweater off.

It’s been a hot humid summer. So yesterday when Ann wasn’t looking, I snuck like a ninja to the thermostat and deftly dropped the temperature five degrees.

It didn’t take Ann long to notice. “Who turned the air conditioning so low, Michael?”

“Those kids,” I responded, shaking my head disapprovingly. I was not lying. I was simply making a declarative statement designed to misdirect.

“The boys told me they didn’t touch the thermostat, Michael.”

“Those kids,” I repeated, shaking my head disapprovingly.

Ann laughed and moved the thermostat back to “where it belongs.” I didn’t argue. I understand her perspective: why burn fossil fuels to lower the temperature of my house so I am a tad bit more comfortable? But frankly, this thermostat thing can be annoying. I feel like I’m married to Al Gore, and every time I touch the temperature control it’s like I’ve sunk an axe in the trunk of the Earth’s last giant redwood.

The Thermostat Battle, Redefined

Over the years, Ann has also successfully colored “our thermostat decision” in what can only be called spiritual terms. With tactful language she has artfully conveyed to me sophisticated thoughts about the needs of the body versus the needs of the soul. I am not smart enough to fully comprehend exactly what she has said, but essentially her argument boils down to this:

Jesus didn’t have air conditioning, Michael, so why don’t you spend more time praying and less time whining?

Last month, Ann left town to visit her sister. It was like Dorothy’s house just plopped down in Oz on you-know-who. I ran to the thermostat like an unsupervised teenager and lowered it not five degrees, but ten. I was going to get all the air conditioning that compressor could muster. That night my house was so cold I needed another blanket from the closet. Immobilized by comforters, I slept like it was the dead of winter.

Condensation covered all my windows in the morning. I shivered when I sat down by myself to my morning coffee. Now this is what July in Georgia should feel like! I thought about getting out that dang sweater. Maybe I should light a fire too?

But after some reflection, I simply turned the air conditioning off. I missed Ann. Morning coffee is more fun with her. I remembered it’s far better to have a home that is too hot in the summer and too cold in the winter, than to suffer again through the fires and chills of a long distance relationship.

A good prescription for a healthy marriage is an occasional few days apart. Truly, absence softens the disagreements – and reminds us of the love.

-Dr. Mike Litrel

June 12, 2011

rock-bottom blog

Like the stock market, my days in residency training in Atlanta’s Grady Hospital were a string of ups and downs—some ups, but many more downs. At Grady it was usually a bear market. Medicine and surgery supplied the highs, but the suffering of the patients at Grady sometimes imparted the feeling of a crash.

Grady Hospital has always been the last refuge of Atlanta’s sickest and poorest residents. It was founded in 1892 as a charity hospital, with 110 beds—ten for paying patients, 100 for charity. In the span of a century it has grown into the mammoth institution it is today, serving over 750,000 patients a year. The bulk of its never-ending work is ground out, day after day, by the physicians in the residency programs of Atlanta’s great medical school, the School of Medicine at Emory University. The school’s young resident physicians are baptized each year in the torrential flood of the indigent, the drug addicted, the abused, and the homeless.

Like every other resident, I was baptized, too. I’ll never forget a homeless cocaine addict who had been in the hospital six weeks when I met her. Beaten and raped by multiple attackers, she’d been found half buried in a parking lot behind a crack house. Thinking she was dead, her attackers had tried to conceal her body. The police report estimated she had been buried for two days. When I first saw her, over a month after her attack, she still had fragments of gravel imbedded in her skin.

I was called in to consult when her pregnancy test came back positive. She had stabilized from her injuries, but her eyes were empty, as though something inside her had died. But the ultrasound showed that something inside her was very much alive—a fetus the size of a fingertip, its heart beating rapidly. I took an extra photo for the patient. She looked at it with apathy. As I was leaving the room, I saw she’d dropped it on the floor. I didn’t bother picking it up.

It had been three years since I’d delivered my first baby as a third year medical student. Two years of intense textbook training had ended, and finally I was caring for patients. The pinnacle of that wonderful year came the moment I delivered my first baby. I looked down at the new life I held in my hands, and I knew in that instant that I wanted to be an obstetrician.

No one seemed more deserving of care than mothers-to-be and helpless babies waiting to be born. Birth was one of the rare happy events at the hospital, and in those intoxicating years as I finished up medical school, the hospital became for me a holy place. Here came people in need, searching for help, and here gathered the nurses and physicians and medical staff, all working together, dedicated to the high purpose of healing all those who arrived at the hospital doors.

For those who seek healing, Grady is indeed holy ground.

