"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 4^th 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.

~j

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