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

Recursive in print

Addendum: By comparison with my other friends in other grad schools, I've often felt like a very lazy student. Like I'm not working much at all. And then I realize - if I add the hours of writing, the hours-upon-hours per poem, the reading of poetry - it could even be more. But I don't count that as work. It's what I want to be doing, anyway.

(approx one week ago - true, then. don't hate it today. more to write, soon)

Some days, I hate that I’m a poet.

As I’ve said before, it’s not a choice. Do I wish I were…a novelist? a journalist? a documentary filmmaker? an influential blogger?

Maybe, maybe, I could do the things I want to do, then.

Thing is, I’m a poet.

And today, I hate that.

I was speaking with one of the program admins/alums today, turning in poems for a scholarship application. She asked me if I like the program (MFA) better than med school. I replied with a decisive “No.” What I didn’t say, the background voice, is that I think I like med school better.

Problematic.

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

Colonized, not conquered, tongues

In my Creole Poetics class this week, we discussed Caribbean poet and scholar Edward Kamau Braithwaite’s “Nation Language.” In essence – colonized people, who’ve had to assimilate to and be taught in the language of the colonizer – need a more natural form of expression. Part of independence, part of forging a national identity and establishing roots, was valorizing that language. Making poetry in the diction and rhythm of that language – iambic pentameter, for example, is not native to Barbados. (Is it actually natural to English? debatable).

I’ve seen this in Cameroon – French is, technically, my first language, but for the first few weeks in country, my “French” was translated into “French.” As I now call it, that’s French-French to Cameroonian-French. I was incomprehensible. I understood what was being said to me, or I thought I did. In time, I changed – I had to. It’s the inflection, the diction, the choice of words, the syntax, the prosody, the sentence length, word order, ways to get attention, non-verbal sounds to punctuate phrases…

Everything.

It’s not the same language.

I see it now as general, amorphous “French” for the basic structure – and there’s the French-French, the Cameroonian-French, the Senegalese-French, the Malagasy-French . . . they’re all different.

(And why shouldn’t they be? It’s obvious enough for Belgium and Québec).

But Africa was colonized.

The marks are there. Senegal was more closely held for longer – the French is closer to French-French in accent. Cameroon got passed over from Germany. French is different – the culture, too, is different.

And then there’s Anglophone – as PCVs, we defined at least three (basic) languages in the Anglophone (previously British-held) provinces of Northwest and Southwest. “Grammar” is the “Queen’s English,” or so they say. (Grammar – reductive; it’s language without culture or any social attachments. Pejorative? True? The way English was taught in former colonies (and is still), it’s the generic, over-arching Language. This Is. How could something so authoritative have meaning to real people, terre-à-terre?)

Anglophone. Not quite grammar, or – it is “grammar”, but we call it something else. English? No. That’s British-English. “Anglophone” is, like Cameroonian-French, related to accent, inflection, diction, syntax, vocabulary… it’s neither British nor American English nor any other Western form. We Americans were not always well-understood speaking American English.

So what did we do?

We spoke Anglophone.

(And many volunteers who lived in the NW and SW learned and spoke pidgin, as well as other local languages – as a visitor to the Anglophone regions from my own francophone province, I didn’t go further than Anglophone and a few phrases in pidgin).

It’s reflexive, now.

This is what we do.

The Vegetarian Carnivore - Rhumsiki, Cameroun

Who wants to be a poet, anyway?

The delay is that – well – since writing is so much of what I do, now, it’s neither escapist nor explanatory nor therapeutic/exploratory to write about, all the time. But it returns, now.

*other poets may disagree. That’s fine. This is my experience. I'm envious, perhaps, and/or admiring of - in awe of - those who are so dedicated to this as I am to no one thing.

The first poem I remember is from second grade.

Poem that I wrote.

I was a better poet then than for the approximately ten years after that –

because I didn’t know, yet, what poetry was. What poetry was “supposed” to be. What “sounded like” poetry.

