Just breathe.

It starts when I enter the room. How many words can the patient tell me without taking a breath? Is she leaning forward, hands on her knees? Can I hear her wheeze from across the table? Can I see her effort to breathe? Is her face blue, are her fingers clubbed? I am always watching. The stethoscope only amplifies what I can see.

First, I splay both hands across her back. “Breathe.” I feel the air moving. Next, I tap lightly in demarcated fields, listening for the hollow resonance. I feel for fremitus, asking her to vocalize a vibrating word as the sides of my hands travel laterally down her back, stepwise. Only then do I take the cold circle, universal symbol of the doctor.

My stethoscope hangs without weight around my neck. I can unwind it in a fluid motion, it tangles itself like a necklace, I am always entwined by my crescent of silver and single tube, encased in blue, leading to a bell and a diaphragm. It looks like a caduceus without wings. The snake head uncoils into my ears. My hand is on her shoulder now. I don’t have to count the breaths; I can feel them. If I pay attention, my eyes will close and my head will sway forward as the ear pieces find their natural places in my canals. They are transmitting sound. “Breathe,” I say. “Relax,” to the patients who await my signal to exhale. “Through your mouth,” I say. It’s louder that way. And I am listening to the inside of her body.

I am listening to the inside of the body. It is telling me things. My patient knows these things, but she doesn’t have the vocabulary to describe to me what is happening. All the viscera are innervated. The viscera are terrible historians, as we say. What we mean is, they speak a language we still do not know. Instead, it is my exquisite privilege to explicate this poem, through every sound and every silence. 

The poet teaches the doctor to listen, and the doctor teaches the poet what to listen for. Every day, I am the scribe to my patient’s story, to my patient’s body’s story. I call these findings “subjective” and “objective.” I am saying that my interaction with the body is neutral and that everything I report is without bias. I am saying that the body, itself, has no leaning and no dramatic metaphors.

I am lying. 

Nothing that is human is neutral. It's like pain - they say pain is the 5th vital sign now (on a whim, and to have something more to discuss with a preceptor, I suggested mood as the 6th vital sign. Last week). There are a lot of different "scales" for pain - there's the one with the frowny faces and the one with the numbers. Some people say 'on a scale of 1 to 10, 1 being no pain and 10 the worst pain you can imagine..." 

"7" the patient says

"but now it's down to a 5"

We've got them trained well. (Personally, I scale pain from 0 to 10 for patients). The MAs ask, too, what the "acceptable" level of pain is. Medicine is getting so pc. We say - and this is true - that there is no guarantee pain will ever be zero.

So it's subjective. Totally subjective. And I used to deride this - okay, sometimes I still do. You look at the patient's face while you're palpating. One says "10" and is fighting to keep from screaming as I lightly touch their abdomen. As I'm just percussing/tapping. And another says "10" calmly, abdomen soft, nontender/non-distended with positive bowel sounds. So in my 'general' statement i'll say NAD for 'no acute distress.' 

And am I judging? I'm trying not to. I'm trying. But seeing those presentations - which I've seen - I instinctually guess which one is in more pain. And there are signs "related" to pain. That much pain, the heart rate should be up. The blood pressure should be up. And the respiratory rate should be up. Then again....

does it matter?

Okay, it's a culture of respecting high pain tolerance. Of course I'm part of that. And this isn't just talking to other friends about pain/illness, and feeling like "wow, that person is REALLY sick and they're not complaining at all!" or, "that person just has a cold and is complaining and I came to work when I was wayyy worse..." We do that. (At least, I do). This is seeing sick people/people in pain all day, every day, listening to people talk about chronic pain, injuries, acute things - and you see people with the exact same pathology and totally different reactions to it. I've seen this with procedures - three endometrial biopsies in a row, exact same procedure, exact same doctor. The women were about the same age, approximately the same level of health. One was totally non-chalant. Another was visibly uncomfortable and flinching. And the third was screaming. 

There was the patient with cancer. Every day I saw her, every day she smiled, said she wasn’t in pain. This was a woman with cancer metastasis all over her body. Dying. Young. Cachectic. On chemo. With platelets so low we transfused her every other day, and with that, her platelets were 1/30^th that of a healthy person’s. And so the one day I went in that she did say she was in pain, (a little), that she was fighting not to throw up or cry or….

I almost backed out of the room. I was terrified. For her to be complaining of pain… I couldn’t imagine how bad it was. Unimaginably bad.

Chihuly exhibit. I'm going to continue adding random photos...

But does it matter. Pain is subjective, but each person is a scale unto themselves. Other things affect pain – mood, situation … everything. But the person is the patient and you’re taking care of one person at a time. Only. So in that situation, the only scale that matters is that patient’s scale. (should matter).

Sometimes, though, it is important in management. Does the patient need to be hospitalized or can she go home? Is this IV or oral medication we’re going to give? And how much? And do we need a CT right now, are we sending the patient to the ED? What’s our threshold of suspicion for emergency, exploratory surgery?

This is why medicine isn’t science. There are things we have tests for. There are things we don’t. And you don’t run every test every time, because…it’s excessive, it’s expensive, it’s not always available, it can take a long time, they’re not all that sensitive/specific, and….there can be more harm than good. CT for everyone? No. Even chest x-ray for everyone? That’s probably the most common and benign one. …No. (could post the letter from UCSF professors to the TSA here. Not terribly relevant, but sortof. In terms of unnecessary testing and doing more harm than good. Medicine doesn’t do it. Medicine does too much of it. Don’t do it and hide behind the medicine in order to say it’s safe and just as benign as what doctors do. Doctors aren’t benign. )

 Hiking in Kenya. I wish I remembered the exact name...it's in Western Kenya, not far from Kisumu, and pretty much exactly on the equator. There are little remnants of the equatorial rainforest over here...it's almost the exact same latitude as where I lived in Cameroon, but it's mostly Sahel, now. Scrub. 

Easy science is derided as “physics for poets,” and – to scientists or to a community at large – poetry is esoteric and “too hard to understand.” To poets, science is inflexible, uncreative, and daunting. Science makes itself out to be intimidating. And, personally, I don’t count science libraries as “real” libraries, and I go there as little as possible.

But medicine isn’t science. In medicine, there is judgment. There’s not supposed to be – but there are tumor boards and transplant boards, and as hard as they try to be objective…they’re just not. I saw a patient in the ICU – 39 year old in kidney failure, I think – who had been declared “futility of care.” Takes a few doctors to do that – at least two – to say we’re not going further, we’re not offering anymore “life-saving” or “heroic” measures. I guess. *I haven’t looked this up. It’s not an official definition, I’m approximating – but it’s pretty close. Anyway, thirty nine. And why futility of care, why wasn’t he on the transplant list? Lack of social support. That’s a criteria – hard to get through recovery and post-recovery for transplant on your own. He was married. But his wife was a polysubstance user – aka, in normal parlance – junkie. So no transplant for him.

Medicine speaks an entirely different language, and not just in medical terminology. Medicine turns commonplace English words upside-down.

“How is the patient mentating?” Thinking. Are we judging? Yes. Cognition, alertness and orientation. We are also judging the patient’s relationship to the world, as if we know how to govern that.

“Is the patient’s sensorium intact?” Is the patient hearing voices or seeing things that other people do not see? Is the patient feeling things that aren’t there?

Medicine auscultates the heart, lungs, carotids, and abdomen, rather than listening.