But after a year of internship, the hospital didn’t seem so holy anymore. In that year alone, I delivered hundreds of babies, scrubbed on scores of operations, and treated thousands of patients. Little by little, my joy in witnessing the miracle of birth was diminished by the growing realization that many of the newborns I was delivering did not have promising futures. Sometimes it seemed that all those babies healthy enough to survive would be dropping out of school in fifteen years, having or fathering their own babies, going on welfare, and getting addicted to drugs.

Treating patients at Grady was like trying to hold back the tide. No matter what you did or how hard you tried, patient after patient continuously washed up on Grady’s shore. As I fought to save the patients, I myself was beginning to drown. By the time I met that rape victim, I had treated more than five dozen rape victims in that year alone. I had come to believe that God had abandoned our hospital for places with more promise.

It was toward the end of my second year of residency that He sent me a lifeboat.

I was seeing patients in the post partum clinic when a young mother wheeled her baby into my office. Her bright smile lit up the room. She looked too healthy to lay claim to the medical chart with her name on it: it was thick as a telephone book.

I flipped to her “footprint” sheet, dated twenty years before, the day she was born. She had been coming to Grady her entire life. I waded through the sheaves of paper until I came to the most recent year. A long stay in intensive care accounted for the thickness. Suddenly I realized that I knew her. She was that patient—the patient who had been brutalized and buried alive. I flipped through the rest of her chart in astonishment that this healthy-looking young woman was the girl with the dead eyes. Sure enough, there was the ultrasound photo I’d taken almost a year ago.

Her smile broadened at my expressions of shock. She told me about her life. The youngest of seven children, all with different fathers, she grew up in a series of foster homes. She ran away at fifteen, living on the streets, prostituting herself for money. She remembered only some parts of her attack, her assailants throwing her into a hole and covering her with dirt. The next thing she remembered was the moment she awakened at Grady Hospital a month later. But things had changed since then, she said. She was off drugs; she was getting her G.E.D. And she was happy.

How did this happen?

She pulled a creased photo from her wallet and handed it to me, eager to share her secret. “This saved my life. When I looked at this, I just knew that no matter what I done, God loved me.”

It was the ultrasound photo.

She cradled her baby like a treasure in her arms. She looked down at her daughter and cooed, playing with the pink ribbon in the little girl’s hair. “I am… a Mother.” Her voice cracked on the word “Mother.” It was her answer to everything that had come before. She had given life to a newborn, and her newborn had given life back to her.

All of a sudden the Sacred entered the room, the Holy returned to the hospital. What was this sensation I was feeling? It was Hope, it was Faith, and it felt wonderful. I knew then that I would survive. I would be grateful again to be a physician in this privileged place.

When she got up to leave, the proud mother hugged me. “Guess my baby’s name,” she said, smiling expectantly. She held the infant up so I could see her soft brown eyes and curls. This was the face of Hope, and yet also a daily reminder of her suffering, the rock bottom of her life—the offspring of a brutal attack.

I couldn’t just guess, so I waited patiently until she finally relented. Her eyes glowed with a light I will never forget.

“Miracle. I named my baby Miracle.”

-Dr. Mike Litrel

March 12, 2011

A Cancer Operation

The operation has lasted three hours and is perhaps at its halfway point. The scrub technicians can rotate in and out as they tire. I watch a scrub tech named Josh arrive to take the place of Cathy. Cathy possesses a quiet competence, a pleasant smile – and has laughed at all my jokes. As far as I’m concerned, Josh can only be a poor substitute.

Dr. Boveri bends over the patient, continuing the precise work of cutting and dissecting. As first assistant, I provide exposure, lifting and pulling aside muscles, ligaments and other structures so Dr. Boveri can see what he is doing. I work as Dr. Boveri’s assistant for the pure pleasure of learning. As an impatient resident under his training at Emory University, I once found the intensity of this Harvard-trained surgeon annoying. Ten years later, I pass my sickest patients into his skilled hands and regard his intensity as a miracle, and a gift to my patients.

Josh, the new scrub tech, seems to think his job includes keeping up the chatter in the O.R., especially, it appears to me, during critical moments of the operation, when a slip of the knife could unleash a life-threatening gusher of blood.

Did you see the game last night? You know, Dr. Snow always prefers the other kind of clamp. Whoa! Can you believe how many worms they ate on Fear Factor?

Dr. Boveri ignores the chatter. A surgeon’s preferred language is one of action. His eyes carefully trace the fingers of cancer that have groped their way through my patient’s intestines. Working together we pry away the malignant flesh, piece by piece, reaching deeper and deeper into the body until we penetrate the abdomen to the cancer’s very source. We are deep inside the pelvis.

