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VOICEOVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Welcome back to Central Line. I'm Adam Striker, your editor and host, and today, I'm joined by Dr. Tammy Euliano, Anesthesiology Professor at University of Florida and new author. Dr. Euliano’s debut novel, Fatal Intent, came out in March. Welcome to the show, Dr. Euliano.

DR. TAMMY EULIANO:

Thank you for having me.

DR. STRIKER:

Well, before we get into the novel, let's tell our listeners a little bit about your background as an anesthesiologist, if you don't mind.

DR. EULIANO:

Well, I did all my training at the University of Florida all the way from undergrad, medical school, my anesthesia residency, and then I did an OB anesthesia fellowship. And then I've been on faculty there since 1996 and originally started mostly doing medical student teaching and working on the full-scale patient simulator that we invented there. And then I progressed to being Residency Program Director and doing a lot of administrative stuff and then eventually made full Professor from doing some research on maternal fetal monitoring and preeclampsia and then started this encore career.

DR. STRIKER:

Ok, well, that's what I wanted to delve into today, because I think that's fascinating, I think, to a lot of us. Why don't you start out telling me how you got into writing what the (sic) was? How long have you thought about it? And just take us through a little bit of, of your process as, as you've got to this point.

DR. EULIANO:

Well, I recently was given a box of childhood memories from my parents' attic in which I was apparently quite the author when I was about five, about a ladybug and a lion, apparently. But I lost that interest for a, a good 30 or 40 years.

When I was teaching the medical students, I went to my mentor, who was Dr. JS Gravenstein, who, who many of your listeners might remember. And I said, gosh, we really don't have a good book for me to use to teach the medical students. And he said, hey, let's write one. So he and I wrote an introductory text for medical students called Essential Anesthesia. And then when we finished it, we both were having such a great time working together, he said, why don't we write a, a fiction novel? So we started, but then he fell ill and passed away, and from there I just couldn't stop. And so the ideas for Fatal Intent had sort of been brewing in my head since medical school. And I took a couple of classes, realized I didn't know anything about writing fiction, even though I had read it and just got really fascinated by a whole new venture.

DR. STRIKER:

Well, let's talk a little bit about the book, Fatal Intent. Can you give us a quick overview?

DR. EULIANO:

So believe it or not, it's about an anesthesiologist, a female anesthesiologist, no doubt. And it's really about her uncovering some patient deaths that occur after she's anesthetized elderly patients for minor operations. And gradually she puts together the fact that there is a mercy killer for hire and through many thrilling events, discovers who it is and tracks him down as he's about to use her husband, who's been in a persistent vegetative state, as his next victim.

DR. STRIKER:

How did you arrive at the thriller concept? Many of us love thrillers, mysteries. What made you decide on that genre as opposed to some other fictional modality?

DR. EULIANO:

Oh, probably the same, I really enjoy reading those and I started writing it, it didn't have a tremendous thriller. It was more of a mystery. And then I went to a writers meeting and ended up going to one in New York City called Thriller Fest. And I had the incredible fortune to meet some of the best thriller writers out there and ended up learning a lot from them and realized that I really needed to make it a more, sort of danger for the protagonist toward the end to keep people riveted. And now I'm, I'm really sold on it. It's very fun to put people in peril and hopefully bring them back out of it, not in my day job, but in my writing job.

DR. STRIKER:

Now, I know the book grapples with end of life questions. Is that intentional and if so, why did you choose that?

DR. EULIANO:

It is. During medical school, I had an interest in it and, and God knows why, I, I had a grandmother who was suffering dementia and, and I saw what it did to my parents. But through my ICU rotations, it was just very interesting to me the, the decision making process toward the end of life, and as I grew and became more mature, it became much less black and white. And so the idea of bringing up controversial topics and presenting it from all the different sides has, has become fascinating to me. Another novel that I've written is about reproductive rights and, and who should make decisions regarding who can reproduce, if you had a society that came to that, where it wasn't a decision to stop fertility, but a decision to choose fertility. So I, I just really enjoy the, the mental exercise of trying to, to grapple with these issues.