Rather than mildly sad, a patient is probably dysthymic, and if they feel normal, they are euthymic. “Thymus,” to ancient Greeks, meant heart, soul, desire, life. In adults, it atrophies, and in opening a cadaver, it is almost gone.

~j

Having Patients

       It’s a possessive thing. They are my patients, and I’m their…well…sortof doctor, for lack of a better word. But in my clinic (yes), we run it exactly like intern/resident clinic. I do history and physical, assessment and plan, discuss this with the patient, do education, etc, counseling, etc, then I go write up my note, write out the prescriptions, fill out lab sheets/imaging/referrals (if I want that), then I present to whatever attending is present. We go over the plan, they mostly sign and maybe change a few things, then we go see the patient and I re-explain everything, add/modify if there are changes, and that’s it. My patient. My patient gets a follow-up appointment with me.

            Or, did. It’s been six months (this is a different sort of medical school program that I’m doing…but…not terribly relevant right now). This was the first week I referred patients to people other than me, made them appointments with “other” doctors (as in, the others are doctors. I’m not lying. My patients know I’m not a doctor, not yet. But they see me as one, because I am providing the care).

            I remember the first time a patient asked me how I was, after I started in with my usual ‘how are you doing today,’ etc. It meant a lot. And it’s happened with most of them now. It means that…it’s not a one-sided relationship. Over time, I’ve learned and thought about how much of myself to share. Personally. No one’s asked me questions I didn’t feel comfortable answering. And of course I know eons more about them. But I’m there, too, and they want to know how I am, how much later I’m working, and to tell me that they like my shoes (the latter, actually, has happened several times).

            I remember the first time a patient hugged me. I wasn’t sure how I would feel about that at first. But…again, it’s always been appropriate. And it always comes out of an overwhelming…relief, sense of partnership, sense that they’re not alone in this and that someone is supporting me. There’s the patient’s wife who asked if she could hug me – she’d come in close to tears, so much going on, so much to manage with her husband who was so sick with so many different things. I helped, in small ways. And it was one less thing for her to worry about. Now, she hugs me everytime, as does her husband, and I look forward to seeing them and hearing about how their family is doing. They’re sad this is ending – and so am I. So am I.

This is where medicine is different – there aren’t that many jobs that are emotional, not that I know of, outside of healthcare fields. I not only know the story but I’m involved in it, involved in trying to improve it, shape it, and just being there to listen when there’s no one else to do that at the moment. I don’t know if I realized quite how much trust patients put in their doctors – not in all doctors, I guess. So many times it’s “have you been able to talk to anyone else about this?”

“No.” (says the patient).
“Do you think you could?”
“I don’t know/I’m not sure.”

Is it because I’m “objective”, “anonymous”, HIPAA compliant? Yes. And I am. But I also carry all of the stories. And I look forward, in each encounter, to learning more about how they enfold.

I was jubilant – out-loud, YES!!!! – in the residents’ workroom in clinic, the other day, seeing my patient’s lab values online. Cholesterol DOWN. It meant that, together, we’d done the right thing. Same thing when handed a chart with my patient's vital signs of the day - NO MORE HYPERTENSION! I go in beaming. (There are, of course, the flip-side stories. Not to write about today, though. Not today).

(No particular reason for the above. Just that...wildebeest are cool. Kenya, Maasai Mara, 2008). 

It’s funny, I wrote a blog post on a now-so-defunct-blog-I-don’t-remember-the-address with a similar title to the above. Six years ago, my first clinical experiences. College. I’ll repost that, just because it’s an interesting contrast. And a number of things are still true. I may start doing that with a few other things, actually. I’ve been writing about medicine for years. I’ve been writing about the conflict, this tension, for years. Some things will never change.

This is the beginning of that post:

“Patients are a virtue”

And this will be dedicated to them.  A few in particular, who have brought up these issues.  As preface, I've been shadowing a doctor in the city for the past few months.  One afternoon a week, I go in to the hospital…and follow him. In essence.  I'm in on the patient exams (except for the few- maybe three, or four- who haven't felt comfortable with a student there. understandable).  I've worked with the practice assistants too (PAs here, though in TX that means Physician's Assistant. very different), bringing in patients from the waiting room, getting height and temperature, starting to fill out their charts. etc. clearly I can't do much in the practical sense, not being ah, qualified, or even in medical school. 

Why am I there.  This particular doctor (RC, simplest to name as he signs his emails) was my professor a year ago for a course that was supposed to be "Literature and Healing." It turned into a poetry workshop, because he was the visiting poet for the year and the demand for his poetry workshop was so high that the admins decided he should have two workshops and no class. Disappointed, yes.  I had arranged my entire course schedule around that one class (and Thursday, 5-8 pm- ain't easy).  But more than that, I had wanted to take a course- any course- with him. To spend any amount of time with him.  Why?  He's the reason I'm still in science.  He is, in short, my hero.

My hero.  At the beginning of last year, I was so frustrated with science- with the curriculum- with the people- with the outlook- that I was very seriously considering dropping it altogether.  Giving up on what I decided ten years ago would be my life's work, and pursuing literature, alone.  OB (poetry advisor, teacher at the time of poetry workshop), knowing this dilemma, gave me a book.  RC's book, essays and some poems, describing his experience with medicine, why he became a doctor, and what it was like.  Reading, I was re-inspired.  His words made me remember why I loved science in the first place, why I did it, and what joy it could bring.  Besides reigniting my passion for research, he showed me that the fusion is possible- he is a physician (internist) and a poet, and pretty damn good (and renowned) at both.  (except for the research I would like to do), he, in essence, has done and is doing with his life what I aspire to do with mine.  He's doing it well.  And the man offered me, a year ago, the possibility to work with him at the hospital and share his experiences and get a feel for the "clinical aspect" of things.  I would have been crazy to not pursue this offer avidly.  As I did.

And my first-draft med school application essay (the fake one, the one I had to send to the pre-med board at college when I interviewed with them three years prior to applying and just prior to Peace Corps....). I wrote about shadowing Dr. Rafael Campo (the “RC” of above. I played at HIPAA with everyone’s names before it was cool…), physician-poet-mentor….

 This paragraph is from that:

Dr. Campo's clinic treats general adults, but he focuses on Latino patients and patients with HIV/AIDS.  I was astounded by the trust and confidence each patient gave him, but I was even more taken aback my Dr. Campo's personal relationships with them, no matter how long it had been since the last visit.  Each case—even the routine checkups—was truly unique, as each patient was unique.  He, as I aspire to do someday, seeks to heal not the illness but the person, to lovingly read each distinct narrative and respond to its artistic demands.  His Latino patients, no matter how fluent their English, opened their tongues a bit more loosely to describe in vivid color each symptom and episode.  One man's cholesterol and subsequent leg pain increased after a visit home to Peru, where we deduced his dietary changes may have caused the problems:  "you know, doctor, what the family feeds me at home!"  I chatted eagerly with another patient, trying to remember bits of my high school Spanish, and thoroughly confused him when I insisted I had a sixteen-year-old hija (daughter), when I meant to say hermana (sister).  "You look young" he smiled at me, indulgingly, his illness taking a backseat to the doctor he loved and his bumbling new assistant.  I marveled at the couple, husband living with HIV, wife sero-negative, who walked in with mountainous folders of information, ready to wrestle and harness science as it manipulated their daily lives.  Sitting silently in each exam, I soaked up the humanity with the medicine, greedily. 