Dr. Boveri leans forward almost imperceptibly, as the surgery reaches the zenith of its difficulty. He places a sponge over a portion of bleeding tumor and pauses in his dissection.

Cancer is cellular growth gone amok, a raging fire that spreads through the body, burning nutrients and consuming flesh in its path. The cancer before us has obscured the boundaries between uterus, ovary, and rectum, binding them together in an unnatural mass of biological concrete. Dr. Boveri uncovers a chunk of tumor that seals the space between appendix and external iliac vein. He gently probes the vein. Its thin walls channel the surge of blood returning from leg to heart. Methodically, relentlessly, Dr. Boveri works to liberate the vessel, separating healthy from unhealthy tissue, cutting flesh to save a life. After forty minutes, the tumor is gone, and the vein is free. It is a master performance.

Josh, however, is not to be outdone. As he receives the piece of malignant flesh from Dr. Boveri, he notches up his monologue, in a self-appointed role as court jester. For much of the operation, words have run from his mouth like water from an overflowing toilet. Now he reaches for his finest moments. Who do you think is the hottest on Desperate Housewives? Hey, what is this? Is it tumor? What do I do with it?

“It’s cancer. Put it in the basin,” Dr. Boveri says.

Two minutes later: What is this? Wow, this is something. Same thing? Put this in the basin too?

Dr. Boveri gestures toward the basin.

Five minutes later, Josh launches into a reprisal. Is this cancer too, he begins.

Dr. Boveri explodes. “What do you THINK it is, Josh?!!” He struggles visibly for self mastery, and can be heard to mutter, tuna fish sandwich?

He takes a deep breath, the furrows in his brow subsiding as he regains his equilibrium. A surgeon reveres self-control above almost every other virtue, and I suspect his outburst bothers him more than it does anyone else. But at least it has the desired effect – Josh keeps his mouth shut.

As the operation nears its sixth and probably final hour, a quiet, smiling Cathy returns to the operating room. Dr. Boveri interrupts his work to thank Josh as he leaves the table, but it is not until Josh is completely gone, having scrubbed out and exited the room, that the surgeon finally allows himself the luxury of full expression.

“Cathy,” he grimaces, “we are SO glad you’re back.”

Dr. Boveri is a surgical oncologist affiliated with Cherokee Women’s Health. He and Dr. Litrel work in an integrated group with nutritionists, geneticists, molecular biologists, chiropractors, naturopathic doctors and others, including patients, to develop better models for health, and to help prevent cancer from occurring.

-Dr. Mike Litrel

celestial-discharge

Three painful months of my twelve month internship in Obstetrics and Gynecology were spent on the General Medicine Wards at Grady Memorial Hospital. Even the Internal Medicine residents – who actually belonged there – hated working the Grady Wards. The hours were long, the patients were sick, and it was a chronic frustration trying to get anything done within the hospital bureaucracy. The typical OB/GYN resident, taken away from Labor and Delivery and the O.R., hated it even more.

I was pretty typical.

So I couldn’t help but sulk as I received a sign-out from the Internal Medicine intern whose patients I was taking over. He handed me a stack of cards, each detailing a patient’s history and their clinical course. As he approached the bottom of the deck, his smile grew bigger and bigger, threatening to explode off of his face. His Grady month was over. Hurray! Hurray! Hurray!

I felt like punching him in the nose.

The last patient signed out to me was a man in his mid-thirties dying from AIDS. His history was detailed on three separate cards, each written in the hand of a different doctor. The man was a “rock,” the intern remarked. “Rock” was Grady vernacular for a patient you couldn’t get off your service. His medical problems were too chronic for him to get better, and too serious for him to be discharged. The Grady Wards were full of rocks. They ate up your time, and emptied you of hope.

I was the fourth doctor assigned to this man’s care. For more than two months, the Intern explained, they had been waiting for his “celestial discharge” – medical slang for death. I hadn’t heard the expression since I’d first been on the Wards as a third year medical student. The intern under whom I had worked at the time was a particularly charismatic person, who camouflaged his compassion with a macabre sense of humor. Whenever a difficult “rock” died, he would slowly kiss his first two fingers and ceremoniously lay them on the patient’s card. “The Kiss of Death,” he’d solemnly announce. Then he’d rip up the card, toss the pieces into the garbage, and cheerfully declare, “Another celestial discharge!”

His antics were unprofessional. But it hurts, taking care of dying people. And sometimes his humor was sadly needed.

Still, I didn’t relish the idea of becoming a jaded intern with a well-developed sense of humor. Clutching the stack of worn cards that represented my new patients, I made my way around the Wards, saving the AIDS patient for last. As an intern simply passing through for a month, I wondered what I could possibly do for him – and how I would get around his nurses.