DR. STRIKER:

Well, I know, we're all familiar with how anesthesia in entertainment has been portrayed over the years. And I think overall, although there are some pockets of accuracy and work that does a complementary job of anesthesiologists, I feel that, you know, for the most part the job of the anesthesiologist has not been done justice in fiction or entertainment. Do you feel, in this book, that you were able to, perhaps do more justice to the role and the importance of the anesthesiologist?

DR. EULIANO:

That was certainly one of my goals. The only books I've read that seem to accurately represent anesthesia, Carol Cassella wrote a book called Oxygen. She's a pediatric anesthesiologist at University of Washington. And, and it, it really fascinated me with the way she described what we do. And, and you're right, the general public really has either a lack of understanding of what we do or a complete misperception based on E.R. and other shows. I watched that Grey's Anatomy scene where the anesthesiologist hands the bag to somebody so that he can leave and avoid the bomb. It's a, it's, kind of shameful. And even other physicians, I think, in, in large parts don't understand what we do. And so, yes, I tried with this book to better exemplify what our role is without going into so much detail that it sort of gets self-serving.

DR. STRIKER:

Well, and did that present a challenge? You’re, you’re writing not to an audience of anesthesiologists, although many will read this, but to the public. How challenging was that to weave in medical terminology or situations that were accessible by the general public and to explain those things perhaps to people that aren't as familiar with what we do?

DR. EULIANO:

That is a, an interesting challenge as you write, and, and certainly something that the four thousand versions of this book would attest to how much difficulty I had figuring that out. But the plot device I used was to add somebody who doesn't know anything. So I would put a medical student in the room while my protagonist is explaining something to her resident so she can use appropriate terminology for talking to another doctor and then step back and explain it in more accessible language. I also have her aunt involved and she explains things to her aunt. But, you know, it's not at all realistic for a doctor to talk to a doctor and not use doctor terms. So there's certainly places where, where they're used. And then I just try to explain them elsewhere. But I've had some pretty hilarious reviews where people don't understand what a CRNA is or somebody thought it was a Certified Registered Research Assistant and thought the entire book was about a research assistant. So I obviously didn't do quite a good enough job.

DR. STRIKER:

Well, speaking of that, how does the editing process work in this regard? Like you, you write things and does the editor come back and say, listen, this, you know, I get what you're trying to do here, but you really need to shore this up, give us a little bit of sense of that dialogue or that, that give and take on how that works.

DR. EULIANO:

Well, it depends a little bit on, on your route to publication. So if you’re self-published, you just decide for yourself, I guess. I wrote it, sent it out to critique partners, so people that I met who were at a similar level to me or slightly above, you know, ahead of me in the writing process, had their comments. They were all non-physicians. Incorporated, whatever I agreed with that. And in my case, I ended up with a small publisher who happens to do a lot of medical books. So she didn't have quite as much to change as maybe would have occurred if I was with a traditional publisher, you know, one of the big four kind of publishers. But yeah, they make suggestions for where they think it's unclear or too specific, and then you decide whether you agree or disagree. But in the end, it's your book, which is, I think, an important point.

DR. STRIKER:

Do you have a process to get writing down on pages? Like I know some authors, they'll go into seclusion so that they can concentrate. Some pick at it here and there. I wanted to hear what your method was.

DR. EULIANO:

Well, my method on the four books I've written has been completely different on each of the four. But what's working for me right now is I have an enormous whiteboard in my office and I do sort of mind mapping and make a total mess of it and then erase things and try to undelete and realize, oops, this is not a computer I can't undelete. So I take pictures of it. And once I get a little bit of an idea of what's going to happen, then I sit down at my computer and start writing.

