Yom Kippur 5779


NPO – Latin for nunc per os.  Nothing by mouth.

Show of hands – who here has ever been NPO in the hospital?  Lots of you, I see.

Another show of hands – how many of you were NPO and had no idea when they were going to let you eat again?  Ooooh, I was afraid of that.  Still lots of you.  Every evening the orders go in for all the surgical patients: “NPO after midnight.” If you’re lucky, you are the first case in the OR, exactly eight hours after your food and water were cut off.  NPO is necessary because humans have an uncomfortable tendency to vomit when anesthetized.  When those same humans are lying unconscious flat on their backs, last night’s dinner tends to end up in this morning’s lungs.  Anesthesiologists do not like this sort of “complication” – and neither do the patients.  Since it takes about eight hours to reliably empty a stomach, that’s how long you wait.

I just got done with an NPO ritual of my own, and in a few days I’m going to undertake an even bigger one.  I’m talking about the Jewish fast days of the Fast of Gedaliah and Yom Kippur.  Gedaliah is a standard sunrise to sundown fast, the completion of a binge-purge cycle after two days of feasting for Rosh Hashanah.  But Yom Kippur is a 25-hour Sabbath of Sabbaths, where even the stomach refrains from labor.  In the Torah it is written, “And you shall afflict your souls” – but the real affliction is in what you do while you are fasting.  Yom Kippur is the day we finish that painful accounting of the soul we started on Rosh Hashanah.  We come face to face with our sins, our mortality, and our character flaws.

Yet if we can emerge from the fast having made amends with a neighbor, taken a step forward in recovery, or identified character goals for the year to come, we end up not feeling afflicted, but accomplished.  We blow a single triumphant blast on the shofar and announce to the world that we’re on God’s team and everything will be OK, that we have survived.  My Muslim friends tell similar stories about fasting on Ramadan: their fasting focuses them on giving more charity and on speaking respectfully to others.  It’s why both my Jewish and Muslim patients are so cagey about asking my advice about fasting with whatever physical affliction I’m treating them for – they actually want to go NPO.  It makes them better people.

And let’s be honest: so does regular NPO.  Last bowl of cereal at 11:55 p.m., OR at 8 a.m., wake up without your hernia at 11 a.m.  Or even better, wake up without a growing but mercifully non-metastatic breast or colon cancer.  Or with a straight back, or a stabilized pelvis.  NPO was a necessary but difficult step in becoming whole again.

When NPO fails is when it becomes a type of suffering without meaning.  When you are not the first case, but the dreaded “fourth case to follow” and you get bumped off the OR schedule by an emergency double lung transplant – and you are NPO all day until some overworked surgical intern remembers to reverse your status at 7 p.m.  Your reward for your troubles?  A cold hospital dinner – and NPO again after midnight for the next day’s OR schedule, where you are once again “fourth case to follow.”

Human beings can endure a lot – if there is a purpose.  What we go through to save people in a natural disaster.  The sacrifices we make for our children.  The suffering we are willing to endure in sickness when there is hope for a cure.  But suffering without meaning, without purpose, leads to despair.  When people undertake a fast and then cannot make themselves connect with the deeper spiritual purpose, they don’t feel uplifted – they just feel hungry (especially when “they” are teenagers forced to wear ill-fitting suits and tight dress shoes).  Even the most spiritually advanced among us cannot find it within themselves to endure some things.  In the middle of a long discussion about “afflictions of love” in the Talmud (Berakhot 5b), two ill rabbis, Hiyya Bar Abba and Yohanan, are quoted as saying, “I welcome neither this suffering nor its reward.”  No word in the Talmud or the commentary on where these two were on the OR schedule…

It’s bad enough when that suffering without meaning happens despite our best efforts, like with the young man I saw this morning who shook his head and said, “I’ve been on so much medicine for so long – you’d think I might feel better by now.”  But what about when we are trying to heal, and we end up inflicting meaningless suffering?  Hard to look at yourself in the mirror, whether we’re talking about keeping someone NPO needlessly all day or trying one futile treatment after another to “save” a person with terminal cancer instead of providing them enough comfort to sit with their family one last time.

We’ve all been taught that doctors are supposed to do no harm – and then we learn that sometimes there is a little harm done after all to achieve a greater healing.  In our new covenant, let’s start by agreeing to one thing – NPO had best be over PDQ, and there’d better be a very good reason for it.  No more meaningless suffering, and everyone gets a glass of OJ and a bagel with lox and cream cheese when it’s over.

OK, maybe next year.  A meaningful fast to my Jewish readers, and a year of healing to all of you, of every faith.

Dr. Jonathan Weinkle

Dr. Jonathan Weinkle is an experienced primary care physician seeking to fix our broken healthcare system by returning the focus to the relationship between human beings. His new book, Healing People, Not Patients, gathers together ancient wisdom, medical science, and the experiences of one doctor to draw a portrait of a partnership—a medical covenant—not just between doctor and patient, but also including receptionist, nurse, transporter, and radiology technician.

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