26 January 2011

“You made everyone have to dance tonight.”

(for current lack of a better word - call this Zen Part A)

My African dance teacher, to me. Tonight.

I’ve started going to (West African) dance regularly again … and by regularly, I mean two weeks in a row. That I plan to maintain as much as I can. Again. I started dancing (this) in spring of 2002, and I got into it more seriously in the fall. My first teacher was Malian, and my first classes were in too-large-or-too-small-classrooms-or-sometimes-alcoves around campus. I had started modern dance around the same time, and I was doing step (African/American, not drill team-like), but once I started classes with Joh…I gave everything else up. It didn’t matter anymore. Nothing compared with this.
It wasn’t like that at first. After the first time, I wasn’t sure if I had done anything difficult, actually, or even athletic-like at all.

Then I woke up and I couldn’t move.

And the next time and the next time. If you’re doing it right (and there are infinite ways to do it right), you use muscles that Western life (and most Western dances) never touch. And the only way to do it right is to stop thinking.

Stop. Thinking.

22 January 2011

"…and she throws things at people who walk into the room…”

 Anna. My angry little girl.

I use angry as an adult term. Little girls might throw tantrums, get mad at their parents for grounding them, want more TV, more chocolate, more toys…less siblings.

This little girl is angry.

And I get it. She’s five. She has a disease that will shorten her lifespan. It will. Significantly? Likely. Will she need a transplant in the future? Probably.
And right now… she has the heart of an 80 year old hypertensive smoker and she needs treatments and she’s on who knows how many meds… She’s in the hospital, at least every six months (and this is if nothing is wrong), for weeks at a time. Right now she can’t leave her room. And her room is covered in pink and princesses – the hospital has a lot of toys they give and loan (it’s amazing, actually). I haven’t figured out exactly which are hers. Sometimes the toys fight – a lot – and sometimes she points out which ones are polite. Sometimes the others have to go in a secret corner.

She’s an angry little girl.

I thought I had won her over today (I’m actually doing pretty well, considering, and compared to how everyone else thought she might deal with me). It’s partly about trust – I was running out, late, and I stopped by to tell her I couldn’t play right now, that I’d have to come back and play tomorrow. (With my adult patients in the hospital? We sit and talk. With the kids? We play… I have learned, thus far, that the nice-black-pants are not good for peds in-patient, because I’ll be spending a significant amount of time sitting on the floor).
I opened the door after I had hastily thrust on my mask, hand sanitizer just starting to evaporate. “Anna, I can’t…” she ran at me. If this was my cousin’s child (or many of the other children of my personal acquaintance), she would have been running to hug me. But no…not quite. She was running at my lizard.*

*It’s peds; I have a bright blue lizard attached to my ever-present bag (WE DON’T WEAR WHITE COATS WITH THE KIDDOS! and the peons rejoice..) It’s the distract-the-child version of a penlight. (ie, open the mouth, shine a light in the kid’s eyes). Also used to check gross and fine motor coordination in the little ones and to just mesmerize them and get them to stop crying as you try to examine…

And she meant to take it.

Yesterday, she stopped talking to me when I left, after dinner was brought in. Her dad had just returned and I…wanted to go home. I was done for the day. And as much as I had enjoyed the time, dusting off my playing-with-five-year-olds skills, it was a good exit point.
“Anna, I have to go now. I’ll be back in the morning…the lizard and I will be back in the morning.” (we’re still looking for a good name for him. I think she decided it’s a ‘him’ lizard. It's blue, after all, in her pink-pink-pink-and-purple-room). “I want the lizard!” “I have to keep him, but he’ll come back with me.” “I want you to give him to me.” “No, Anna…”
It goes on. And on. I leave. Only when I return in the morning and am greeted somewhat grudgingly (she was busy typing stories) do I start to make my way onto her good side.