Most of the nurses at Grady Hospital were more than adequate, some simply superb. Nurses tend to be the kindest and most compassionate people you will ever meet. But still, a seasoned Grady ward nurse with decades of experience in the trenches is not about to take orders from an intern still wet behind the ears. So I wasn’t surprised when his nurse refused to locate the patient’s chart. Not being one of the more compassionate ones, she said simply that she was busy. And besides, her fingernail polish hadn’t dried yet.

I found the chart on my own and saw the patient.

He looked like a concentration camp victim, emaciated beyond reason. Curled up in a fetal position and too weak to answer my knock, he nodded when I introduced myself. His mouth was parched, and his voice was too soft to hear, and his eyes almost empty of life.

I sat by his bedside and read his chart. It was a telephone book of illness and suffering. His most recent problem was a herpes lesion on his backside, for which he was on intravenous antiviral medication, in addition to the multiple medications that were part of the AIDS cocktail. Reluctantly he agreed to let me see it.

He gasped in pain as I tried to open his diaper. Very slowly I pulled it back. He wept dry tears in his agony, his body shaking. I held his dry bony hand in mine. His long yellowed fingernails dug weakly in my palm, and I squeezed back in a futile effort to provide comfort.

My jaw dropped in surprise at what I saw. A sore larger than a record album covered his entire backside. Bright red with a white border, it resembled a giant cold sore – but it covered twenty percent of his body.

The day I had started internship, dressed in my new white jacket embroidered with my name on the pocket, I had stared at myself proudly in the mirror, convinced I was going to be the best doctor there ever was. In the months afterward, I had strived always for the highest degree of professionalism – how best to present myself to my patients, the nurses, and other doctors so I was worthy of their admiration.

I was full of myself.

But staring at that man’s bottom, all my aspirations of being professional crumbled. I had no idea what to say to this human being. I had no idea what to do. His physical agony was beyond reason.

And he was abandoned. Not a single human being had visited him during his entire stay. He had contracted a disease through sexual relations or intravenous dug abuse, and now he was all alone. Part of me wished that he somehow deserved it, that maybe it was a just punishment for his life style. It would make me feel better. But as I stared at his ulcer for a long while I knew for certain no one deserved what he was enduring. I wanted to be a good doctor and help this man. But my mind was blank.

Finally I heard myself speak. “I am so sorry…I have no idea what to do for you… No one should suffer as much as you are.” I felt his hand weakly squeeze mine. I was surprised to see a look of gratitude in his eyes. I had to lean down close to hear what he said next.

He was asking for pain medication. Of course, I assured him. Back at the nurse’s station I read through his medication list. No pain medications had been ordered during his entire hospitalization, by any of the exhausted residents rotating through. I was infuriated. At least we could help his pain! But his nurse shrugged her shoulders. He’d never asked for anything, she told me apathetically.

I wrote for morphine and hovered over the nurse to make sure the medicine was pulled. I reassured my patient I would see him first thing in the morning. I was not going to neglect him like the previous intern had.

He died in the night.

And when I found out the next morning I was grateful.

That was more than a decade ago, and since that time tens of thousands of patients have come under my care. But in my mind’s eye, I still see this patient clearly, feel his bony fingers with nails like claws in the palm of my hand. Nagging feelings percolate among the memories, and I fight away guilt about the timing of his death. For the hundredth time I ask the questions: Why did he linger so long? And why, under my care, did he die?

And at last, the other day, an answer unfolds in my thoughts.

Maybe he had just been waiting for a friend.

-Dr. Mike Litrel

turtle-story-272h

Despite its lifetime warranty my bathroom scale is broken. No matter how many times, or how gingerly I step on it, it keeps telling me I weigh more than I do. Also, my clothes are all shrinking, despite labels which clearly state they are machine wash-and-wear.

My problem is not weight gain. It’s defective merchandise.

Okay, the concept of weight loss is not that difficult, just challenging. Eat less, exercise more. What could be so difficult? All I want now is to get back down to what I said I’d never get up to. So this past Father’s Day I decided to forgo the “all-the-donuts-I-can-eat” tradition and work out in the basement.

Father’s Day Challenge #1: Health

Years ago I made the unfortunate discovery about myself that I am less the natural athlete and more a natural couch potato. Thus I have developed my well-known personal interior decorating philosophy, which involves surrounding any and all television sets in the house with exercise equipment.

My Schwinn Recumbent Cycle is the best piece of exercise equipment I own. The workout itself is not spectacular, But it’s very comfortable to sit in, and perfect for watching television. It’s like a lounge chair with pedals.