It may be an “easy way out,” posting things I wrote six, no, six and a half, and five and a half years ago. My knowledge base has changed, certainly. I am, now, becoming a doctor, and in terms of getting the degree, pretty far into the becoming. This is two-thirds through the third year (of four). But, younger, less knowledgeable, a good deal less Spanish, I wasn’t wrong.

For now.

~j

November ending in red ribbons

Ok, it’s official, I didn’t win NaNoWriMo this year. (and by win, I mean write 50,000 words in November).

It may have been a bit ambitious to take on, alongside third year of med school and concomitant hours in the hospital/studying. Then again, I have been spending an hour – two every day writing; it’s just been poetry or essays. Or researching writing.

I did start. Like last year. I was planning to not write something new – I was either going to revise and finish last year’s novel (now at 65,000 words), work on poetry, or do…something. Else. But I sat down on November 1, taking one of the many, many breaks that are scheduled during anesthesia (seriously. The attending come into the OR every two hours. “Want coffee?” “Want more coffee?” “Have you had lunch yet?” Etc. No other specialty does this. I can imagine the surgeons glaring or snickering behind their masks, after they’re been standing for 8 hours without relief. At any rate)….

And a voice was there. So I started to write. It made me feel a little bit smug about my development as a fiction writer, as the voice arrived in first person and she is most definitely not me. Last year, I had started in first person and had to switch to third to keep myself out of it.

It’s an interesting story, maybe, though I don’t yet understand what’s happening, at all. I’ll finish it someday. The characters are: the main character, a little girl (nameless so far), the president (maybe Obama, probably not), and a few three-headed, wooden dogs. So far. I appear, as well, as a bystander at one point; I’m not sure if “I’m” going to be a recurring character. (At least, it’s someone who looks like me at a very particular point – ie, in Zoebefam when I was building the water project there. Only time will tell, I suppose, if it’s “me.”).

            This was a very different experience, in terms of writing – last year’s came to me in words. It’s very fluid, very poet-y prose, perhaps Jeanette Winterson-ish (if I flatter myself. All my influences are somewhere, after all). This year was all images, like I was flying/gliding somewhere and just writing down everything that I saw and encountered.

And it makes no sense. This story takes place in a world that is magical realism, perhaps, in another time period, perhaps. It seems to be some sort of speculative fiction – a genre I’ve read only small amounts of and do not know much about.

A sample of this year’s story, somewhere beginning-middle-ish:

(Context: I have no idea).

The girl looked strangely familiar. She probably lived in a candlestick. She walked toward me with a bounce, little flaring navy dress over transparent knee socks. Looking back at the president, his hand came off in her hand and she continued, unconcerned. The girl started floating a little, like the hand was attached to an invisible balloon without a string (and what do we need strings for anyway except cheese and hamsters?)

Looking into glass, she bit my ears. “This isn’t a wishing well,” the little girl said, “but I’ll throw coins on you anyway. Are you made of stones or salt? I’ll try not to melt you.”

“How would I know if I melted?” I asked her. This sounded concerning.

“Do you carry an umbrella?”

I looked at my elbows, Nothing there except some trailing ribbons.

“Then probably you don’t. “

Compare with last year’s random sample:

(context: Sera, main character, just smashed her finger into a wall, and she’s watching the skin change colors. This is from the middle/end of the scene).

Prisoners, tower-locked in membranes. Not the ones filling her skin. Catabolism – sanitizing catastrophe. Reversal of what is expected, from katastrophein down and turn. Strophe like ballads. Body like dead.

Delicate cleaving, coordinated cycles. Green comes first, biliverdin (Verdi like spring), carbon monoxide floating into tissues. Silent killer. Verdin turns to rubin, darkened red stone, breaking cells – monk-like chambers - into light. The white carriers, protein, to eat and build and break, albumen from alba, docks filled with too much color. In bodies red and green makes yellow, turning eyes and skin to gold.

Insensitive, unseeing to the slight new crook in the bone, Sera went to X-ray to earn more narcotics. White on black, gray for fat, water that wasn’t water. Photographing bones. Calcified proof of how long it would take you to dissolve.

The mind is strange and fascinating.

...And then the patient who does not have schizophrenia (who I thought, previously, likely did).

 This is relieving. I’ve been seeing him most days for the past few weeks, over which time he’s come to think of me as his psychiatrist or similar. – No, I never told him that, and he does understand I’m a student/in training. I am the one who recommended staying with the first drug regimen and adding one, though. I am the one who wrote the initial psych note and the follow-up notes. And somehow, somehow, this is counseling. Therapy. What I do with him, what we do. There was a study that did a case-control (not double-blind, but…something) on therapy with trained professionals versus therapy with other sorts of professionals masquerading as therapists (ie, architects, scientists…whomever). The patients did decently well. I’m not saying the discipline is useless – I believe the contrary, these days, actually. It is specialized, it is important, and the drugs can and do work.

Point being – part of the whole deal is just having someone to listen to you, who cares and is all-in. Who’s unbiased – as much as any human can be – because the only context in which they know you is what you’re telling them. They might get collateral (friends, family, previous physicians). But in general…

So I sit, in the yellow disposable isolation gown, with gloves on, and we talk. He talks, I ask questions, sometimes. The narrative bit is amazing. I have the agency to ask And then what happened? It’s an unfolding story to me, and somehow, in the telling of the story, he feels better – he says, at any rate. And I don’t think he has schizophrenia. Something, certainly, but it doesn’t seem to be that.  One of the psychiatrists who taught us a few years ago called it the “cancer of the mind.” True. Not for everyone – some people can recover from an initial episode of psychosis, and that’s it, or maybe they’ll have another one far down the line. That’s not what we see as often, though – but working in the hospital is its own bias. We only see the people who are sick.

(banner below is from AIDS Action Committee's website. Because I think they're really cool (used to volunteer there)). 

......And I’ll segue into World AIDS Day, a thought debate on does-this-sort-of-“visibility”-help-anyone, and December.

Addendum on the One Campaign – as far as I could understand, in 2005, their main message was “Africa is poor. Africa has AIDS.” Both of which are DUH, as in, clichés in language, at any rate, empty of meaning, digressive, pejorative, and oversimplified. Take that. But THEN, you get celebrities to play concerts around the world, bringing together tons of liberal, left-leaning, world-loving young adults to chant “Yeah!” to that sort of a message. And you don’t harness the energy. At all. You don’t use it to raise money. (“Awareness” in that arena is… what. Meaningless, in any manner I can see. Maybe someone with far more vision than I could create something spectacular). So, money. Volunteer hours. Donations of other sorts. ANYTHING. Millions of people there for free. Nothing happens. Except they buy rubber white bracelets, maybe (are those still in fashion?) And they go home feeling good about themselves. It’s like expensive shoe stores in Berkeley or similar telling you some minuscule percentage of the shoes you buy goes toward breast cancer research, or something. So you feel good about going shopping – there’s your good deed for the day. (at least that’s raising something for something. maybe. maybe.) At any rate.

I work in an HIV clinic in the states, now. This is a poor town (where I am currently). These patients do not have much income, and they get assistance from the Ryan White foundation (and federal) for ARVs and such. There are social workers in the clinic, case managers, a psychiatrist, nurses who do home visits…

And the patients look good. They look damn good, in fact. For 90%, you’d never know. They may have presented with AIDS, even, cachectic from tuberculosis or PCP or something in the hospital. Then they got into a care, on a good regimen, and they got better.