She’s an angry little girl.
(few days later)

Now she runs to hug me when I walk into or exit the room (try to exit the room, let’s say). Me with my mask on – at least we don’t have to war the alien yellow paper (are they paper? some sort of strange consistency. Something disposable) precaution robes (can we talk another time about how random/arbitrary medicine really is when it comes to precautions? K). (At the VA, at least, they’re real cloth and thus washable. These, everytime you leave the room, you throw out). With her, it’s just a mask, but the plastic shield covers my eyes. I throw that out, too. Anna can’t leave her room – not yet – maybe in a week. They want her heart to be a little better before she leaves, this time. This hospitalization.

It’s morbid to think about another kid dying. Eventually, she’ll need that. Eventually. Maybe she’ll be adult-sized by then, though. But then I think about a young-healthy-organ-donor-adult dying, probably in some sort of trauma, so the organs are still good. Morbid? Yes. But as humans, we/ (I) care about the particular and not the general, the angry little girl in front of me and not whoever else will die to help her live. Someday.

This time (again, a few days later), she won’t let me leave the room, she’s climbing up me and is entwined and firmly clamped around my legs. “NO!” It takes awhile, but eventually, I get to go, after we’ve pretended to travel to magical lands (she instructs me how to do this, obviously), and we’ve taken the princess suitcase (probably at least as heavy as she is, but she insists on carrying it) with us on the pretend airplane.
I try to do the doctor bit, too, a little. I listen to her. I check her pulses. I tell her to eat, I talk about the treatments she's supposed to have. But I do the same thing with my adult patients – I sit, and I talk, and this time it’s on the floor and playing and figuring out what she thinks/wants through what she plays. She hasn’t been making her toys fight, the past few days. And this angry little girl... it's when I'm pulling her off me by the arms, picking her up, getting her to sit or stand on the chair or stand up and stop sitting on my shoes... that I remember she's six. Not that she acts any older - it's the emotions she projects, it's the room.

Anna reminds me exactly of my cousin’s daughter (in France). That one, Catherine, is a little younger. There hadn't been a girl this...well, girly...frilly...in my immediate acquaintance (or genetic pool) in a very long time. Not one I'd spent this sort of time with, at any rate, in this capacity.
Catherine’s also into princesses. Princess dresses, dolls, coloring books, stories…everything, everything, everything.  It’s what she got at Christmas. And it’s what she pulled me down onto the floor to play with her. And she was running around and ordering me to come after her and didn’t want to leave me (this time, I was staying). We didn’t go outside together – it was frigid, actually – so maybe it didn’t feel all that different, in that respect, from being with Anna (and when I am with Anna, I can't go outside, anyway, for awhile). Who could leave. Who could go. And she (C) isn’t really angry – bossy, yes, commanding, yes – but not angry. Her parents think she’s impossible sometimes. (...as do Anna's). And, gods, imagining her trying to comply with medical treatments without throwing tantrums (that’s one thing we’re working on with Anna…her heart might be better right now, it’d be a shorter stay, maybe fewer medications at some point, if only she’d let people….)
They’re pretty similar, these two. They don’t speak the same language, not verbally, but I know that wouldn’t matter. If C had a hospital room it would look exactly the same. And her mother would stay, too, and leave when I was in there, and sit and talk to me while her daughter ran around the room. We’d do that.
But one is sick and one is not. Anna looks like…well maybe one of those characters in a 19th century novel. One of the little ones with TB, so little, long hair, eyes a little sunken, pale, pale, pale. Those little girls didn’t run around the room and throw things – though probably they did – it just didn’t seem like the thing to write about, at the time. Maybe Beth in Little Women. Maybe the girl in Jane Eyre…what the heck was her name… when she was young. One of the orphans in one of those books, around this age. Fever, fever, burning bright. Consumption. The romantic diseases... I’m reaching for names of books I haven’t read in... a decade and a half? More than that, but not quite two. It’s been awhile.

I don’t think about prognoses until I ask. I know them, I can figure it out, after all. For the most part. But doctors are terrible at this part. Terrible. You always want to think the best. And sometimes that works out. And sometimes there are miracles…(see that). I’ve seen it. And as time goes on, I’ll see more miracles and more not, more things going exactly the way numbers will and more things that are surprising in either direction.