So on the morning of my seventh Father’s Day, with the boys I love beside me, I began my First Annual Father’s Day Workout. Out of respect for the widely accepted traditions of fathers’ birthrights, I also commandeered the television remote. I chose something we could all enjoy – the CNN News Update.

Regardless of Father’s Day tradition, it wasn’t long before Tyler and Joseph, sprawled on the floor in front of the screen, were complaining about my God-given right to choose the TV show. I capitulated and switched to the Cartoon Network, which was broadcasting some inane piece of animation I’d never heard of. Evidently the boys must have found it boring, too, because pretty soon they were arguing so loudly that the character dialogue was moot.

My kids have me at a disadvantage when I’m working out, and they know it. When my breath gets short, I can’t yell at them so loud. Also, there’s always the chance that if I get up to discipline them and interrupt the workout, that will be the end of it. But this time the combat escalated to the point where I had to actually get off the bike to bring them into line. Which brings me to something ironic….

Father’s Day Challenge #2: Children
I think it was George Bernard Shaw who said, “Never hit a child – except in anger.” Having gotten up, I was angry all right, angry enough to threaten bodily harm. But I’m not a fan of corporal punishment. My parents, if not big fans, were at least mildly enthusiastic camp followers. Back in those days, my father didn’t own any exercise equipment, so I think his major cardiovascular workouts consisted of the time he spent spanking my bottom.

Ann and I don’t rule out spankings entirely, but more often we fall into the “Time Out” philosophy of our generation. In a burst of enthusiasm for parenting during the first six months of Tyler’s life, we listened to numerous tapes of experts with “parenting” advice. The main piece of wisdom we acquired from the hours we spent listening to these experts was the location of the perfect place in the house for “time out” — the bathroom.

According to the experts, the bathroom is the most boring room in the house, the perfect place for quiet reflection. I suspect this to be true, because despite the inevitable first few minutes when my boys seize the opportunity of bathroom confinement to take care of essential bodily functions, they soon lapse into the crying and complaining that let us know the deterrent is working.

Regardless of whether it works, it’s strangely satisfying. As I closed the bathroom door on my battling boys, a warm feeling came over me. Maybe I should have put them in separate bathrooms. But that particular nuance was not covered in the parenting tapes, and it’s easier to put them both in the closest one. After a while they seemed to quiet down into the appropriate reflective mood, so I let them out and resumed my workout.

In a familiar routine which constitutes the classic defense for corporal punishment, Tyler and Joseph soon launched into another argument, which unfortunately coincided with my noticing that the pulleys on my Joe Weider weight set were broken again.

That did it. I turned off the TV. “Stand up!” I ordered my boys. My face was dripping with perspiration, my teeth clenched in anger.

“How many times do I have to tell you not to play on my weight set?” I demanded.

It was a rhetorical question, but Joseph, my four-year-old, took me literally. “A million times,” he replied meekly. “You have to tell us a million times.”

I smothered a smile and kicked them both out into the back yard. My decision was final. This Father’s Day, I wanted to spend my time as far away as possible from the two people who had made me a father. I told them in no uncertain terms not to interrupt my workout again – unless it was an emergency.

Fifteen minutes later, Joseph came running into the basement. “It’s an emergency, it’s an emergency!” He pulled me into the back yard, and there, away at the bottom of the hill, were the bodies of Tyler and his friend Sami Leonard, lying prone on the ground. They didn’t appear to be moving.

I fought my instinct to run down the hill. This was something you learn as a medical student at Grady Hospital. One night as I was urgently wheeling a gunshot victim toward the O.R., a surgical resident flagged me down. “Don’t rush when you are in a hurry,” I remember him saying.

When I got to the bottom of the hill, I saw that the boys were not injured or unconscious, but simply lying on the ground talking to each other and looking at something. Their faces shone with wonder. They had found a turtle.

Challenge #3: Life’s Interruptions

“A turtle does NOT constitute an emergency,” I told them. They disagreed. The turtle needed water or it would die.

Miffed at another interruption, I still noticed how excited they were over their discovery of a turtle – a memorable event in the life of a child, unexpected, but not to be ignored. I studied it with them for a couple of minutes before advising them, for the turtle’s sake, to send it on its way. As I turned to leave, Sami whispered conspiratorially to Tyler. They turned to me, they wanted something, but were hesitant to ask. Tyler mustered up his courage: “Can you write a story about this?”

“What?”

Sami was more enthusiastic. “Can you write a story about us finding the turtle and include all our names, including our last names?” asked Sami Leonard. That’s Leonard, L-E-O-N-A-R-D.

No way! was my first thought. But their faces shone with such hope I couldn’t say no. They cheered wildly when I acquiesced. The day had deteriorated into one long string of dead ends, irritations and interruptions. It was not inspiring material.