From seven to seventeen, there was subversion, inversion, and perhaps glimpses of things that had merit! maybe! that said something! maybe! But it “sounded like ‘poetry’” – which is, really, not good at all.

Even poetry that conforms to rules – i.e., Shakespearean sonnets in strict iambic pentameter, for one – is good if it’s so natural that you don’t know for awhile that that’s what you’re reading (unless it is, obviously, Shakespeare). The rhymes, the rhythm are not forced. They’re what exists – and what happens to be in that form. And then you look and realize it’s three quatrains, ABAB, CDCD, EFEF, and a couplet – GG. Ten syllables to the line in iambs. Trying that – doing that – is hard, and often sounds heavy-handed and sing-songy with inverted structure to get the right rhyme at the end. I think everyone goes through that phase. (and maybe it becomes something amazing and there is the real poetry. Not for me, not now).

But at seven I was a poet.

To be a poet is not a choice.

Who would choose this? It’s a lonely vocation. You sit, alone (or alone in a crowded room, as we crave the (prototypical?) background noise of cafés. Street and people-watchers, listeners, we are). You spend an inordinate amount of time in a difficult headspace that most people don’t have to inhabit so often. You – if you’re really going to write – are connected as much as possible to everything, and you’re always listening, and open.

It’s dangerous.

Nselang, Cameroun - you can't capture the greens of the forest in a photograph - can't - This isn't a great photo, but that's irrelevant for this point -
and you can't capture everything with words, but we try

The Imposter

17 August 2011

For several reasons, I wrote this approximately 3 weeks ago, but I haven't been able to post it until now. To be read in the context of mid-to-late August. I'll write soon about the up-to-present. And how I saw the writer from "Stahnding Room Only" (February) again last week.


After a job interview, my new boss suggested I check out St. John the Divine. “Have you been there?” “No .” “It’s the largest cathedral in North America.”

I walked up Amsterdam to 110th . I like cathedrals – it’s a place to commune, to be quiet. I like the stone and cold, windows and dark light. In Paris, it’s Notre Dame (however clichéd) and everywhere else. Here, it’s…

            I went in, similar feeling, similar, except not nearly as cold. Quiet. Leaving, I walked up the street to discover more of my new New York. Next to the cathedral, there is a hospital. Pause. Ridiculous – no – nothing to do there – to see whom?

Pause, but there's a small pull and I walk towards the main entrance. It’s unfamiliar (but I’ve worked in 7). It’s private (never done that) and there’s a guard at the desk.

The title is a lie.

(to follow)

There is literally nothing that did not happen today.

I spoke with a friend in Cameroun.

I found out that the research article section I wrote is, in fact, good, even with the inclusion of some writerliness.

I went to a county hospital, participated in infectious disease rounds; spoke with HIV doctors and people working in public health in Africa and people teaching about narrative medicine.

And then I went to a poetry reading with a new poet friend and we went out with one of the readers and all her writer friends after.

Dizzy.

I was in three of my major communities – Peace Corps/Cameroon/public health, medicine, and poetry.

And only in the third did I feel intimidated and like an outsider with little to say or knowledge of how to interact.

I carried a white coat to the poetry reading in my doctor bag. I wore Cameroonian clothes. I had my med student ID. Just in case. It’s next to the MFA student one. I wrote new poems on the subway. I’m better at that than reading in transit.

At the hospital, not-quite-just-a-visitor and not-quite-a-student, I asked, “should I masquerade?”

The Mental Status Exam and obsolete ethernet cables

I’ve written the neuro exam, the respiratory exam, the cardiac exam? (not yet) – what else. Pelvic exam will certainly deserve something. Anything that intimate. Eye exam (except I’m not good at it/we don’t really learn a good one, in med school). Musculoskeletal could be interesting.

Dermatologic, again, we don’t really learn, but that sort of scrutiny to the outside might be the most similar to psychiatry’s scrutiny of outside-to-inside-to-outside.