On our team, at this hospital, the kids don’t have just one rare disease, but at least two. The multipliers are staggering. Within a rare disease, they probably have the rarest subtype. That’s what it is to work at a tertiary care hospital (I am, currently).
The interesting thing is I haven’t used Spanish in over a month (this is bad, actually. And, okay, not technically true. I used it very briefly to explain to a patient on neurosurgery that he had not, actually, had another stroke, after the neurosurgeons rushed out of the room. They assumed he understood English in the way he nodded his head, and, after all, getting someone to help talk through that would take more time. If they did take more time…well, I know what the days would be like. At least there are NPs to provide the patient care, later in the day. It becomes sidelined in surgery).

And there is the major, major, part of me that is not a surgeon. At all.

I digress. Medicine, hospital medicine, and the part of the day that is spent on patient care is an entirely different issue…

The Spanish thought was ancillary, perhaps. And maybe not. Each day in medicine feels like a week, and it takes looking at calendars and counting days to realize how little time has passed. I have spent five consecutive days on this team, in pediatrics (we started on Tuesday). And yet…
each day is a week, each week is a month, and each month…well. It’s draining and it is different, completely different, than a lot of other jobs. Because of this bit.  The people bit. And the disparities in healthcare bit – it helps with kids that they’re all eligible for some type of insurance. I'm not as incensed about inequality and unfairness and...it does become a question of ethics... multiple times per day. Not this week.

But why haven’t I pulled out the Spanish dictionary in over a week – why does it live in my bag in the MD charting room, right now, and not in the ever-present one? It’s tertiary care, it’s really really sick kids with really really rare diseases – why not the same percentage of Latino kids as there are in the state, in general? The demographics don’t reflect this city, at all. Particularly in that there are a heck of a lot more Latino kids than white or anything-else-ones. (I guess one of my patients this week was part Latino. Okay. English-speaking parents though. The patient is non-verbal. He's 23 years old. At any rate).
So it’s an issue in accessing care, then. Has to be. In knowing about how to get it, in getting in primary care in the first place and somewhere someone will recognize something and send you on. In the parents knowing about the system, in that being as ever-present in their lives or knowledge base. Haven’t used Spanish yet and I can’t figure out another reason why. (I mention this in socio-economic terms partly because of the numbers, partly because of where I’ve worked before, and partly because … if the patients are monolingual or mostly monolingual Spanish speakers, in general, they’re not upper-middle. And that’s when I need the dictionary). Not all these patients come from middle to upper middle, not by a long shot. But still. Demographically and language-wise, there’s something odd about this hospital.

And Monday I’ll see my angry little girl again, because she’s not leaving soon. I think I’ve been there enough that I’ll be forgiven for not going in on Sunday. Maybe.

And none of this is because I care more than the actual doctors. I have more time. And I’d rather put off the studying to play with the angry little girl… there are other times for that… and other times I need to use for that…I just have more time. And while I can do a lot now (I can be useful! It’s getting better…), I’m just carrying two-four patients (two got discharged today), and I can’t sign orders, and I’m not the first person who gets paged, and the residents have to check in on the patients, too. And while I can and do write notes for all my patients, the notes have to be read over by the interns and residents, co-signed, and posted. Which means that has to happen after I’m done, which means they stay later. 
So the ones who don’t have quite as much time, not nearly, get the finger from Anna when they go in to examine her. It's her favorite finger for the pulse-ox machine, too. The ones who are there more often – like the therapists for various things – don’t get that finger anymore except when she's kidding, and they don’t get things thrown at them..

These are the good parts. And then I too can forget for a bit that she is sick, chronically, and that the rest of them are. That, actually, I'm sitting on the floor but there's a stethoscope around my neck, and the lizard she keeps stealing is a medical tool/toy. She always remembers to give it back, now, and she was worried today that I might lose it in her room.

My angry little girl. Not always so angry.