But as I surrendered any intention of completing my workout, and sat down to try and put this all into perspective, I began remembering. It was seven years ago that we discovered Ann’s unexpected first pregnancy. I brought her to Grady for an ultrasound. There in her uterus was a fetus smaller than a fingernail, the beginnings of my son Tyler, his fluttering heartbeat almost imperceptible. And although I was a physician specializing in obstetrics, the miracle suddenly had arrived in my own life.

For the past seven years, I have watched my children grow and become individuals, God’s works in progress. And occasionally, in watching them, I chance to remember everything that I have ever known to be true: That what we call the challenges of life, often unpleasant, are its gifts as well.

God sent the turtle. The boys saw the gift right away. It took me a little longer, but I finally got it.

-Dr. Mike Litrel

Disappointing-Tumor

I once removed a tumor that weighed nine pounds and twelve ounces. Before the operation I had told my patient that the mass on her ovary was at least ten pounds. So I was four ounces shy – and very disappointed.

I asked Diane, the operating room nurse, to weigh it again, stressing to her that my expectation had been that the tumor be at least a ten pounder.

“I’m sorry, Dr. Litrel – it weighs the exact same,” Diane assured me in her sweet southern voice. Diane is quiet and competent – one of my favorites – but her answer was annoying and I told her so.

“Why couldn’t you just have said it was ten pounds!?” I asked incredulously. “It wouldn’t make any difference and I’d feel so much better!”

Diane laughed like I was joking, and I joined in. But maybe I was serious. You see, surgeons can be megalomaniacs. Or at least this one can. And occasionally they don’t mind saying things like, “you should have seen the size of that incision,” or, “this morning I took out a ten pounder.” It’s a chest beating thing.

But despite the four ounce shortfall, there was wonderful news, too, and much more important. Not a drop of cancer. The capsule of the tumor was smooth and glistening, unlike the surface of a malignant mass. In a few places it had become stuck to my patient’s intestines. But once the scar tissue had been cut, the large mass lifted easily and cleanly out of her body. And the patient was ten pounds lighter.

Well, almost.

The incision was more than a foot long, spread wide open by the retractor. Anywhere but in the operating room, this would have been a mortal wound. But here it was bloodless, opened layer by layer in a clean surgery. We had entered her abdominal cavity and removed the source of her pain. My patient would quickly recover. And she would no longer suffer from this tumor.

Pain was the reason she had first come to my office. Her family practitioner had been treating her “menstrual pain” with stronger and stronger medications. She had finally appeared in my office because the medication wasn’t “holding her,” and she wanted a stronger pill.

She hadn’t known about the tumor.

Another patient, Pamela, visited that day and also wanted a pill to make her feel better. Her pain was even worse. But unfortunately, there was no tumor to account for it. In the end, it’s the lucky patient who has a tumor. Once the tumor is removed, the pain comes to an end.

Since having her children over the past ten years, my patient Pamela had become increasingly depressed. She found herself turning forty, with a weight problem, low sex drive, and a profound sense of disappointment. Somehow life had not turned out as she once had imagined it. The long stretch of middle age ahead seemed barren of hope. Over the years, she had received treatment from several different physicians. Antidepressants had once helped her improve her mood, forget her suffering, and feel better about her life. But by and large, the years had brought no change, no new purpose, and finally, no hope of ever feeling really good. She had just seen a television commercial featuring a vibrant woman advocating the latest and greatest antidepressant. Maybe that was the pill for her, she said to me.

No where in the anatomy textbooks I studied in medical school will you find a description of the soul. Yet the soul exists, just the same. And as the years go by, I see in my patients with more and more certainty: the process of life is biological – but its purpose is spiritual. We are not human beings with spiritual problems – we are spiritual beings with human problems.

The disappointing tumor is the one that cannot be seen, cannot be cut out. I suspect that Pamela has a tumor on her soul. She can cover up the pain with medication, just as my first patient was masking the evidence of her tumor with stronger medicine. But this will not mean the tumor is not there. For Pamela I can prescribe pain medication, sleeping pills, or antidepressants. Or she can self prescribe in the usual ways – overeating or drinking.

The more difficult but effective task is to locate the tumor on her soul. God puts suffering in our lives for a reason. Just as He has given us pain to signal a physical problem, depression can signal that there is dire spiritual work that needs to be done.

My own drug of choice has always been food – sweets, in particular. In times of stress or upset, I have been guilty of imbibing a box of chocolate glazed or cream filled delights, a half dozen at a time. I quote one of my all time idols, Homer Simpson, when I say: “Mmmmmm… dohhhhnuts…Is there ANYTHING they can’t do?”