And damn, they look good. They come to the HIV clinic, get refills, basically, and take care of their hypertension, diabetes, hypercholesterolemia, insomnia, depression, chronic back pain, headaches, sore throats, etc, etc, etc….

We give them graphs of their viral loads and CD4 counts. This is pretty amazing to see, too.

They look good.

In Cameroon, I did see some who looked good. And I saw a lot who didn’t. And I saw a lot of babies die. (Another day. Another day). World AIDS Day? It’s pretty incredible what’s happened here. I won’t say it’s not. It’s absolutely incredible what the transformation has been, from GRID to the 1993 HIV/AIDS definitions from the CDC, ACT-UP, AIDS memorials (movements that did, I think, do something), the literature of HIV of that era (Mark Doty. Thom Gunn. Etc…), Angels in American, And the Band Played on, Rent, even... We’ve come a long, long, long way. So it’s easy to forget sometimes. Even fellows doing infectious disease/HIV don’t often see the kinds of opportunistic infections I’ve seen (wow, lucky me). We should celebrate the progress. We should disseminate the progress by figuring out ways that make sense to do that for other countries. And we should show the rest of the world – the southern world, the developing world, whatever – how well people can do with ARVs (HAART), and how well life can go on. This is the reality. “Poor” and “AIDS” and “Africa” have lost all meaning in connection to each other.

Far away, on the forgotten continent, who remembers Africa as more than a pop cause?

~j

And I leave you with a photo of my health club in Cameroon, performing a skit they wrote for World AIDS Day. December 1, 2006. (friends of mine). Below. 

I know the hospital well enough to walk with eyes closed.

I feel guilty. Like I'm betraying my patient, even. Giving such a nice, cheerful, engineer the diagnosis of schizophrenia. Maybe schizoaffective. Am I right? Does he have it? Yes, probably. Likely. But it feels like the kind of thing that shouldn’t happen to “people like that.” (I asked. He told me about the voices. I asked what they said. He told me). My bias. Societal bias. My judgy-ness. Societal judgy-ness. Whatever it is, it’s somewhat ingrained. It’s not that I think badly of someone who has it. I might feel sorry. I might pity. It’s a terrible label to give or to get. It’s one that doesn’t go away and one you certainly don’t want on your records, anywhere, if you’re going to be highly functional.

(but this is true of mental health diagnoses in general. Now, we’re not supposed to be denied for pre-existing conditions. We’ll see how that plays out. If it’s true – that would help eliminate/decrease one of the most unfair/unethical/immoral part-and-parcels of the health care “system” in America. (I said I wasn’t going to get political. I can’t help it. I’m incensed, everyday, over the injustices I see, everyday). There are some drugs you can hide behind. “Oh, it wasn’t for depression, it was for chronic pain. Smoking cessation. Epilepsy (harder to hide that one – epilepsy would inevitably show up, somewhere, if you had it, rather than bipolar disorder). Neuropathic pain – diabetes. What else do we prescribe them for. What else don’t we prescribe them for. Short course is easy. Maybe. Maybe).

So, the patient with schizophrenia. I’m trying to keep it that way. “With schizophrenia.” Psychiatric diagnoses – no, every diagnosis, ever pathology – is a noun. Yet we turn them into adjectives. The patient the team called “cancer girl” was the patient with cancer. “The schizophrenic patient, the bipolar patient, the dementia patient, the psychotic patient…”

The ones with, the ones with. (I’m starting to sound like the titles of a Friends episode).

It’s not just linguistics, not just semantics, to me. Giving people diagnoses as adjectives means they cannot be separated from their disease process – schizophrenic person like French person or blonde person. Yes, it’s a chronic disease – it can also be relapsing/remitting, it can be in remission – but that’s not the point. Unless a person embraces the diagnosis as part of their identity – there is a blind community, there is a deaf community, diabetes? (juvenile onset, maybe), there are groups of cancer survivors – but that still doesn’t mean people want to be identified or to identify in that way.

So it’s a shortcut. “The patient with schizophrenia” is one whole word longer than “the schizophrenic patient.” The latter, of course, becomes “the schizophrenic.” And in health care, we do “tag” people by diagnoses – it’s like a mnemonic.( I try to add to that names of loved ones, little anecdotes, home towns – small things. It’s a way in, back to the patient, in any return visit, next day, next month, next year. And it’s not just being PC or having good ‘bedside manner’ or whatever – it’s important to maintain that doctor-patient relationship in order to have a good therapeutic relationship, to work together in the treatment and prevention and management of illness and whole person).

But even at this early, early point, patients are starting to blend together in my mind. (The little tags help). People start to look alike, they have similar-ish stories, at least on the level I know, similar demographics, I’ve seen them in the same context, they’re taking the same medications, their lab values are approximately equal, we’re working on the same things…etc, etc, etc.

There will be something. The one who came in with her 23-year-old daughter with Down’s after I’d seen her for something-I-don’t-remember. The Latina woman, 40 something, with hypertension, hypercholesterolemia, diabetes… on metformin, lisinopril, hydrochlorothiazide, and simvastatin… except this one is estranged from her daughter. This one came in with her grandchildren once. This one had surgery and has a dividing scar on her abdomen.

Etc.

*

Psychopathology is hard. It’s hard to see the ones that can’t be reversed. And that can be treated, maybe. Maybe.

I saw a patient regain a language the other day. The story is one of the ones in medicine that makes me furious, which means it involves – always – some sort of human injustice and discrimination (these are the things I argue with attending about). And I argue about with anyone in this country who does not believe that health care is a human right and that the discrepancies in health AND health care are a violation of basic precepts of fundamental humanity. I could go as far as to cite the Geneva Convention. If you get me on the topic.

Well, watch this: http://www.pbs.org/unnaturalcauses/ . That’s one thing. Food for thought. And fodder.

Not going to talk about excessive spending. About full-body CT scans. About Parkland hospital and 7 counties punting responsibilities for a county hospital onto one. About how long my patients have to wait, about people in the ER 3 days, and about the little, little I can refer people for (dental? ophtho? mental health? substance use, versus acute detox in the hospital? The patient who came in with DTs and was in the ICU for weeks? I get angry. I get incensed. And I want to write about it).

Back to my patient. Because we learn through individual stories, I think, by putting a name or a face or a particularity to a narrative and not to statistics. My patient had Hep C and subsequent fulminating cirrhosis. He was doing pretty well with medications. He’d stopped drinking, hadn’t used IV drugs in about 20 years. He came into the hospital vomiting blood^*. From the liver disease, he’d developed a deficiency of clotting factors. During the hospital stay, he developed a worsening, severe headache. After a few days, they did a CT head – and it turned out that he had been bleeding, slowly, into his brain. At this point, he was obtunded, didn’t know where he was, could barely speak, and didn’t make any sense. Neurosurgery refused to take his case – to shunt, to operate, to do a spinal tap. Nothing. “He’s terminal,” they said.

After a consult from infectious disease and hepatology to say the patient was not terminal, that his bleeding diathesis could be treated, and – besides which – this immediate problem was reversible – they decided to do the procedure.

*Ok the medical facts might not make much sense because I am making them up. Altering, rather. To change the actual story, enough. The gestalt is true, though.

This is when I saw him.