18 January 2011

The thing is, I'm not super - anything

(still on brains)

Wednesday, surgery from 10 am to 6:30 pm. We were standing, in lead coats from neck-to-knees (starting at thyroid), in an already unseasonably-warm OR. It was the same surgery on Friday (see last), but it took much longer, even though the patient’s case was technically easier.
No eating. No leaving.
A nurse brought in cold juice with straws for the surgeons – I guess it’s sterile if you do that below the mask – but they didn’t end up taking it.
(The lights are flashing in the neuroradiology reading room as I write. Am I leaving? Not yet. Things I ignore. Does it mean a machine is going off? Mostly, it’s not beeping. I’m early because parking was easy for once. In this city of public transportation and convenient shuttles between hospitals, neither option will get me here early enough. Driving alone at 5 am…that’s another story).

10 am to 6:30 pm. The intern and resident were closing around 5:30; they had already pulse-lavaged the spine, all clean, no active bleeders. The muscle was back together. The fascia. The subcutaneous fat…almost to skin. The attending walks back in. “WAIT – did we **???” The resident. “Mostly, yes, but we didn’t re-do that after the surgery.” The attending walks out. Few minutes pass. Attending walks back in, having deliberated. “..And we’re going back in.”
At this point, starting to feel faint – all of us had realized (and this was true) our scrubs were completely soaked through with sweat, it was so hot under full lead wraparound coat…), standing there a few feet from the surgical field and leaning, leaning to peer in as much as I can…(this attending did not let me do as much/get as close as the one from last week)…

I stepped away from the table. I went to sit down in the back of the room. Do I go back? Is there a point, at this point? After a minute, I pulled off the top pair of gloves, pulling the gown off with them, putting the entire spattered bundle into the trash. Second pair of gloves. Now, dear gods, the lead coat….

And I stood, hands crossed in non-sterile gloves, and I stayed.

(The lights are still flashing. How do you even evacuate a hospital? They didn’t, for Katrina).

There was another surgery that was going to go as an add-on. Maybe. The patient was stable, urgent but not emergent, and she’d taken two (full, 325 mg and not the 81s) aspirins that morning. (One of our attendings/teachers in the first two years tells the story of his famous third-year mishap. On morning rounds, he proudly pronounced that the patient was taking “ecasa.” Not knowing what it was. “ECASA”… is enteric-coated acetyl salicylic acid. Aka, aspirin). The attending was worried she’d bleed too much. The surgery was a ventricular shunt revision, which basically means they go in blindly, apparently, and if there’s internal bleeding in the brain, they won’t see it.

It was unclear when or if the add-on would go. I left. 7:30.

(Buckets on my porch in Mvangan, waiting to gather water before the impending storm)

The next day, I found out the surgery had gone, and rather than being fairly straightforward, as they had expected, it went until 4am.
A sub-intern would have stayed.
A superwoman, super-medstudent would have stayed.

I went home.
I couldn’t stay.

I was barely lucid even going home after the first one. We had to jump my housemate’s car, and I kept not understanding what she was saying, that we had to do it now (and could do it now) because she did have cables and I did have a working car and we were not, after all, waiting for someone to arrive, bearing cables, magically.
(if that doesn’t make sense as a sentence, neither did the situation in real-time in my head).
I just kept talking, and I alternated standing and jumping back onto the kitchen counter, finding odd bits of food I had. This was a day, and I’m even on a two week (done) rotation without evaluations.

There is nothing super or more than human about me.

And yet – and yet. I’m mostly close enough to see the surgical field when scrubbed in, in the OR. I’ve gotten used to crowding surgeons and they’re trained to be used to elbows. Small field, small incision (funny how scalpels are the symbol for surgery in word and in deed – they’re only used to cut skin, nowadays, and that’s so little of what’s done. Tiny minutes of the hours).
It’s a small surgical field and there are a lot of people. It’s useful to be claustrophilic.

(Kalabash! Market in Tourou, EN, Cameroun)

Time in the OR can drag, but that case didn’t feel like it was 8 hours long, and it’s fine and interesting. Fine. Then..I’m directly over the surgical field and I’m stunned. I’m fixated.
It’s unbelievable, unbelievable, unbelievably incredible that I get to be here. Looking into the interior of this person’s body. And not just looking but acting.
Part of me… a not small part of me…is a surgeon.