I started, one of the books, I started by writing the key scenes and I think that may have been my best plan. The one I'm writing now, I started on page one and, and page one has now changed a dozen times. So it's, everybody has a different plan. The first one I completely outlined every single scene and, and now I outline maybe three or four scenes. And when I get to that point, then I outline the next three or four. But it's really kind of fun how, you know, just like for anesthesia, you, there's a lot of different ways to approach a certain case and, and for writing, I think that's true, too. And you just trial and error until you figure out what works for you.

DR. STRIKER:

And getting back to the, the content of the book just a little bit, I imagine that your real life work as an anesthesiologist permeates in the book. Were there any scenes or situations specifically that arose from actual events?

DR. EULIANO:

There were. I am fortunate not to have lived the life of my protagonist, who has had some pretty bad things happen to her. But some of the events, for instance, there's a scene where she talks about an issue with a family where they are upset about the idea of turning off grandma's ventilator and they're confronting her about it. And that's based on an, an actual event that happened to me during medical school, or during my internship, when I was cross covering at night. And other scenes related to things that she and her husband discussed before he became comatose. But, yeah, I mean, you can't help but put in things that you've actually seen. There's a lost airway scene that is very similar to a lost airway scene that, that occurred to me, and also a loss of a baby that's very close to a scene that we had where we used an organization, it's actually a national organization that will, of professional photographers that will come in and take pictures of the family, and, and I talk about them and that scene.

DR. STRIKER:

Well, and you mention that the book focuses on some mysterious deaths of patients, and as you've alluded to, indeed, several of your main characters die in the first few pages. Can you talk a little bit about the psychology of losing a patient due to an unforeseen circumstance?

DR. EULIANO:

In this book, the patients are dying, not on the table, but, but days later and she sort of coincidentally learns of it, and that would be true in our careers, that if the patient doesn't die before our post-op note, we, we may not even know that they passed away, which is distinctly different from actually being in the operating room and having the patient die in front of you, which I fortunately have not experienced too very many times.

But losing a patient the way we do is, can be, very devastating. And I talk about that a little bit about how paralyzing it can be if you spend all, a lot of time rehashing every moment of the case. What if I'd done this differently? And so I talk about that becoming more of a teaching moment and present presentation at an M&M and a root cause analysis for everyone to learn from, as opposed to making you paralyzed with indecision the next time you end up in a situation.

But the, the loss of sleep, the, the nightmares, that's all real. And I, I try to bring that up because I think the public would be interested to know that that we don't just walk home from work or drive a Porsche home from work or whatever they envision and, and that it's gone from our minds that we really do live with this 24/7.

DR. STRIKER:

Absolutely. I mean, it's certainly a serious aspect of what we do and one that I'm glad you're brought to light just because it doesn't end for some time when something like that happens to an anesthesiologist or, I mean, to anyone in the hospital that has to deal with this, but especially with the unique set of circumstances that we deal with and second guessing and going back and losing sleep and trying to walk in the next day or even days or weeks later and questioning yourself and every decision. So I, I think that's, that's such an important concept to, to highlight and to, to everyone, not just anesthesiologists.

DR. EULIANO:

Right.

DR. STRIKER:

What did you think about portraying death? I know it's a thriller and I know that, that's part of the plot, but associating a number of deaths, you know, with a protagonist that's an anesthesiologist. Was there any concern about how the public might make that association not with this particular anesthesiologist, but with the specialty of anesthesiology or the act of undergoing anesthesia in general?

DR. EULIANO:

Yeah, I think that's a real concern, and, and I did debate about it a lot. I had one of my residency mentors read it and asked for his advice on, on whether I was portraying it without too much potential for backlash. And, and you're right, the possibility that this could actually happen, that an anesthesiologist or anesthesia provider could cause danger to patients. Well, it happens to be true. Gratefully, we are cautious and professional and, but similar to Robin Cook's Coma, you know, I think people realize bad things can happen and crazy people can cause bad things. And I hope people will recognize that it's fiction. But also, that I try to give my bad guy a motive that's not pure evil. And so I, you know, some of this is the patients’ families are trying to do what's best for the family members. And we don't have a mechanism in the United States to help people end their lives if, if that's a decision they want to make. And I don't make a judgment on whether that's good or bad, only try to bring up the fact that there aren't really any mechanisms for this. And my, my evildoer is trying to fill that void, but not in a good way.