That day, he only spoke Vietnamese, and I was able to communicate with him – a little – through the translator phone. He knew his name and birthday, he didn’t know he was in a hospital. (Are you in a store? a hotel? a hospital? your house?) (and…yes, this is the patient exam described at the end of the last post). Alert and oriented to…person, basically, not time or place or situation.

I returned the next day. He looked at me, smiled, and spoke in English. He started asking about when he could go home, joking about how much better the food would be there… he knew exactly where he was, why, and what would happen next. Few transfusions of clotting factors and he was okay. Otherwise healthy.

As I've heard about with stroke or with dementia, people can revert to only earlier memories, the more deeply ingrained ones. Language - there's not much more primal, urgent that is learned. He had it, sort of. And then when the pressure on his brain was relieved, he got the other one back.

I haven't seen many miracles like that.

 ~j

On Love and Medicine

I think a lot about “for better or for worse” these days. In medicine, you see a lot of “worse” and “worse”, and I see a lot of partners who are there for both. For anything. Siblings, children, grandchildren, nieces, nephews, friends. I guess these would be the ‘chicken soup’ or whatever stories (are they even still publishing those?) But it’s true – rushing around, where so many things are difficult and sad – it’s something to stop and think about. Or try to remember to stop and think about. With the sickest patients, it’s their loved ones that I know. The ICU patients, the altered mental status patients, dementia, kids…whatever. I’ve spoken with a lot of family members. In anesthesia, wheeling people into surgery, you leave Loved Ones at the corner. (They call it the ‘kissing corner.’ Really). And you see them into the waiting room, point it out, say go get coffee or whatever, we’ll be ____ hours, and don’t worry, we’ll take really good care of X. Your X. I’ve seen the wide eyes when we push through the doors again, X is barely waking up from surgery, likely has an oxygen mask over her face, and we’re rushing into the PACU. It doesn’t mean anything’s wrong. It’s normal, and it means the surgery’s over, and if people don’t look like they’re freaking out (The doctors), everything is probably fine. It’s a vulnerable position to see someone in. And in the OR, they’re alone.

There’s the couple who came in with the wife’s entire medical history typed out – each had their own version – with a list of questions. She suddenly went blind, no one has any idea why, no one has any idea if it’s part of something more progressive – probably. So they’re searching. And with each doctor, they get more frustrated at not having answers. But the other point, to me, is that it’s always both, it’s really about their health, and the patient is – almost – both. Making sure you do speak to both.

There was the man whose wife died of ALS (Lou Gehrig’s disease). She lived with it for twelve years, far longer than the average prognosis. At the end she was, as they are, completely paralyzed, ventilator-dependent, and could not speak or do anything independently. He ran marathons with her – there were photos of the special chair he ran with. For ALS research. There were vacations…. everything you can imagine that is so hard to imagine in those circumstances. So when she died, he wanted to donate all of her special equipment (hundreds of thousands of dollars, I think), some of which he had designed or modified, to other patients. He drove across the country with this. He’s still working with ALS.

And there’s the patient who had a second stroke on top of her first one and was almost comatose. Before the second one, she and her husband had been living with their daughter, just while she was doing rehab. He kept trying to convince us – again, again, again – that she was fine, that they could go back to their own home. They’d been together over 60 years. All he wanted was to take her home. And then there was the second stroke, and she wasn’t talking but I saw him every day, the daughter, the granddaughters. He left to get food sometimes, when his daughter was around. Otherwise.

There is love in medicine. And it’s the patients who don’t seem to have that support who are the hardest, for me. Almost doesn’t matter what the diagnosis is. When you can’t send a patient home because there’s no one to help, there, or the people there will not help… it’s hard. And it does change the medical plan. It’s been gratifying to me to realize how much this is taken into account. Teams don’t – or try not to, anyway – discharge patients without knowing where they’re going, and how. (and yes, then they pawn the patient off onto a social worker. but that’s why everyone is expert at different things).

But medicine has to be a little bit about love. It has to be about healing. When we’re in surgery waiting for pathology to call back – cancer or not cancer – everyone is holding their breaths, a little bit. Everyone wants to know what is finally said. And yes, people get jaded when they are overworked and overtired and it’s overwhelming to care individually about every single person in a day that you’re caring for, and if you’re in the hospital, some of them will die. I’ve heard  people comment about the annoying paperwork of death certificates, rolling up the sheets (like we do with everything else) and sticking them into a pocket. Everyone’s job has lots of paperwork and bureaucracy. In this job, the papers can say things like “full code/do not resuscitate/ do not intubate.” A progress note can describe a scene of death, at what time, what exactly happened, who was there. And it can also describe a birth – clinically, the first moments of someone’s life, and not just that but exactly what happened before. And who was there. And what happened. It’s a little bit of personal history before the lungs are even shocked into expanding and the fetal vessel connections close, and, and….

This is our bureaucracy. This is our paperwork. Birth, death, prescriptions, and “orders.” And “progress notes.” And more “orders.”

To me, it’s a heady thing to decide how much pain medication to give someone – what drug, how much of it, how often can they take it, and how many (the decisions are often left up to me, with the attending shrugging “sure!”. Then the attending signs the prescription I’ve pre-written). I write admission notes and orders, and yes, everything I do gets co-signed, but not every resident is going to re-read every line. I wrote out the medications and dosages. It seems like a small thing, maybe. But from my scrawled handwriting, faxed to the nurse’s station, to the patient’s chart, to the pharmacy… I’ve decided something, I might have changed it, I might have screwed it up. I decide a lot of things for patients, now, and as long as it’s a “fine” idea, it generally gets signed. There are a lot of choices, a lot of not-right/not-wrongs, and it can be unnerving. For another patient, her subspecialty doctor decided to proceed to surgery for her rather than medical management – based partly on my exam. My exam which had not been verified, up to that point, but done and recorded by me. I was terrified of this responsibility until we went to the other specialist who confirmed my exact findings. I wasn’t wrong. But I could have been. Easily. (and residents are, too. and attending are. this happens). There are so few things directly in my control, currently, that each thing that is can be terrifying. Shattering. What if I’m wrong. I’m in no life-or-death position, yet. Yet. It’s really not very far away.

*

Another patient hugged me today.

I’m not exactly sure why. I told her nothing was abnormal with her on my exam – which sometimes, under the circumstances of having annoying/uncomfortable symptoms – I would think would be frustrating to hear. Apparently, she had been worried about “something wrong”, however, even though she hadn’t said it. And so she hugged me.

This was in urgent care – we hadn’t talked for more than 10 minutes, my whole exam was five, then 2? 3? discussing results and giving her a prescription.

And she hugged me.

Another patient today, when he started discussing serious depression (this is not in psych clinic) said “wow, I’ve never talked about this with anyone before…”

I get that a lot.

And it sure as heck is ego-boosting.

Is it true? Who knows. Yes, probably. But it’s the white coat, the concerned look, leaning forward, attentive body posture, language (is it true? Yes……is it true every minute? …no). I am listening, caring, I am making notes. I’m also conscious of what I’m doing, though it is becoming fairly ingrained. (And I have an agenda, and questions I want to make sure I get to, I have a time frame, and I do have to redirect and interrupt). It’s not anything anyone can’t do. The mistake people make sometimes is forgetting all the human skills they already have, had before medical school. The best, most rewarding, most meaningful things I have managed to do, have, for the most part, drawn upon things I’ve had for years.

And maybe I’m more comfortable now than I was pre-med school in discussing difficult topics.