Proprioception is important at all times in the OR (see: the neuro exam). Proprioception – sense of your body in space. There are blue things everywhere. Blue means sterile (except for the blue non-sterile ubiquitous gloves by the door. That’s confusing). But everything else blue is sterile. The blue (Kimberly Clark has the monopoly, here) sterile surgeon gowns we spin around in. The OR dance everyone does. The blue gloves that go on beneath the whiter ones (though, sometimes, these are green). The blue cover on the instrument table. The blue towels. The blue drapes over the patient. The blue drape that separates anesthesia from surgery.

And your personal sterile field is a tiny window, just-below-shoulders to waist, basically. Arms, but mostly up to elbows. And that’s it. The back of you is not sterile. Do not turn your back to the patient. Do not touch the front of a sterile person with the back of your gown. Do not brush against the instrument table with any non-sterile part of you; they will have to completely re-open (and if you come close to doing this, you get yelled at. A lot). And somehow, magically, in the large OR that becomes a tiny, crowded, space, this almost never happens. You have to know exactly where you are in relation to everything and everyone else at all times to know how you can move. Awareness of yourself. Awareness of where the patient is.

I’m getting better at this, maybe.

This Friday, I saw something I’ve never seen before.
An attending had to back away from the case, sit down, scrub out, put his head down, and not pass out. He didn’t pass out. Attending, high-powered way-up-in-his-career surgeon. Super-sub-specialized. He had to stop. Another doctor, a non-scrubbed one, went over to him. Checked if he was okay. Spoke to him, gently. Was he having chest pain. Did he need to lie down. Someone went to get a stretcher. Someone else went for juice and chocolate. The sugar helped with the hypoglycemia. Whatever else… he left the room for awhile then returned and resumed his part in the case as if nothing had happened.
Doctors are supposed to be super-everything, surgeons in particular. I had never seen this happen.
Later in the case, this attending’s resident had a break in his work; ie, the resident from the other surgical team (this was a collaborative case) was taking over for a bit.
The resident backed away and sat down. You can do this and be sterile. But he sat down. At some point, he also scrubbed out to go to the bathroom, maybe, get food, maybe.
This was new to me.

For the other cases, it’s amazing to count how many nurses come and go. They have shift changes and they have mandated breaks (doctors don’t have unions. Or clauses). Anesthesiologists take breaks, too. Every few hours they’re relieved by someone else. In and out, in and out, faces and names and voices (behind masks) change all day in the OR. The surgeons are the same. And they almost never leave and never falter.

(Rhumsiki, EN, Cameroun. Continuing to be random)

I might take back some of what I said about neurosurgeons. Maybe it's the hospital where I am. And the particular team.

But in medicine...

Take the case(s) of Ms. Lee and Ms. Li. One is 35, the other is 65. One speaks Mandarin, one speaks 7 Chinese dialects and some English. One has metastatic cancer to her brain. The other has a primary tumor, we think, without the full pathology report, and all that's been done so far is a biopsy.
One went home yesterday and the other is still in the hospital.
And the team can never remember which is which.
"The Lees".... luckily, they're on different wards in the hospital, but that doesn't actually end up helping a lot.

"This" thing. Woman dying. Old. Sick. How much does she understand? We're not always there with an interpreter, we don't know.... and the family won't get together to make her DNR. As if this is the only acceptable option. It's true that for this patient, intubation might count as battery in the sense of...do more harm than do good. Legally bound to, however, without that order. Without physicians declaring "futility of care." (I can't remember if I told that story... perhaps later).

There is an actual story coming later this week. Almost done. Perhaps a little more...upbeat? 
There's also a much funnier story about the rest of what happened on Wednesday, during the surgery. Perhaps. If asked. And with a little levity.


08 January 2011

"It’s not Brain Surgery"… okay…actually…. it is.