It’s applicable to anything. In psychiatry, actually, I did a presentation on the mental status exam and interpreting poetry – poetry I blurred on the projector screen so that you couldn’t read the words.

Mental status includes action, includes movement and speech and anything that indicates internal state in externalization.

I spend a lot of time, lately, searching for wi-fi.

Crossing into Chad

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.”

The Luckiest

It’s said in many ways.

Absence makes the heart grow fonder.

Nostalgia in looking back.

Selective memory.

And, per Ben Folds, “The Luckiest.”

This usually refers to, I think, people/place/thing. Certainly people. Certainly place. Time period. Self at a different stage of life.

It’s not usually used in reference to career.

It’s now been three days since I was an active medical student.

And I miss it. A significant lot.

I can’t wait to be a doctor.

Kribi, Cameroun

Licensed to

In James Bond terms, it’s a license to kill.

In philosophical terms, it’s a license to heal or to help live.

In pragmatic terms, it’s a DEA number and a way to bill and get reimbursed by insurance.

In French, license means bachelor's degree, and permis means license. Unspoken, assumed permission. Allowed.

Person to person

I got a patient’s blood on me the other day.

(not unusual)

A patient’s blood splashed in my face the other day.

(unusual)

A patient’s blood spattered over my face, little drops over my neck, cheeks, forehead, and one on the inside of my lip. That I felt – one. None in my eyes.

A patient’s blood spattered on me and her eyes were closed and she was concentrating so hard on her breathing that she didn’t notice I stopped, stopped the procedure. I stopped for a minute, maybe two, at most. More like 90 seconds.

Paused.

We are holding you here

Danger to self, Danger to others, Grave disability

For the past month, my patients have either been dying or seriously troubled. Or both.

These might be different sorts of dying.

This may be an introduction for stories to follow. There were more patient moments of transcendence, on palliative care. That’s next – what it means to be able to imagine a life for someone when you’ve never really met them before almost-death. There are the hours and hours and hours of stories, now. The Mental Status Exam – there’s another piece. Will be. But for now, by way of segue, and because the writing for the evening is meant to be five closely hand-written pages on my patient’s background, the factors that have contributed to her current situation, and an assessment and plan of what, in the hospital, we can do.

Cameroun, primate reserve/rehab near Yaounde

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

Living changes everything

My patient invited me to his funeral.

 Indirectly.

 He asked for my phone number so that his daughter can call me when he dies (he’s dying). He asked for my phone number so that his daughter can call me when her daughter, his granddaughter is born – she’s due in August. He might be around. He might not be around. My patient said that maybe I can see photos of his granddaughter, maybe I can see her grow.

He won’t see that.

My patient invited me to his funeral. It felt sacred but not strange. This many months, years into med school, I’ve learned what boundaries are right for me. I’ve learned that my patients – most of my patients, the ones I truly have relationships with – will not cross those boundaries. So I wrote down my phone number and my email. And maybe his daughter will contact me.

Not everything in pathology is dead

That is, perhaps, what I’ve learned in two weeks. I haven’t been in what’s popularly thought of as pathology – no dead bodies, no tissue specimens. Vials and vials and vials of things, petri dishes grown from people, blood and bone marrow biopsies.

Parts of people, taken out, to see if they are still alive.

(or, parts of people, taken out, to analyze and see exactly what’s in them and what they’re doing) .

It still feels like an inexact science, in some ways. Microbiology is detective work – but this isn’t what they show on House or CSI; it takes days and days to grow. (Then, clinically, what’s the point? In the immediate. . . there isn’t one. Patient is sick, patient looks “toxic”, you treat as if she’s bacteremic.* (Has bacteremia) . Septic. (Has sepsis) .

Rat glioma, nuclei

Sustainable - Ecstatic.

Everyone talks about 'sustainability.' 'Sustainable development.' (which, by definiton, should be sustainable - otherwise - it's patchwork construction and shantytowns, metaphorical or literal). The environment.

Etc, etc, etc. It's as much of a generalized buzzword as "global health" is becoming in medicine.