I’ve got the… license to do it (technically speaking, 1/3 medical license). I have gone through all these years and still am going through them in order to be…trusted? Trustworthy? Organic chemistry certainly didn’t make me that way.

I am engaged in each encounter. I try to be. But there’s also the walking briskly down the halls, always, around people in the hospital, looking busy-and-important. And trying to read my watch while a patient goes on and on and on because I’m going to be late for rounds and I still have to write down the vitals and the labs and do my assessment and plan and I have to present and I’m already supposed to be on the 9^th floor and I keep interrupting anyway but…

*

In a hospital (this isn’t true of all of them) with widespread, good, easy-to-access wi-fi and cell service, I walk down the hall reading and answering email (thank you, ipod touch, and medical school that requires PDAs in the third year, and younger sister with a job and a penchant for buying the latest gadgets and sending the older ones to me…). I know where I’m going and I don’t need to look. I can do this at the same time, and I’m not wasting time. I’ve walked down the hall writing progress notes, before. It saves time. Today, between 7 am and 4:30 pm, I found 5 minutes in which I could – between dropping off orders on the second floor and running back to meet my resident in the ER – sit for 5 minutes and have cereal left in the resident lounge.

(This is a sometimes-but-not-always-necessary occurrence. As is the 4.5 hours of sleep – some things are self-inflicted, as I sit writing this rather than reviewing current guidelines for opportunistic infection prophylaxis, adrenocortical insufficiency and leukocytosis, or TIMI scores. Or differentials of syncope and alcoholism and dehydration. Or bullous pemphigoid. Or altered mental status.)

But I digress. AGAIN.

Here is an interesting exercise. “What is your name?” Correct answer. “How old are you?” Correct answer.

 “What is the date?” Confused mutterings, similar to “what is the day?” and “where are you?” This is where, in psych, we start in with choices. (Psych or neuro. same diff). “Okay. Are you in a store? A hotel? A hospital? your house?” Still no answer. I think maybe next time I’ll make it more interesting and add zoo or something…. heck, I have a friend whose grandmother had Alzheimer’s and lived in a delusional world that consisted of a perpetual cruise ship. Not bad, as far as delusions go).

Yet – the patient knew – “What city are we in?” “What state?” and “Who is the president?”

The things we retain.

~j

I used to do this to fruit flies, and sometimes I forgot*

I’m in anesthesia now (the rotation¹). It’s alternately seen as the your-patients-are-asleep specialty, the knock-them-out-quickly specialty, the bring-people-close-to-death specialty, the more-drug-addicts-than-any-other specialty, the control-the-level-of-consciousness specialty, and, as one resident said to me, the anti-death specialty.

It is surreal. Which is more like playing god? The sterile, scrubbed, blue-gowned ones on the body cavity side of the blue-sterile curtain (now: blue equates to sterile. It does in the OR. Synonymous), the ones who are cutting through skin – the ultimate violation – and putting their hands in and manipulating another person’s internal organs.

Or. The ones on the non-sterile side of the blue curtain, the head side (usually), who put a tube down that person’s throat and connect it to a machine to breathe for them, who tightly control drugs (by feel, actually, more than by dosage) to keep them awake/not in pain/not remembering/not alive/not. Yes, the machine plugged into the wall is playing god².

You’re going to go to sleep soon, I tell the patient. You’re not going to remember any of this.

And they don’t.

¹(Though – note on that – dinner with friends the other night. Friend of Y’s showed up, and Y asked me something along the lines of “didn’t you have anesthesia today?” or “weren’t you on anesthesia today?” Her friend looked at me kinda funny… I guess I looked fairly alert for someone he presumed to have recently had surgery. I raised my glass at him. “AND then I drove over here!” Oh, medicine….)

² Being a skeptic, I may overuse this phrase to the point of meaninglessness. Apologies.

*(to take them out of the freezer). I’d take them home sometimes … forget exactly what I did to them there, separated them, maybe I could tell wing shape or color or what have you. And the way you anesthetize them to get them to stop moving is to put them in the freezer. Quick and dirty. And yes, sometimes, I forgot to take them out. In the lab, in college (freezer was high school experiments – maybe it was just taking them home to babysit as no one would watch them over the weekend?) we used CO₂ to put them to sleep. And sometimes you use too much. And it’s fruit flies, which, though they have taught us so much of what we know about genetics, we can shrug over and move on. It’s a 10 day reproductive cycle. Born to reproduce. More or less, cross them again, again, again.

Today I put (read: rammed carefully and deliberately) a tube down a woman’s throat to help her breathe. Successfully.

For the sake of argument, I’m going to compare myself to Obama for a moment (because… well that’s nice).

The woman had a disease, not life-threatening at all, a little uncomfortable, and she came in for elective (doesn’t mean, like, plastic. Just means it was planned and not emergency surgery) surgery. She’s basically very healthy. People out of my control and out of her control started to give her drugs through her IV:

one to make you feel like you’ve had a few too many cocktails (Versed/midazolam)

one that is numbing medicine (lidocaine)

one that will sting a little. This one will put you to sleep (Propofol)

and one that will help with pain (fentanyl).

All together, they depress her drive to breathe. She is no longer able to breathe on her own; her brain can’t interpret the signals that she’s filling up with CO₂. Now, these people/actors on the economy… are not totally malicious. Before giving the drugs to make her go to sleep, they put an oxygen mask (tight, uncomfortable, pressed down) over her mouth and nose and have her take deep breaths of oxygen. This too makes her light-headed and sleepy.

And as soon as she’s out. “Ms X? Ms X?” Touch her eyelids. “Open your eyes, Ms. X.” Nada.

And Obama enters the office and tries to do something for…the economy. Everything.

The mask stays on awhile longer. I’m holding it as tight as I can – harder than it sounds – gripping under her jaw bone and thrusting her chin up. Forcing oxygen through a balloon into her lungs. But I can’t do this forever. It’s a several hour surgery. I’ll get tired. My hand could – and will – slip from the mask, from the balloon, over this period of time. Besides which, we have millions of dollars of machines next to me, beeping.

 Then -

The mask comes off. And out come the instruments to ram down her throat. I look. Try not to break her teeth as I pull UP with the laryngoscope, finally see the vocal cords, and thread the tube down them. I attach the oxygen to the tube now jutting out of her throat and continue to squeeze in air, for awhile, while we check it’s in her trachea and not in her esophagus (… as it was the first two times I tried this week. Oxygen to stomach? Not. Helpful). And then I flip the big switch to the ventilator and the accordion does my job – up, down – and the people who put her to sleep and paralyzed her and made her stop breathing in the first place add inhaled anesthetic to the oxygen. Keep her drugged.

Paralyzed. Unable to breathe. And I help by placing a tube in her throat at this time.

There’s nothing more helpful to do, yet.

And sedation?

American voting public, perhaps.

My resident was confused about why I asked to come in late so that I could vote (ie, polls open at 7, can’t get to the OR at 6:30). In planning for the next day, he said, “oh, yeah, you’ll be coming in later because of your “voting thing.” Yup, it’s pretty kooky of me to want to vote on election day. Very original idea.

Change parties, cause, yeah, it takes time and work to revive someone brought to the brink of death and paralysis (making someone not be able to breathe or move?) Long-term and short-term.

And/or sedation to not caring.

Politics. Medicine. And it’s November, so there are words flying….everywhere.