I saw a woman’s brain today. I didn’t touch it – not even the intern, MD,PhD in neuroscience – did. But I was standing there, inches away, peering over the table and into her cerebellum. The surgeons were pointing with instruments – there, there. There’s the tumor (metastasis). There’s her normal brain. The cerebellum looked like I imagine mitochondria look on the inside, the maze of cristae folding back on each other. Or, the stacks of thylakoids in chloroplasts* Beautiful, regular, waving folds, just like in the pictures and the models. I’ve seen brains before. I’ve held a brain in my hands – we had them in anatomy lab. I’ve dissected a cadaver’s head to get to the brain, and I’ve dissected brains whole.

* Disclaimer – had to look up the words, I just remembered the pictures. It’s been… not sure how many years since I did any plant biology. Perhaps 10.

I didn’t dissect this brain. I didn’t even touch it, not this time. But I looked into a woman’s brain today. And she was alive.

I’ve decided that neurosurgery is perhaps the worst career in the world. Even as 4th year med students (not me) and certainly as residents, you’re on Q1.Q1. Q refers to call schedule, and the number refers to how many days between calls. In residency, Q3 or Q4 is common. Q3 means on call one night (overnight), post-call the next day (ie go home around 1pm, theoretically), normal day the next day, and then you’re on call again (you slept two nights between calls). Q2 is fairly common for neurosurgery residency as well – you sleep every other night.
Q1, you live at the hospital. The resident can stay home, but realistically he gets called for something at least once every night, likely many times, and almost always has to come in. Work hour rules (currently) state you have to have an average of one day off per week, or four per month. So there are some of those. But you’re basically taking care of (on our team) 30-35 patients, yourself, your pager is going off every few minutes  (it makes me nervous and jumpy and I’m not even wearing it!), and – it’s brain surgery – there are emergencies. Lots of them. Having a neurosurgeon on call 24 hours is what qualifies a hospital as a Level One trauma center, actually, and I’m at a Level One. (there’s a House episode on that issue).

Tree rings...yosemite. Another kind of inside intimacy.
I wonder what correlating hours are for rocket scientists.

They were in the woman’s brain and somehow, later, after she was all put back together, she woke up. They were in her brain and she survived – maybe normal. Maybe-ish. They took out a large tumor from the cerebellum, about the size of a walnut, a friend described it as. Metastasis. They sent the frozen section to pathology in the middle of the surgery. We waited. We waited. “Metastatic carcinoma” came the phone call. It wasn’t a surprise. The most common brain tumor is a metastasis from somewhere else – breast, lung, lymphoma. And if cancer has metastasized and spread to your brain, it’s already pretty bad. The surgeries, then, are often palliative. Not going to be cured. Maybe a few more months, maybe a year (?!) but they were inside your brain and they took out pieces of it. You don’t always survive that, and when you do, you don’t always survive as the same person.

And there are scissors and microscissors and wax and hemostatic foams and sutures and bovie (cauterizers) in your brain. And you wake up and part of you is gone. You give this amount of power, this amount of trust to someone who has gone through, yes, that many years of training in that special kind of lack of sleep. (Terror? Hell? Torture? Not going to judge). Somehow, the group of neurosurgeons (interns, residents, attendings) are, on average, perhaps the coolest group of doctors-in-a-specialty that I’ve worked with, and one of the groups I’d most like to hang out with. Very laid back. This…surprised me. And maybe it’s not true everywhere. But they’re all very casual (in a good way), easy-going. If you thought all day about how you were in people’s brains, maybe you would go mad with the stress. I might. They don’t – at least not for now. And the ones who have completely burned out would, by definition, not be there for me to meet.

I would trust them as much as I would trust anyone to be inside my brain. And I’m not sure I’d trust anyone.

A general surgery resident remarked on why she didn’t want to be in neurosurgery – “The patients don’t leave the hospital walking. They might have come in walking. They don’t leave that way.”

(Yaounde, my walk to work summer 2009. Capital city yet such beautiful views..I will continue to be random...)