If there's one thing I learned in Cameroon, it's that I can't take on things much larger than a village. A small part of a health district, perhaps. A health district (rural). A larger health district (someday). Part of a small NGO (someday). One project, perhaps two. Other things are less sustainable.

In medical school, the largest thing possible was a small, student-run clinic in a homeless shelter, operating for a few hours two nights a week and a morning every other weekend. That, in itself, was enormous. And there were several of us. (Alone? Possible? One person is not sustainable).

The Mall, Washington, DC, February 2003

In college, I was actively anti-war (can't even be apolitical in writing). (and I've learned that the strict position of 'anti' isn't useful anyway.) Peace marches, protests, demonstrations, a dizzying 'march on Washington' (to be done once in a life, at least, if politically inclined) gave a sense of community and something greater when the state of the world was terrifying. In this state, there are rallies at the state house for single payer healthcare. I haven't gone. It’s the global and local thing. Someday, maybe, WHO-type work. Someday, definitively, public health education/behavior change communication and program design. Local to larger to local.

Relevance, irreverence

Were I not taking a year off from med school, I could be a doctor soon.

This sounds obvious. Yes, in the practical sense, in 12 months I would be an MD.

Instead, I’m doing three months of fourth year before taking off for an MFA. The fourth year schedule (for later) is so flexible that I could actually spend an entire quarter not here, doing a third semester of my MFA in an entirely different city. And graduate with an MD.

Soon, I could be an MD.

I won’t be.

To take a leave of absence, you have to formally withdraw from school. The form asked what I’m doing - simple. Then it asked what the relevance is. Relevance. (the career advisor/head of ob/gyn department asked me the same question. Relevant. How is poetry relevant. I’m not going into ob/gyn, anymore*) .

*for many reasons, but the above was probably influential on some level

A year for patients

For K and K

The first patient who died and the first newborn I took care of in the nursery – have the same name.
K--- .

I wish I could write it. Suffice it to say, it’s a beautiful name and an uncommon one.

The first patient who died, the first K, was 29, with metastatic cancer. Latina.

The first newborn in the nursery, the first birth after K and a string of other deaths, was 6 hours old when I met her. Half Japanese, half Turkish.

And they have the same name with the same spelling, and, most likely, the same black hair.

Born thirty years apart.

This year, I’ve kept track of all my patients who have been born and who have died.

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.”

Addendum...

A word on iodine... after talking to a thyroid surgeon. What I didn't know is that, for various reasons (including reactors releasing radioactive iodine), thyroid cancer is the most common neoplastic sequela of nuclear explosion/accidents (Chernobyl...). You can't prevent leukemia or lymphoma, obviously. But if you give supersaturated potassium iodide (SSKI), it...supersaturates iodine receptors on the thyroid, blocking immediate uptake of radioactive isotopes. And iodine has a pretty short half-life, so those go away within...not too long. Other isotopes, though...are around much longer.
And apparently Homeland Security has stockpiles of SSKI at various undisclosed locations in the US in the case of such a disaster.
And iodized salt, in general, is a major public health advance/success of the 20th century.

Iodized salt poster! N'djamena, Chad

Fluid balance

Nature is generally more impressive in poorer countries. Cause and effect.

Insult to injury to injury to injury. It's like tropical diseases that are almost impossible to eradicate in vectors. It's like cultural staple foods that decrease iodine uptake and are almost devoid of nutrients. It's like the balance of climate change falling where farming and subsistence depend entirely on climate and predictability.

In the city where I grew up, tornadoes only strike on the south side of town. The bad ones, anyway. (With the exception of one recent instance). Always. And that’s the poor side of town. Living to the north of that, after a number of years, I learned to not really worry during the watches that sometimes turned into warnings. Basically, we'd always be okay. It's a lulling, a complacency.

And so somehow it’s more marking, and there’s more news (or that’s my current perception) when this happens to a richer country. It’s more of a shock, so to speak - because when insult does get added to injury to injury - the magnitude, at a point, is no longer imaginable. Maybe.

