03 April 2011

Dance is a good complement to medicine.

I’ve been doing a few different types of dance, lately, and I just spent an evening watching semi-professional break dancers and circus performers and aerialists and capoeristas and…whatever else…just play. There were photos of Cirque de Soleil-type poses around the performance space. Having seen the spine, knowing some of the physical mechanics of the human body – it’s astounding to me to see that it’s capable of this. It seems as if it shouldn’t be possible. These are the things we learn.

When I see patients in the hospital, they’re in bed. The note, in fact (assuming the patient is doing well) will include something like this in the General subsection of Objective findings. “Comfortable, resting in bed, NAD (no acute distress).” If it’s a psych note, it will also state “dressed in hospital attire,” and I might make some comment about the state of dress (disheveled?) or hygiene – as indicators of state of mind, situation, possible delirium, connection to the outside world - or supposed to be. I might say “looks older” or “looks younger than stated age.”
(I rarely do this, but I had two patients in clinic the other day – same disease, basically the same operation. One was 62 and one was 82. Having read the charts, then going into the rooms, I had to double-check the names. The 82 year old looked much younger). Same for the 87-year-old who plays 18 holes of golf everyday and catches very large fish – he had a huge abdominal aortic aneurysm, without any symptoms, and by all rights, he should have symptoms, or have been sick. He wasn’t. It could kill him, so it had to operated on. Otherwise, he was very, very much alive.


There’s not much that makes an awake person look more vulnerable than lying in a hospital bed in a hospital gown. Regulations. It’s easier access for everything we have to do. Add lines and catheters and other things to make them look/be more trapped and helpless. There’s privacy and there’s not. We try. Some are better at it than others. But in the hospital, there’s an endless parade of health professionals of various types, all day, coming in to exam you. In, out, in, out. Physically, it might depend on your particular reason for being in the hospital as to how intimate/invasive an exam might seen. Some things, though, everyone gets.

I’ve had patients from the hospital then follow-up in my primary care clinic. They looked like completely different people. (Good lesson, that). Home, able to dress and shower as they liked, in their own clothes, and standing and sitting and walking around the room. Comfortably. Some patients do put on gowns, but mostly, they don’t (or didn’t, in this particular clinic). Even if they did, I usually saw them in street clothes either before or after. They walked in. They didn’t look as vulnerable anymore. In the hospital, I sit down next to the patient’s bed, when we’re talking, and at times I sit on the bed. But there’s a major inequality there. In the office, we meet more collegially. Longer term problems are more of a team thing – for my patients to stop smoking (three did) takes both of us talking and working on it. Hypertension, diabetes, anything. It can’t be just me and it can’t be just them. In the hospital, though, you’re more helpless. Other than the powers of positive thinking (true), things are happening and being done to you, in the acute sense. You have no control over food. You might not be allowed to get up (fall risk) without another person around, and if you do get to take a walk, you’re dragging an IV pole. You can’t cure your own pneumonia or small bowel obstruction or COPD exacerbation or lupus exacerbation, while you’re in the hospital. There’s not much agency there.
I had a 15-year-old patient with acute kidney failure, and we were severely restricting his fluid intake to make his body re-equilibrate sodium (the treatment). To know if we were doing this, we had to know “Strict I’s and O’s” – input and output. Fluids. His rebellion against the medical system was to not to use the specially-designed urinal to record volume (important? actually, yes). He forgot, or he didn’t, and this was the one way he could – not – do what the doctors were telling him, in this instance. So little participation required or asked for in those settings.

Sequoia national forest

Anyway, patients are vulnerable. On a work basis, I don’t see bodies in motion very much. The moving targets are the doctors, rushing around, up and down and rounding and rounding and having team discussions while running in the stairwell and…if you don’t keep up, if you linger riefly to do something else, you will get left behind. I write notes while walking, sometimes. The mandatory alcohol hand sanitizers in the hallway? You never stop to use one, it’s a drive-by thing. Most things are. And the times we run – the codes, the emergencies – are full of adrenaline.

Even in the office, patients get up from chair to table and back again. I know if they walked in. I ask about activities. I might test range of motion, so I see how – actively – they can flex and extend, and then I check passive motion and move the joints for them.

The amazingness of the body is the physiology, in this sense. It’s hearing the heart and lungs, feeling the liver and spleen in the abdomen, finding neurologic abnormalities, seeing internal organs from the outside. In the OR, it’s everything that’s still alive, pink and pulsating, and that, gods, all the structures we learned about and then saw in cadaver dissections are really there. Each part is full of life; so is the incredible whole.

Around Nselang...things that shouldn't be possible, but are

Patients don’t always get to show me their amazing. One patient, who was supposed to get open-heart surgery last week, had high blood pressure up to 250 systolic in pre-op and then 315 when anesthesia was starting to put him under. I’m still incredulous – though I knew, and I knew – that you can be alive with a blood pressure that high (‘normal’ systolic is < 140).
So that was amazing. But it was a physiologic response. The patients who are so sick you’re not sure how much better they can get – and then they do – are amazing. The patients with completely uncontrolled diabetes that has been so uncontrolled they can no longer feel their feet – who work hard and get their blood sugars under control – they’re amazing.
I had a teenage patient, post-severe concussion, who’s a dancer and told me about his ethnic dance group. There’s the kid who broke his hand playing basketball. I know, I talk with them about what they can do physically and how important it is to them.
But I don’t see it.

Seeing bodies in motion, then, seeing things that shouldn’t be able to happen due to gravity and bones and ligaments and facet joints between vertebrae – is a reminder of why what we do matters, in the long run. It’s the why. The living that isn’t just being alive, but the celebration thereof, and everything concomitant. They why does come up – operative or medical choices and how they impact a particular person’s life. With the basketball player – he had championship finals coming up the next week. To me, that meant that if we let him go with just precautions and no splinting or formal treatment – he would certainly reinjure himself or fracture what, at that point, was just an “almost.” For the dancer with the head injury, I needed to know if he was dizzy when dancing, if he was falling over, and if he had trouble remembering dances that he used to know well, or learning new ones. For my patient who worked nights, I made sure to get him the latest possible appointments in the afternoon, so that he could sleep. All of that is there in the encounter – particularly in the outpatient ones. And we talk about it, and I try to remember. But we don’t see it. In the hospital, especially for the sickest ones, I try to remember – and to find out, to ask – what they do, who they are, who they were when they weren’t sick. I want to imagine that. This is why it’s a good reminder. It’s absolutely incredible what people are capable of, what they can persevere against, and in the moment, all you can do is watch and be awe-inspired.


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