In the end, though, that box of delights with ten thousand calories actually contributes more to my problems than it solves them. And the source of my suffering remains unexamined, untreated.

Not all suffering is in vain. God has created us with the capacity to suffer, so that we will know when there is sickness in our spiritual lives. What is the spiritual work that Pamela needs? Only she can figure that out for herself. Prayer and counseling can be part of the surgery to remove it.

But if she does not examine the source of that pain, she risks its growing presence for the rest of her life. She will continue to find her life disappointing.

And who wants to be disappointed?

-Dr. Mike Litrel

Look-what-I-did-honey

I usually ask the father to cut the umbilical cord when he’s at the delivery. It’s not that I need the help. Rather, cutting the cord is an important symbolic event. An expectant woman becomes a mother, a family is born, hope wonderfully fulfilled.

But there’s another reason to involve the father. Fathers can be pretty useless at times like this. Women understand this sad fact but for the most part keep it secret from us men. A man’s ego is a fragile thing. We’ve convinced ourselves we’re strong and smart and in command. But as we bear witness to the awesome struggle of a woman’s labor, even the most dim-witted of us begin to suspect something is up. The moment the baby is born and new life is miraculously brought forth, we begin to understand the errors of our thinking. It’s a life-changing experience – the realization of the true beauty of the mothers of our children.

We are humbled.

But we men don’t handle being humbled very well. We confuse humility with humiliation. A new mother’s life is difficult enough without having her husband’s damaged ego to nurse as well as her baby. With this in mind, I’ve found it useful to distract the husband with an accomplishment of his own so the mother’s postpartum course is not unduly burdened.

So, he gets to cut the cord.

Cutting the cord is technically less difficult than cutting coupons out of the Sunday paper. Most men realize this, and although very well satisfied with their small contribution, keep their self-congratulations to a minimum: “Sweetheart, with you carrying the baby for nine months, and all those painful contractions and pushing, and me cutting the cord so well, I think we both did a pretty good job.”

Yet the occasional father takes it to the extreme. “Look what I did, honey!” He looks to his wife, exhausted from her labor and blood loss, for approval. “Did you see me? I just cut the cord! By myself!” Chest swelled with pride and beer belly drooping over his belt, this is the kind of man who walks around for the next couple of decades completely self-satisfied with the thought “that thing would still be attached to you if it wasn’t for me.”

Some husbands, on the other hand, are appropriately appreciative.

One of these appreciative husbands came to my office with his wife every visit. They had already tried for several years without success to conceive and suffered tremendously from a sense of failure and loss of hope. They submitted to the usual battery of tests in the painstaking task of attempting to time the miracle of conception. After several months with no success, we were considering a reproductive endocrinologist but then out of the blue my patient conceived.

Throughout the next nine months, her husband was an unfailing source of support and encouragement. On the day of the delivery he was beside his wife, holding her hand, from the moment of her first contraction. “You are so beautiful!” he told her. “You are doing so well!” Throughout her long labor he rubbed her back, he hugged her, he got her sips of water. And again and again he repeated his mantra – “you are so beautiful, you are doing so well.”

Finally the baby emerged. The father’s hand trembled as he cut the cord, and when I placed the baby on the mother’s abdomen, he began to weep uncontrollably. I watched as he hugged his wife and newborn daughter, and at that moment, as the family began their new story, all the self-doubts and suffering of the past seemed to evaporate in an instant into an indescribable joy. It shone from their faces through their tears. And the room could hardly contain it.

“You are both so beautiful,” he told his family, his voice cracking.

Their past trials hadn’t darkened their happiness, but like a piercing light, had made their happiness more clear. Unlike the quick snip of a cord, with its illusion of accomplishment, the suffering they had borne for so long had opened their eyes, so they could see their child for the miracle she was.

I think this is true for all of us. The burden of pain that accompanies us throughout our lives can sometimes be life’s most mysterious gift as well. It strengthens our vision, so we can recognize the miracle of joy that often waits for us, just on the other side of despair.

-Dr. Mike Litrel

February 12, 2011

rock-bottom blog

Last week in a Labor and Delivery Suite with my patient Tina, I watched her five year old boy stay glued to the television, while his mother went through all the travails of labor in the bed just behind him. He seemed oblivious to the fact his younger sibling was about to appear in the world, and that his mother was in unbelievable pain.

The show he was watching: Sponge Bob Square Pants.