And today I saw the inside of a man’s neck, I saw the surgeon remove parts of his spine, and I screwed bolts into metal rods millimeters from his spinal cord. Unbelievable, unbelievable chutzpah. And yet… this is why surgeons are known as arrogant. They have to be (and these, somehow, doing arguably the most high stakes/dangerous work, are the least arrogant I have met). You can’t hesitate. You have to make decisions with confidence. Or someone dies. You have to work quickly and confidently or they could be paralyzed. They could be comatose. They could wake up being someone else. Or, they could wake up, be able to move again, be awake and alert again, and regain their own personalities and selves (see: man who regained a language).

But the point is….medicine is the only career in which the thing that we use in our work is the same exact thing that we work on. We use our bodies to work on other bodies. They are thinking, intently, while working inside the part of a patient that makes them, that allows them to think. Hand surgeons use their hands to fix someone’s hands. This is what has marked me most in my personal practice (hands being very important to me. Which is the other point and why we can’t ever separate… we’re not different than our patients. We are them, at times, and they are the people we know). Holding my cadaver’s hand in my hand while I dissected it. Thinking about my own tendons and bones as I uncovered hers. This summer, examining a patient, newly diagnosed with lupus, on her swollen joints and arthritic hands. My aching joints (not nearly to any similar degree) holding her, turning them, without being able to tell her. Not always. Sometimes. Sometimes.

This is the unbelievable intimacy. I have seen the inside of people. I have spoken with them, I have examined them, I have met their families, I have talked to them about their fears, and I have seen the inside of them and touched it. Last night, when one of the lamina (back part of the vertebral column, protecting the posterior part of the spinal cord) was removed, I held it in my hand, cleaning it carefully, and turning it over and over and over. My sterilized hand, enclosed in two layers of sterile gloves, was cradling and examining part of what had protected this patient his entire life, what had been such a crucial part of who he was. Is. This patient had broken his neck, in the literal sense, and somehow the cord hadn’t been touched, yet, though some was beginning to show signs of compression. I saw the inside of a woman’s brain and I talked to her before and afterward.

I have seen, I have touched parts of patients that no one close to them has ever seen. No parents, no lovers, no children (usually). And maybe they don’t care and maybe it doesn’t matter to them. But I’ve seen the parts that keep them alive, that are working all the time, that have grown and changed as they have grown and changed and show signs of wear, of injury, of things no one else knows. This is where pain has come from and been felt. This is the heart that speeds up, or slows down, or sometimes feels like it’s about to burst out of their chest. This is the organ where they think, and we don’t understand how that happens (I don’t, at least) – but we know where it is. We talk so much about hearts and brains…I’ve seen them. The loci, maybe not really connected to the feelings about them. And maybe so.

And this is where I see poetry. (the thesis and strong connection * may * because I’m  currently trying to convince grad school admissions committees of why they are the same, and why being a writer will make me a better doctor and vice versa). My favorite quote about writing is: “Writing poetry is easy. All you have to do is find a vein and open it.”

Nothing is more true to me. And this is why writing real, writing good poetry…hurts.

And this is why there’s an incredible sort of intimacy in writing workshops. It’s different than anything else I’ve experienced. The poems are not about the specific thing they are describing or talking about, exactly; they’re what it means. They are the most exact, precise way to describe it in the fewest words and spaces and pauses and line breaks. Friends may know what or whom I’m writing about, depending on the details and depending on when I write it. They are either wrong or right or, more likely, some of both. The person I’m writing about or to may recognize it, or not. I don’t know. Maybe the particular details that marked me so deeply and crucially…didn’t. Maybe I wrote it years later. Maybe they’ve forgotten entirely.

I write about myself in first, second, and third person. Depending. As in – the “I”, “you,” or “she” might be me. Sometimes I write in the voice of other people as “I.” This is why I/we try to remember to separate speaker and author. Often the same? Sure. Not always. And what’s written is usually not exactly what happened. In the moment or directly after, I usually write too many details and too “exactly” what happened. Over time it’s easier to cut and change – it doesn’t hurt as much to change and remove lines I’m attached to – it’s not where the poem is. Often not. For now.