DR. STRIKER:

Who is Aunt Erm?

DR. EULIANO:

In this case Aunt Erm just happens to be the great aunt of my protagonist, but she came from when Dr. Gravenstein and I started our novel, he put Aunt Erm and it was his great aunt. He was born in Germany before World War II and was orphaned there during World War II as a teenager. And his Aunt Erm was one of the, the few family members that remained a part of his life. And so he told me some really cute stories about his interaction with her. And obviously I didn't meet her, but I created her as a, a German aunt who has a little bit of trouble with the idioms of American English. And so it allows for a little bit of comic relief, but also some, some nice grounding. She has come to live with Kate, the protagonist, when her husband goes into this coma and she's just a, I'm just having a blast. She was going to be a really tiny bit part. But the people that read the book really liked her a lot. So in the sequel, she's got even more of a role.

DR. STRIKER:

Well, let's talk a little bit about the protagonist, Kate, and, you know, you talk a little bit about loneliness and isolation felt by Kate. I imagine you think that's common for medical professionals, but particularly anesthesiologists. And maybe just talk a little bit about that particular aspect of, of what we do.

DR. EULIANO:

So in her case, it's even worse because she's lost her husband and lost her baby. But in general, you know, when you're training in medical school, you, you go on rounds and you go to conferences and you have a lot of interaction with your peers. Anesthesia is really much more isolated than, than those other fields. And, you know, I talk to my residents about they really don't know how well they're doing because they never really see each other perform. They might take over a case, but that's about it. They, when they're in the OR, it's really just them and of course, our supervision, and then the surgeons and the nurses. But, but a lot of what we do is, is fairly solitary, especially if the patient’s under general anesthesia and then studying while they're still training. And so there is a very significant possibility of feeling very lonely. And that’s maybe a lot of our profession is people who are introverts. But I try and point out to the residents how important it is that when they get out of the operating room, they do things with other people, family, friends, to maintain their psychological balance.

DR. STRIKER:

Can you tell our listeners what impostor syndrome is and how it relates to your main character?

DR. EULIANO:

So in my mind, I don't know the strict definition, but in my mind, impostor syndrome is the belief that you are probably working beyond your skill set and that nobody realizes it yet, and that, at some point they're going to realize that you aren't all they think you are. In the literature, they seem to think it's more of a female thing than a male thing. And I don't know 100 percent if that's true, but I think it's very common in the residents that I work with and the medical students that I work with, and the junior faculty and, and even the senior faculty, where you just feel like you've been misleading people all along and you actually aren't as brilliant as they think you are and, and you're sort of fearful at some point that's going to be uncovered. And so Kate suffers from that, but also recognizes it in the junior people that she is mentoring.

DR. STRIKER:

Do you think that the public and anesthesiologists are going to pull different things from this novel, when they read it, and do you think that's good?

DR. EULIANO:

I do think that's good. I think everybody comes to a book with a different history and a different experiences, and so they take something different from, from kind of every book they read. But anesthesiologists are definitely gonna, well I hope, they will read the OR scenes and just think, oh, that's cool. Whereas the non-anesthesiologists are going to maybe feel like they're getting a peek into a, a different world that they are excluded from.
I certainly dislike reading books where there's a lot of medical fiction that is totally made up and completely wrong. I just read about a man who said he gave his girlfriend some propofol to drink so that she would sleep for seven hours. Mmm, that's really interesting. So, so I tried to make it realistic so that anesthesia people will find it interesting, but not oh my gosh, I did this all day at work. I really don't want to learn any more about it, but be intrigued by the characters in the story and, and maybe a little bit extra for people who aren't in our field.