~j

The Importance of Letters and Light

In brief. Before we take off on 30 days and nights of literary abandon (NaNoWriMo.org , thanks for that phrasing and the Office of Letters and Light reference), something on the importance of writing. Writing is important. (and..done). In science, I fight the stereotype that it's not. That literature's not serious. That pursuits of the arts arenot (as) important. That "easier" physics is "physics for poets." The easy, blow-off majors. Can't be serious if it requires fewer credits (college) and doesn't include hours drudging in chemistry labs among fumes and uncomfortable metals stools. 

Writers change the world, too. Writers dictate what we know about the world, everything that we cannot directly ascertain for ourselves (which is most things). Speechwriters, copy writers, editors, blog writers, journalists (obviously) - influence. Everything. I was influenced in no-small-way to work with the Obama campaign, to go to Chicago, after reading Dreams from My Father. In medicine, every single thing we do with a patient, we talk about, must be documented. Is written down.

But that's "non-fiction", if such a thing, complete objectivity, exists.

(even in medicine - it's fascinating, reading through a patient's record, to see how the past medical history/family history/social history "changes." As in, that particular writer asked different/more questions, didn't ask/wasn't paying attention, or the patient said something completely different. )

Sumerians, Hammurabi, hieroglyphs, Rosetta stone.

But fiction changes the world, too. It's how we learn about different cultures, different ideas, different times - stories, personal ones, are what make things poignant. Make them stick. In getting into a character's head, you start to understand - something - else. It changes the reader and it changes the writer. And poetry? Poems are listening, seeing, paying attention in a different kind of way, and trying to connect with a human experience. Reading and writing. The ether, the Jungian collective consciousness. To write more about poetry, I really need to reread Plato.

But I digress.

Whatever it is you write, fiction/not, 50,000 words/not, handwritten, typed, online, in a letter, in an email. it's important, it's November, so - write.:)

~j

Dear Media

(of corporate America)
(and peer-reviewed medical journals)

Stop. Advertising. Anti-Psychotics.

...and every other drug.

More soon.

~j

The Joy of Inflicting Pain

In a discussion of DSM IV axes of psychiatry, Dr. A, the department chair, asked us what we thought the most common psychiatric diagnoses amongst physicians were. We came pretty close to guessing. His top 3? Obsessive-compulsive disorder. Masochism. Narcissism.

The first is probably self-explanatory. The second…in brief… is related to the extremely delayed gratification process we willingly go into. I’m not sure any other career (tell me) is like this, in the time between deciding what you want to do, the years and pre-reqs until you can actually start school, school, training, and practicing on your own. And the hours, oh, the hours…

Between my starting pre-med classes and finishing residency, at least 14 years will have elapsed.

(it is possible to do a bit more quickly. But not by a lot, actually. Shortest duration would be approximately… 9).

The third. This may seem interesting in juxtaposition with masochism, but I think it goes along with a martyr complex. Do we talk about the hours we work? How hard it is? How much debt from school? The pay in residency, which works out to close to minimum wage, calculated per hour? (assuming 4 weeks vacation, 80 hours per week (and it’s really closer to 100), not taking out taxes, hourly is about $11: 4 years of college, 4 years of graduate education, and an MD).

(I just said it). Do we complain about pre-med classes, in particular organic chemistry, and the weeding-out process that does make things brutal, demoralizing, and…just…mean at times? (Professor for my second semester orgo lab course – “congratulations! You’ve made it this far, we don’t have to weed you out anymore. We’ll stop deflating grades.”). To get into medical school, we take an 8 hours- straight – test. It’s not that it’s hard. It’s about endurance. So much of this is about endurance, sacrifice (because of the god/martyr complex. Because you’re going to be, to do something “good” in the world).

Do martyrs complain?

Maybe.

But this goes along with narcissism. It’s a very elite club. We believe we’re “special.” And, as Dr. A said, we’ve grown up being told we’re special. You’ve got to be high achieving for awhile to get into med school, later. Not smarter. More competitive? Harder working? Maybe. Goal-oriented? Yes. And getting in – well. Families like to brag about that. There’s an awe, a halo, a cachet about the profession. We’re “special.” Orientation week, we were already in the alumni association (true). We had a white coat ceremony – a whole ceremony, with parents/etc, to have our advisors put the *&^%#$$ (my current feelings about them) white coats on us as we walked solemnly across a stage. And then we repeated, solemnly, the Oath of Lasagna (formerly…Hippocratic. This is the updated one. And yes, it’s really the oath of Lasagna).

You get a new name when you finish medical school. My preceptors, many of them, will walk into a room and say “My name is Dr….” (Somehow, I prefer “I’m Dr….”. Yes, you are that. But saying it’s your name? As if you were born with this, this indelible…? Maybe the verb “to be” seems more permanent than “name.” Maybe it’s just me). PhDs don’t get called doctor as often. My patients often call me doctor, even though I do tell them I’m not one. Nurses will call me doctor, and I tell them too. (Some get annoyed, sometimes, asking me a question, calling something to me, “Doctor!” when I’m sitting down, back to them, reading a chart. I don’t turn around. Talking to me? Must be someone else. “Doctor’ isn’t my name anymore than Ntangen was. It’s not their fault. They don’t always know my name. And calling out “medical student” might sound odd. But I’m not in the habit of responding, anymore than I would respond to someone else’s appellation).

Our entire lives, we have been told we’re special. We’re “special.” And then we enter a profession in which we are allowed to defy societal norms of behavior, every day. I walk into a room and tell someone to take off their clothes. Do they? Yes. Do they let me touch them? Yes. Granted, it is with a therapeutic purpose, and that’s why they came to see me in the first place. Particularly in exams where they can’t see my hands, I tell them “You’re going to feel my hands now.” Or “I’m going to start by examining your neck.” Or your eyes. I ask questions that, if I asked to any other strangers, I would get yelled at, hit, or thrown out of the establishment (potentially). At the very least, people would probably walk away. While examining…say, a person’s abdomen, if I see a scar (particularly if the patient told me she had never had surgery – this happens more often than you might imagine. People forget. A lot), I ask “what’s this?” “What happened?”

And they don’t get to ask me questions back – though sometimes – very benign ones. And they don’t get to touch me.

We think we’re special. I was thinking about medicine in relation to massage, the other day. Supposedly, doctors have “healing hands.” (some surgeons insure their hands. I’m pretty sure this is true). Overall, in the grand scheme of things, yes – things doctors might find with their hands could lead to serious findings, could lead to healing. But our “healing hands” often cause pain. During the exam, discomfort, at the very least. If I find something that hurts, I’m going to press on it at least twice. I need to check. And then, again – “does it hurt more when I press down, or when I let go?” After a visit to the orthopedic surgeon, my hands ache – a lot – for at least a day, if not more. Does this hurt. “Tell me, if at any time, this hurts.” And I write it down.

We have the power to inflict pain. “Things that are good for you.” Injections. Drawing blood. Procedures. I like procedures. I like having practical skills. So, do I enjoy lancing the abscess, doing the incision and drainage (I&D)? Yes, I do. Did I enjoy doing my first paracentesis the other day? (after ultrasound, I used lidocaine to numb the skin of the patient’s abdomen and then stuck in a large bore needle to draw off fluid from his ascites, 2/2 liver cirrhosis. At least 5 L of fluid. Getting the fluid out helps him breathe better, be able to walk without stopping to catch his breath every few feet, being able to sleep at night without waking up, gasping. He knows this. I know this. But when I put the needle in… victory! For me. Pain – for him.