For the uninitiated, Sponge Bob is a cartoon sponge who wears, well – square pants. He lives in an undersea community with his fellow invertebrates. In this particular episode, Sponge Bob was being threatened by a bully. Quivering with fear, Sponge Bob closed his eyes in expectant terror. But when the bully’s blow came, Sponge Bob – whose body is made of, well – sponge – didn’t feel a thing. The bully persisted in his futile and increasingly frantic efforts to inflict pain, punch after punch, until he finally passed out in exhaustion, while an untroubled Sponge Bob went about his normal daily activities. Tina’s son squealed with laughter.

Tina had another contraction. As it built up, she began to cry out in agony. The epidural wasn’t working too well. “This is my last pregnancy – I’ll never do this again – I can’t believe how much this hurts!” She had been complaining about a hot spot and was acutely tender on one side – it made her labor feel like a branding iron being applied. “I can’t stand this – why does it hurt so much this time?” she asked plaintively.

“Oh, you wanted an epidural on BOTH sides of your body?” I said in feigned confusion. It’s the kind of comment I’ll remember years later when I’m sitting by myself wondering why all my patients have stopped coming to see me. But Tina smiled halfheartedly at my joke, and the truth is, we both needed the distraction – she from the pain, and for myself to provide some objectivity in the face of the baby’s heart tracing – which showed that the baby was not happy.

Tina and I knew each other well. Three years ago, I had delivered her last baby after a perfect labor. By perfect I mean her baby’s heart rate was reassuring throughout, and that Tina was never in significant pain. In the early hours of the morning, she delivered her baby without making a sound, in fact, not even rousing her family, all dead asleep around her in the room.

Tina hadn’t wanted to awaken anyone. She smiled mischievously, like a child opening Christmas presents without permission. When I protested that at least a family member should cut the cord, she volunteered. So I handed her the scissors and for the first – and only – time, had the mother cut her own umbilical cord.

It was a beautiful baby boy, with an angelic face. Looking into those clear eyes was like peering through a window into the heart of God. He began to cry softly, awakening his startled family, and it seemed the perfect beginning to a beautiful young life.

Ten days later, he died.

An infection was listed as the final cause on his death certificate, but Tina’s son died of a broken heart. His heart was made wrong. It’s called Transposition of the Great Vessels – the large blood vessels are connected to the wrong heart chambers. Throughout Tina’s pregnancy and labor, there had been no indication that anything was wrong. But after her little boy was born and had to rely on his own body, not hers, for survival, the secret of his broken heart was revealed. He never really became vigorous.

He was transferred to Eggleston Children’s Hospital for a corrective surgery called a switch procedure – the aorta and vena cava are disconnected from the heart and the vessels switched around. It sounds complicated, and it is. But in the hands of an expert pediatric cardiothoracic surgeon, nine out of ten babies survive. But one does not.

Losing a child can shatter a mother’s life and often does: emptying her soul of joy for the rest of her years. And certainly, Tina was devastated at the loss of her son. But in the coming months, she arose from her depression, bearing witness to the unbroken clarity of her faith. I don’t know why some people attain spiritual courage; as I watched her fight her way through her grief, I was filled with admiration, and perhaps a bit of fear – that when my time comes, I may not be so brave.

We don’t have a choice about how God makes our bodies; we cannot choose the physical framework of our heart. But we are free to choose its spiritual makeup. My patient chose to trust God – both the pain and the joy that He had given her. I have seen many others fixate only on their suffering, walking through the rest of their lives like the victim of a violent crime, jumping fearfully at every noise.

I jumped fearfully when a year later Tina’s pregnancy test was positive. For nine months I hardly let her out my sight. Ultrasound after ultrasound revealed a perfect heart inside her baby. But the memory of her loss still terrified me. So for forty weeks she had one uptight doctor, and now that she was in labor and the baby’s heart rate was less than perfect, she had to put up with my feeble jokes about her epidural.

I helped pull out her baby – another angelic boy. As his strong cry filled the room, I knew that not only the mother, but the child, too, was blessed with a strong healthy heart.

Later while I filled out the paperwork, her five year old lost interest in the miracle of birth and turned once again to the television set. It was another episode of Sponge Bob Square Pants. The boy’s laughter filled the room at the antics of this goofball character.

I thought about Tina’s second child and her emotional trauma, and of her third and the pain of the labor. It would be useful to be like Sponge Bob – made of sponge and impervious to all pain, taking punch after punch from life with an oblivious smile on one’s face.

The worst blow of all is grief. But when we extend our hearts in love, we don’t just risk terrible suffering – we guarantee it. Our time here together will end. But whether we are here ten days or ten decades, our life on Earth is a mere moment when held up to eternity. Yes, the body is mortal, but the soul lives on. So as frightening as it is to love, to risk loss and the terrible face of grief, it is the only choice. And when you choose faith, only then, will you hear the immortal heartbeat of the soul.

-Dr. Mike Litrel

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