DR. STRIKER:

I imagine that's just the nature of the beast when you're engaged in fiction and trying to paint a picture of what life is really like, whether you talk about shows involving legal dramas, or things like E.R. as a medical drama, you know, you know you're never going to hit the mark entirely with, with realism, but you try to get as close as possible to capture some of those tones. And I, it, is that just the nature of the beast?

DR. EULIANO:

Yeah, I mean, absolutely. If you were writing it only for anesthesiologists, you would certainly do it differently. But you're right, you can only get close, and try to avoid major errors and hope for the, the grace of the people who read it that they won't string you up for, for making a mistake.

DR. STRIKER:

You mentioned how much you enjoy writing about your character, Aunt Erm, and I was wondering through this experience, have you found that you like writing antagonists or protagonists better, or supporting characters better, or all of it?

DR. EULIANO:

So far, I'm having a great time writing all of it. I'm more of a hero person, so I like writing about my main character, but it's so much fun to try to figure out how things should inter relate. And I end up with these ridiculously complicated backstories that aren't even going to end up in the, in the book. But it's, it's sort of like when we were working on the simulator and trying to make all the different features come together at the same time. It, it's really interesting. And then you'll hear writers say the character took over and did something different and you go, that's not possible. It's all coming out of your head. But it, but it really is sort of true when you live with these characters for a while. And you're trying to make them do something in your scene and it just feels inauthentic and, and so they do sort of create a, a three dimensional life of their own in your head. And I'm finding it easier to picture the protagonists that way. But it's, I'm having a great time trying to make the antagonists interesting and believable, and you know that the story, the antagonist is the hero of his own story and trying to figure out what that story is, is, is intriguing.

DR. STRIKER:

You mentioned a sequel. Where are you in that? Are you still in the process of writing it or is that done?

DR. EULIANO:

It's, it's supposed to be done, but it is not done. I, I had a first draft and then last week I met with some writer buddies and basically they tore it to shreds. So, I’m, I'm about halfway done with the corrections to it, because they pointed out some really important problems with my structure. It's just so interesting. You know, you work really hard on anesthesia and you feel like you finally got a handle on it and then you start a new career and you think oh, it’s just writing. And then you realize there's a lot of rules not just where to put a semicolon, but the structure of story is, is a real thing. And when you don't follow it, it doesn't work. So, so it's been very interesting to sort of start over and retrain my brain in a different field. So it's, it's about maybe two-thirds of the way done about another. This one's a little more pure evildoer, but it's, it's medical devices gone awry.

DR. STRIKER:

I wonder if you have some advice for our listeners. Some may want to follow your footsteps and write. I know we have eager professionals in our profession that, that like to be engaged in, in some of these activities. And schedules can be tough and it's not easy to find time to do this. So what, what would you say to anyone that might be interested in pursuing writing or some other, some other pursuit that that takes this kind of devotion and time?

DR. EULIANO:

It definitely takes time, and so you have to prioritize. Nik Gravenstein, who is, is one of our long-standing faculty members, gave the advice that every 10 years you should reinvent yourself. And I have not done it every 10 years. But people talk about, oh, you're on a balance beam and you're trying to balance life between family and work and whatever. And I, I think of it more as a wobble board where there's so many things pulling you in different directions, it's you just have to be cognizant of where you're spending your time and, and realize that some of the time you're spending is, you could be putting somewhere else, so, so family first and then work, and then something else. And there's going to be times in your life where you won't have time for it. So you just have to look forward to it in the future. So I didn't really start writing until my kids were in high school because before that I was spending a lot of time with them. But I think it's really important.