Then again, tragedy is always tragedy.
And no matter where something happens, it's the poorer, less advantaged, less resourced, more dependent-on -the-natural-movements-of-the-earth that is the most devastated.

Japan.

And the fact that the US was worried about the coast of California is…well, if something thousands of miles away could have a visible, tangible, destructive effect... it just shows how small so many of the things we’re capable of doing really are. Any of the things

Happy 50th, Peace Corps

(50 years total for Peace Corps. 49, continuous, in Cameroon)

My stock answer when people ask me what was Peace Corps like?: Best thing I ever did.

It continues to be true.

And it’s the group I’m proudest to be a part of – I saw someone else said that, with regards to this anniversary. Still true. Clichéd. True. I was strongly considering extending for a third year, and, if my MCAT scores hadn’t been about to expire, I might have. I’m one of the luckiest ones – a year and a half after leaving, I had the opportunity to go back. And it was paid for. (research project – see Cameroon posts from summer 2009). I’m one of the luckiest ones – I got to go back and see several of my projects still in motion, growing, and significantly stronger and better than when I had left, thanks to the volunteers who came after me.

I remember my Peace Corps interview, beginning of senior year of college. I remember the recruiter who had been in Mali, raising chickens. She asked me how I would deal without electricity, without any amenities, without anyone from my culture near me. I said I thought that I could do it, but I didn’t know. Peace Corps challenges you in ways that nothing else does. Nothing can exactly prepare you for it. Nothing can tell you if you’ll be able to, if you’ll be happy, if things will work out. There are millions of unknown and unseen factors.

…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.

Words we use with kids

Toxic. Non-toxic.

(sick/not sick)

CF-er.

(kid with cystic fibrosis).

Heme-onc-er.

(Kid with cancer).

FTT: Failure to Thrive

(losing weight/not gaining weight, either from chronic disease or from neglect)

Crumping.

(going quickly downhill/possible to death)

Two kids I saw in the office, who were completely fine.

Baby L. Perfect newborn exam. Perfect. Slight ductus arteriosus, I think, that was closing. Breastfeeding was going well. Mom had 4 other kids at home, lots of social stressors, but her husband was involved, there was a grandmother somewhere, and maybe one of the older kids was around to help out, too. History of post-partum depression and chronic mental health issues – we talked about that – but doing well, couldn’t take meds during pregnancy but on top of her symptoms. In touch with a social worker.

Minor issue – her 20 month old son had a cold.

Okay.

Well, try to keep her away from the new baby.

(easier said than done. Baby wants attention away from the new baby).

Sunday, I was in the ER, and I glanced over at the list of patients admitted the previous day. Baby L was on there. And Baby L was in the Pediatric ICU (PICU).

I had seen Baby L in the office on Thursday, I think, and the attending had seen her as well. Doing beautifully, as they say, with the requisite “congratulations!” and “what a cute baby!” “what a perfect baby!” Baby L was doing fine.

…and then Baby L caught RSV* from big brother. And Baby L started having apneic episodes, when she stopped breathing. And Baby L came in by ambulance and was in the ICU hooked up to monitors, now.

*respiratory syncytial virus. In adults, it’s almost asymptomatic. In a number of toddlers, too. But some of the ones who get sick, and some of the babies…get sick fast. There’s no treatment.

Reading palms

I spend most of my day touching people.

My patients might grasp my freshly alcohol-gelled hand when I offer it, walking into the room. And they might be too nervous or distracted. And they might be the ones who, overwhelmed, hug me before leaving (I’ve stopped counting those). And yet I touch them…everywhere. In that sense, nothing is sacred; but in the other sense, everything is.

Some doctors put on gloves for the entire exam.

I don’t.

I’ve learned both ways, and now, we choose things. It’s a mixture of universal precautions and respect – always, always gloves for any genital exam; always, always gloves when touching anything with secretions. A rash. The inside of the mouth. Anything bleeding or with pus. Anywhere the skin might be broken.