One of the patients I I&D’ed asked me if it was the worst abscess I had ever seen. Well, it wasn’t, not remotely, and I told her I’d seen worse. Did she want to hear that, or did she want to hear that she was “special”, too? I hastily reassured her about her pain – I know it’s very painful. Can’t intimate that this is, should be easy for her. I learned suturing on foam, then pigs’ feet, then patients in surgery. Now, I do it on patients who are awake. We tell them, the lidocaine, the numbing medicine injections, hurts more than the procedure itself. Is it true? I don’t know.

Surgeons, actually, don’t inflict pain. It’s much easier to forget that the space you’re cutting into, that layer that takes a little pressure from the scalpel to slice neatly through and start spreading open layers, separating beautifully….

Is human.

It’s draped. The surgical field is draped in blue, there’s a hole, and that’s where you cut. The hole might actually be sticky plastic wrap, which helps keep the skin in place and keeps the area a little neater. Slice through the plastic. Into the skin. You can’t see the patient’s head – anesthesia gets that, on the other side of the curtain. It’s not sterile on that side. But to anesthesia it looks like a head with tubes sticking out of it, maybe, eyes taped shut. Things beeping. Lots of machines with things beeping. And vacuums and containers and things flowing out of tubes, and the smell of the cautery…

maybe not everyone wants all their senses engaged with this one.

I will always be grateful for the first surgery I observed. This was in Mvangan (Cameroon). I won’t say “scrubbed in on”, though in American parlance, I did. I walked in, wearing sandals. December 30^th, 2005, must have been. It was the same day I left village for the first time after moving there, going up to Ebolowa to celebrate New Year’s with other volunteers and some of our Cameroonian friends.

Doc knew I was interested in surgery, so he’d invited me in – I was hesitant, the first time. He was scrubbed, and he was the only one in scrubs – no, maybe Eco was too (first assist). The room was hot, humid, in the perennially 85-95⁰ rainforest with 90% humidity. Approximately. No screen on the window. No power – but this was daylight. We did have sterile drapes. No general anesthesia, without electrodes or intubation or any other way to monitor. It was ketamine and..something else…that I wish I remembered. Description for another day.

The patient, 30 or 40 something year old man, had been in a moto accident. His bowels, perforated. Had to be fixed. They had trouble putting him under – everyone was saying he must use drugs, he must, he must – they couldn’t do it. He wasn’t lucid, but he wasn’t completely out, either.

And so for the entire operation he was moaning. Moaning as he was cut into. Moaning as he was eviscerated, bowels piled on his abdomen as Doc searched for the defect. And then he started kicking. Knee into Doc’s stomach. I reached over and grabbed his leg, held it down, whicle the surgery was finished. No one in that room could ignore that this patient was alive, that what they were doing, this violation of bodily integrity and autonomy in the purpose of – to put it succinctly, playing god – was to someone with a beating heart. Whose lungs were function on their own – proof, the moaning. Proof, the kicking. ABCs? Check, check, check. He was alive.

And he lived.

When you’re operating – open, laparotomy – on someone who is moaning, you know you’re inflicting pain, you know the pain will be even greater when they wake up, and you have to concentrate even more (I imagine) on the task at hand. With a patient fully sedated, you can focus. Hands. Anatomy. Moving things carefully.

I do remember that day. First worried about what my own viscera would do when faced with…viscera, outside of another person’s body. But then, you do what you need to do. I wasn’t quietly in a corner, holding a towel over my hands if I hadn’t scrubbed. Trying not to fall over , standing for so many hours, as I kept shifting my weight. I was there, I was active, I was doing something basic to help. Keep the patient from kicking the doctor whose hands and knives are inside him. Can’t get sick when you’re concentrating. And not a single thing about me was sterile. My hands to his foot. That, too, is necessary.

~j

Almost November....NaNoWriMo. Just write.

One year ago, a friend challenged me to join her in National Novel Writing Month (NaNoWriMo) – which occurs every November. (www.nanowrimo.org). It started in SF ___, and the point is to write 50,000 words in November. We were, then, in our second year of medical school.

I’m mostly a poet (a year ago, I might have said “only”), and, a year ago, I’d never written any hold-together-able short story – that is, beginning, semblance of middle/end – longer than 2000 words. If that.

But rather than turn down a challenge….

Before November 1, I was terrified. I had no idea what I was going to write. Could I modify it and try for 100 poems? Write something non-fiction about Peace Corps? Try to write some short stories? How could I write a 50,000 word (that’s about 200 pages) story when I had no plot in mind, nothing, nothing, nothing….

Then it was November 1, and, while sitting in a café, (s/p a Book Festival – perhaps that helped with inspiration, too) – a voice started telling me a story. And I wrote it down. I didn’t even know (her) name for a few days, not until she went to work and someone called her by it. And I didn’t know exactly how things were going to turn out in the story (I still don’t) until about 2/3 into November. I didn’t figure out her motivation (ie, she didn’t reveal it) until about that time, or later.

And it was an incredible and thrilling adventure. Every night, sitting down to write (tried for an hour a night…sometimes made it… and more hours in the end) was like sitting down to read a book, because until I started typing, I had no idea what was going to happen. Somehow, somehow, I got to 51,000 on November 30. I’m around 60,000 now on that one, with more to go – and a lot of cutting and editing to do.

And my friend and I both won – ie, we got the 50,000. Together. (or in tandem). It was an amazing month. It’s like being part of that collective unconscious (…Jungian) into which we were all tapping, everyone writing, all having this experience.

It doesn’t really matter what you write – that matters to you, and the transformation matter. It will happen. It’s not about being “good”, technically or in whatever other aspect.

Writing is a way to discover things, explore new ideas, employ and exercise the mind and imagination. And when you let yourself go, with abandon, without self-consciousness, there will be new thoughts, new connections, new solutions that you could not have pieced together otherwise. The beautiful thing is – when you’re going for word count – you’re certainly not editing, because that takes away words! That can happen later. Just write, write, write. And don’t self-edit, limit, or stifle.

It’s how I see African dance, in a way. To do it – to really do it – you have to let go of everything. Everything. There is no counting, there is no self-determining of beats or numbers or rhythms. The drums determine. And by following the drums, you become part of the music, you are reacting to it and you are in it, you are integral and integrated, and you can’t think about how you look or what you’re doing or how you’re doing because something else is driving you. And that, precisely, is when it becomes right, exquisite, and everyone is doing it slightly differently but it’s all beautiful and all works together as part of the whole. As such, writing does not have to involve conscious thinking. It comes.

You don’t have to do NaNoWriMo in the haphazard way I did. Some people are capable of planning or prefer it that way. Or you don’t have to plan at all.

You can start pondering now. Or wait until Nov 1, waking up….whenever… and do it then. Or a few days later.

You don’t have to write fiction. One friend just said she might try it with letters. Write ideas. Whatever. And even if it isn’t 50,000, for November, it could be a goal to try to write something every day (which I’d only once before even had the discipline to do. As someone who tries to be a writer….)

Both my friend and I, now in our third year of medical school, are going to try again. We might not finish this time, but….that doesn’t matter as much as the process.

 I did this because of her, last year, and so this year I really want to recruit more people. Anyone. Everyone. And yes, everyone can write.

Just write.

~j