One of the biggest pieces of advice I give to my residents and, and junior faculty is to, to recognize money is only money. And if you can get a day off a week, if you can afford to work 80 percent instead of 100 percent, it makes a huge difference to have that day and then don't spend that day cleaning your house and doing laundry, but hire somebody to do that and, and do the thing that you want to do that isn't anesthesia and do it for real, like as a second job. Not that you do it even when you don't feel like it, but that you, you credit yourself with it. You're allowed to do it. It's not taking away from something else. It's something you're also committed to. And you take classes and you, you know, whether it's ballet, or writing music, or sports, but you owe it to yourself. You only get to go through this dance once. And if you put off everything you want to do until you're older, you suddenly realize that you're older. And my tennis game is not what I had thought it would be when I, when I said, I'll learn how to play tennis when I'm older.

DR. STRIKER:

That's good advice, I feel that a lot of times we're our own worst enemies with how much we demand of ourselves, and it's, it’s good to give yourself a break, if at all possible, and, and allow yourself some other avenues to help with your well-being.

DR. EULIANO:

Right.

DR. STRIKER:

Well, you also mentioned at the top you're an educator as well as a doctor and writer. What advice do you give your residents?

DR. EULIANO:

Well, like I just mentioned, finding balance, spending time intentionally figuring out where you're going to put your time. Yes, you need to study, but you also need to have a relationship with the people you care about, because once those relationships are destroyed, they're, they’re really hard to get back. So I tell them the things that I feel like now that my kids are older, what they tell me I did right. So one of those was I went down to 80 percent and I spent the Tuesdays that I was off, each afternoon, I would pick up one kid from school and we would spend the afternoon together. So it was my, they call it their mommy day, and now they're in their twenties and they still remember mommy day. And we would not do anything expensive. We would go to the bookstore and curl up in a chair together and read, or my son and I would go out and throw the football or go feed the ducks. So being able to be with your kids one on one is really different than being with them as a group.

I mentioned hiring people. You don't have to spend that much money to get your house cleaned every two weeks. And, and you're helping people who need the money and will spend it in the community. And meanwhile, you're not scrubbing a toilet when you could be spending time with your kids.

And then we had a date night every week. We went and played softball with our church team. And that was, I think, very important that as a couple we were prioritizing our relationship. But also if you just say, oh, yeah, we'll go out once a week, then you forget that it takes time to find a babysitter and to set everything up. And so we just had one baby sitter who came every Thursday night at six o'clock, rain or shine. And if we didn't have a softball game, we went and had dinner. And I think that was very key to us now being married for twenty-seven years and still going strong.

And then I also tell them that while you're a resident, you need to soak up everything you can get, because even though you're exhausted, even doing healthy cases teaches you a ton about how to recognize when it's not going well. So, and I think they do a pretty good job of, of working when they're at work. And we're blessed to have some really great residents. And I learned a ton from them as well.

DR. STRIKER:

That's great, it's great advice and it's so nice for you to share that, that kind of advice, which we should be bestowing upon our, our residents. Tell us when the book is going to be available.

DR. EULIANO:

So it, it came out in March. It's available on Amazon, Barnes and Noble, whatever booksellers there are. The paperback, I don't know the actual publication date of that, but it's definitely out in hardcover and e-book at present.

DR. STRIKER:

And are we going to expect to see you on the talk show circuit?

DR. EULIANO:

You know, people that I know who have written to do like book clubs and they did, you know, book signings all over the country and with COVID, all of that has vanished. So mostly, this is, you know, I'm doing some podcasts and some paper interviews, but I don't know whether book signings will come back, and, and Oprah has not called. I don't even know if that show is still on. But that's the only one I know of.

DR. STRIKER:

Well, Dr. Euliano, it's been a pleasure talking with you. I appreciate you sharing your story, the preview of this book. We're all excited to, to read it. And so thank you so much for joining us.

DR. EULIANO:

Well, thank you for having me.

DR. STRIKER:

Well, this is Adam Striker thanking everyone for joining us on this episode of Central Line. Please tune in again next time. Thanks.

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VOICEOVER:

Don't miss the latest issue of the journal, Anesthesiology, filled with the latest discovery, knowledge and insights available now at anesthesiology.org.

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