Kevin in the elevator

Dear Kevin-in-the-elevator,

Yes, I am using your real name. As told to me. Assuming you are real. Assuming I did not walk around 14 floors – as directed by the guards, this is a very secure building, with my large box of office supplies and binders with information on buprenorphine – and down, around, past more guards (how secure if I don’t have a badge yet?) – to end up on a not-real elevator in a not-real building.

But really, Kevin, imagine my surprise when the elevator door opened – me and my not heavy but awkward box, my colleague M with the dolly that refused to take corners well; we took turns with that and the box – and there you were. I’ve called it a folding chair when I tell this in person, but I don’t know what to say the chair was – nicer than a lawn chair, not folding, but the kind with spindly legs and textured plastic seat. I think. Did you even have a cushion? It was the Metro paper folded underneath – the free one. There’s very little light in the elevator.

We mentioned our surprise upon seeing you, me and M. And you responded, “Oh, I’m new, I’ve only been here since Tuesday.” It was Friday. Kevin, M and I had never taken the freight elevator, alone or together; you seemed to assume we’d known your predecessor. Or it was just another bad or awkward joke. She asked your hours. We were shocked at the – constancy of them. Eight to six, you said. Hour lunch break I assume. And every day. Who gets weekends? Or is there no health department freight on weekends?(the buttons, after all, are the pretty normal push-‘em kind, you know).

When we got back on the elevator, I remembered your name – M was impressed. How many men living in boxes does she know?

Name, man, elevator.

Market, N'djamena, Tchad

Freedom fries

(This is a sketch of a post. The rest...later).

I used to actually hear that, fairly frequently, in 2001 and 2002. Somehow, that was a response to my being French.

It's an interesting word, "freedom."

It has a number of negative connotations for me now. "Operation Iraqi Freedom." et al. (not going into that now). It's a way to wrap things in the flag. That flag.

"Land of the free, home of the brave."

from Emma Lazarus, as engraved in the pedestal of the Statue of Liberty:

"Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!"

from Tom Petty, "Free Fallin'" (incidentally, excellent Americana song, too..)

"And I'm free, free fallin' "

As one who's been in freefall, before, I preferred parachuting down (skydiving). Freefall is too fast. In sixty seconds (less? I don't remember) we descended 5000 feet or so. However the physics works out from starting at 13,500 feet and parachuting from somewhere around 6000.

It was too fast to experience, really - that would take another jump, but as - even if I jumped tomorrow, it would be 6.5 years later - might be like starting over again. Freefall. Fun? How would you remember? Too much to process, see (and I had to adjust my goggles; seemed like they were going to fall off. I do remember that).

Freedom.

I was at Riker's Island today. Famous NYC jails (and poss prison too? unclear). Tens of thousands of detainees/inmates/incarcerated...today was my second time doing any sort of prison work; I'm just starting to learn the language. I'm working with the NYC Dept of Health, and, in particular, with Harm Reduction services. Every month, we go to Riker's to teach about harm reduction, clean needles/syringe exchange on the outside, hepatitis C, and, today, overdose prevention and treatment with naloxone. It was wonderful to get back to that work.

Being in a prison is incredibly strange - the checks, the IDs, the leave-everything-including-everything, all the bars opening and closing behind us.

I had done that before. And the similarities with psychiatric wards, also (they're co-morbidities, anyway) are fascinating...

That's not the point.

On the bus to Riker's (MTA bus goes directly there, from Queens), you pass La Guardia Airport. And then thirty seconds later you're on Riker's Island.

People worry about planes landing in the water? They could just as easily, truly, land on Riker's, on any of the jail complexes. It's an unbelievably short distances. The planes were, essentially, there. Everyone's looking for the NYC skyline as they land - who sees Riker's? Notices? I never did.

What could symbolize more freedom? International airport, busy, restricted to people with some amount of money/privilege, vacation vs business vs...

airplanes. coming. going. landing. taking off.

Right over Riker's.

As to Emma Lazarus and "The New Colossus" - the Statue of Liberty and Ellis Island are well-within view of downtown Manhattan. I remember the towering displays of suitcases at Ellis Island. But then - and now. Now. "Give me your..." to whom, for whom, and for what reason? It's not Arizona in most of the country, certainly. But the sentiment...is so ...condescending. "Wretched refuse"? Wretched how and in whose eyes? "We" certainly take people with very diverse backgrounds - including very high levels of formal education, wherever they come from - and say those things don't count. At all. Redo, redo, redo. Or pretend "whatever" wasn't done at all. In medicine, the ones who get counted as doctors (after however many years of practice, retaking boards exams, and entering the Match) go where students from American med schools don't want to. For the most part.

"Give me your tired, your poor..."
Wretched. Demeaned. Demoralized. Dehumanized.

"Send these, the homeless... to me"
Because other homes aren't a home.