Otherwise, I wash my hands two to four times per patient visit. (Once outside the room. Once inside, prior to the physical exam. Perhaps once after, before leaving the room. And then maybe again in the hallway.)

Recently, I had a patient whose arm was in a cast. After a week, he suddenly spiked a fever and started to feel pain in his arm, which he hadn’t before. Common things being common, if you hear hoof beats think horses, not zebras (the platitudes of medicine), it’s probably a bread-and-butter pediatrics case. I.e., cold. Flu. But it could be something else, something we can’t see.

It felt like black box medicine. Diagnosing without seeing what you might be trying to either diagnose or rule out. What are the proxies. How can we see without seeing, know without knowing. The fingertips were visible – warm, well-perfused, good capillary refill, pulses intact bilaterally, sensation within normal limits. Nerves, vessels intact.

Then to the proximal side – the side closer to the body. I touched the arm above the cast. I touched the other arm in the same place. Cooler. Again. Both hands simultaneously. Switching hands. One hand at a time. I closed my eyes, trying to feel the temperature difference. There was one. It was subtle. But how subtle is subtle, and how warm is just from being enclosed in fiberglass?

Standing Room Only

Zen, Part 2

 (Trigeminal nerve, CN V_1,2,3: Superior orbital fissure, foramen Rotundum, foramen Ovale. SRO).

 (Single room occupancy; marginal/subsidized city housing. SRO).

It had been on my calendar for months.Historic bookstore (in the sense of..literary history). Reading. Writers recently published in The New Yorker. Including a physician-writer, Chris Adrian. Introduced by Deborah Treisman.

Nothing imperfect.

We arrived – less early than I would have liked, but still with plenty of time – and there was almost no one milling about the stacks. It was quiet. I thought we had time. Walking slowly through the store – there must have been time to savour it – I saw a group of four chatting in a corner. The writers. I knew only because I recognized the events coordinator. The writers. But where was the reading? I’d never been to one here before. We walked to the back of the store, to the stairs – and there was the line. The reading was upstairs. And the line was all the way down the stairs – two to a stair, leaning against the wall, ready to rush up and into each other when the words started to float down. So everyone could hear. We assumed that if everyone was lined up here, it must be backed up to… I had no idea how big the room was. How many people might have been in there. And whom. All I knew was that the writers weren’t, not yet, until they passed us, single-file, along the stairs.

Where it is located

I’ve realized, again, that the lower back is the genesis of much movement in African dance. It’s the center, the core in a different sense than is described in Western forms of dance (the Western “core”, at least from what I’ve heard/been taught, focuses more on the anterior, the abdomen). It’s the center of gravity if you’re bending back, held up to the sun with an invisible force, giving homage with joy to everything above and around.

It’s different.

If you’ve been to Africa, backs – particularly women’s backs – look different. And this is why. Somehow (and I haven’t identified this, anatomically) these are muscles that aren’t used as much in other parts of the world.

It’s more than standing tall, proud, unadorned.

It’s carrying a bucket of water on your head, touching lightly with fingertips on one side.

Not swaying. Not spilling any.

It’s doing the same with laundry, régimes of plantains, furniture.

It’s walking back from the fields with the woven basket on your back, tied around your arms with the two lengths of fabric. Machete hanging out behind, probably, with the plantains and manioc and arachides.

It’s carrying children there. The crook not of an elbow, but of a back. Shifting on the hip sways you to one side – it’s uneven, it’s not ergonomic. It’s not long-term. You – they – can walk forever with the child cradled there, just so, tied in a pagne.

It’s the classical pose of the drummer reaching for the sky, pausing between tam-tam beats.

It’s the wooden statue of a women with a water jug on her head.

It’s the machete raised high overhead to reap plantains and papayas and coconuts and palm fronds and avocadoes and…

“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.

"…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 19^th 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.

~j

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.

Blue.

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.

~j