"I lift my lamp beside the golden door!"
And try to see inside. Gold, shut tight; if it's pure, maybe the lamp will melt some of it and allow an opening, an acquiescing, a bending.

"refuse..."
For Riker's Island, over 20,000 people, there was no evacuation plan during the hurricane. As stated, it's essentially sea level. At La Guardia.

In French, "La liberté éclairant le monde" - liberty lighting the world.
Floodlights that can be seen...well, across a large river and probably farther.
After all, electricity is an unlimited resource, not a commodity.

Let freedom ring.


~j

The Procedure

(This was written several weeks ago – refers to all month of July)

Today I used sound waves and a plastic transducer to take moving photos of a fetus-squiggle. I was outside, it was inside, and now it doesn’t take long for me to find the uterus, to see the black-filled-collapsible bladder on top of the double-stripe collapsible uterus that now, in pregnancy, isn’t so collapsible (potential space). The black-fill is water, and there’s a tiny yolk sac (depending) and there’s a little squiggle (this early). And it turns and turns and turns on a stalk, and I have to move, patient, to capture it. Length-wise. Freeze. I measure. My machine converts that to weeks.

And I print the photo, attach it to the woman’s chart on which I’ve written LMP/Gs and Ps/prior c-section or surgery. Bleeding or pain? Prior ultrasound?

I’ve filled in provider (the attending), the clinic, the date, and the patient’s name, DOB, medical record number are stamped at the top of the carbon-copy page. White copy on top.

I write in the length I found (if it’s first trimester-early, it’s crown-rump length - descriptive, no?) and I write it in mm and I write the gestational age.

I mark: + IUP.  + FCM

Single, intra-uterine pregnancy

Fetal cardiac motion

Under “reason for exam” I write “dating – undesired pregnancy.”

Learning language

The following is slightly modified from a recent graduate admissions essay. (The first paragraph, alone, was posted in December). It may be a cop-out to post something I've already written - and, quite differently from everything else I write here - this one is highly edited and revised. With help.

This, however, is the manifest - and I wanted to explain what the connections are, for me, between the disparate interests. It's like writing poetry - once I've written a poem about something, describing that (event, feeling, person) in other words and sentences falls short. It isn't exactly, not quite, what I mean. Hence the quoting-of-self that happens. Inevitably. This, I imagine, must happen to all writers. So, rather than expound upon what's already been written:

***

It starts when I enter the room. How many words can my patient speak without needing

air? Is she leaning forward to breathe? Are her fingers clubbed? My stethoscope hangs without weight. My hand is on her shoulder now. My eyes close. “Breathe,” I say. “Relax.” And I am listening to the inside of her body. It’s telling me things my patient knows but lacks vocabulary to describe. It is my privilege to explicate this poem.
            I was born speaking two languages, and, as a bilingual child, French and English were imprinted in entwined synapses. I do not always know which language I am speaking. If I read a book in English that takes place in France, I “remember” the dialogue in French. I transpose. In this way, I have learned that translations are only approximations. I connect most with those who speak both my languages because that allows me to use the most precise word possible.

            I speak two languages. From my early years in school, I was drawn to science because of its inherent beauty and creativity. I decided to pursue biology the first time I looked into a dish of pond water under a microscope and discovered an entire invisible world. I spent late hours in the lab, peering at 400x magnifications of cells I had stained green for mitochondria and red for nuclei in a 12-hour painstaking process. I would forget to count and simply stare.

Cacao field, Mvangan

Getting it right

*(I’m studying for boards (at writing) /just took boards (at posting) = Step2 CK)*

I hate the questions I get right – cancer, terrible diseases, medications, hard side effects to deal with, long-term complications – that I know, for sure, because of anecdotes

Anecdotes.

I know how you died.

I know how you might die, I know why your life is and will be difficult.

There are the simple ones – the amoxicillin prescriptions we wrote for kids with ear infections, the reassurance, reassurance, reassurance of parents.

The patients who came in with the side effects to medications that I’d read about – EUREKA! moments – your cough, the nagging cough, and you started lisinopril at the same time.

I know the answer to the puzzle.

I win.

Un des lions indomptables, Ebolowa

…And back to the original precept of “medicine: the microcosm.”

The Middle East is exploding – maybe to long-term good, at least in the countries with more peaceful revolutions. Vocalizing freedom, enacting change, moving toward a more internally-designed governing system. Hopefully. Then there’s Libya… it’s still hard to have personal, visceral reactions to things when announced in numbers and not names. If one of them was my patient. If one of my patients had family there.

But as much as I – when I remember – try to remain engaged with the world in, at least, a passive way, I have no idea what’s going on.

How do I know that California (one part of the country not ever really in winter?) is expecting snow tomorrow, for the first time in 30ish years? Patients. Same way I knew it was going to be in the 60s last weekend – a patient was preparing for a trip to New York.

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

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