For New York, it’s an intimate-but-not-in-an-unpleasant-way venue. Bar, a few tables, a stage, good but not overly-imposing-or-meaning-to-impress atmosphere. The amps weren’t too loud. I was as close as possible – close – and the sound was right, and I could hear all the words.

After a day shuttling between medicine, public health, and poetry contexts, with many, many subways and miles of walking in-between, I re-learned what it means to be an artist.

Rachael Sage.

If I have a favorite musician – a singular one, one who is alive and performing and now, and who is not so very well-known or widely-played to be obvious – it’s her.

And it’s been her for the past decade – little more than. A friend gave me Smashing the Serene in the fall of 2001. It’s technically Rachael’s second CD, but it was my first. As I told her tonight (crazy, idolizing fan like I’m the crazy, idolizing fan with some of my poets): “I realized that I’ve had a relationship with your music for over a decade, now. That’s longer than with most of the people I know.”

It’s true. That’s formative years (aren’t they all?) Music, good music, can be both background and foreground. One of the four options (she gave) for her last/encore song was the first Rachael Sage song I ever heard. (“Sistersong,” Smashing the Serene). I know the words to that one and to many others. And the ones she sang that I’ve heard – but not memorized – brought the same knowing smile of familiarity, triggering memory and attachment.

That’s what it means to be an artist.

That’s what you want it to mean, to be an artist… to mean something. To get to be part of someone else’s story, in a way, to have given and shared that gift.

It’s the same with poets. Cyrus Console read a section from a book I love. I hadn’t memorized, not by a long-shot, but I was familiar enough with the words that they were little triggers. Anytime I go to a reading and someone reads a piece I love. Poets publish CDs, sometimes, of themselves reading. (see: Li-Young Lee, Behind My Eyes). There’s an art to that, to reading – and learning how to read (out-loud) poetry was an important part of my poetic education. Digressing.

For any show, musicians have to include songs that are “known” with the new ones. Would we be…disgruntled otherwise? Maybe. But you can best, I suppose, develop a relationship with the new pieces through segue with the old ones. The nostalgia (and the triumph!) for older ones, knowing-the-words-ones, isn’t just for the piece itself but for whatever particularity it evokes. Whatever life it has taken on, now, for the listener. Everyone owns a little piece, and each piece is now different. Poets often read from both published books and new, unpublished poems. (fiction writers – same. etc, etc). For the artist, it’s part of trying out the piece – does it work with an audience, what does it sound like in that context, etc, etc.

One of the best things about poets is that when you tell them you’re skipping out on a social event to go write – they not only understand but are excited for you. If it’s urgent, too, that means the Martians/muses/whatever are visiting, now, and something might be happening or about to happen. This happens to all of us, planned or unplanned. Poet-in-tandem, poet-interlocutor days. And poets-need-to-be-alone days. After a friend’s reading, one night, I told her she’d inspired me to write, and that I had to go home and do so. It was true – and I knew, too, that it was a gift to tell her that. The best response to a reading you can have, she said.

More recently, I sent a poem(s) to my workshop, for them to read before we met. One poet/friend replied to my email, saying the poems made her want to write again. That’s an incredible thing to say to a writer, and from a writer who knows what it means.

I had written most of a piece about art school versus grad school, and what it’s like to be in art school, and … I’ll finish that soon. Later. Also. I’d been thinking about the process – and all of it is a process. More like a continuum. Like a day of medicine-public health-poetry.

***

At a health policy colloquium at a medical school, today, a Distinguished Professor introduced the speaker with the biography she’d given him and a little ad-libbing. “...where she majored in English. . .which is extremely related to medicine…” I would have been annoyed, had the colloquium coordinator not already told me that the D.P. supported and was very interested in people doing medicine and humanities. (He was less eloquent, later, “My son-in-law is a poet!”)

*

At Poets House, later today. As the library was closing, and I was leaving, one of the staff (whom I’ve met before) came over to chat. He’s also a poet. I had the Collected of Wallace Stevens on the table, as well as Nerve Squall, by Sylvia Legris. He asked about the latter. “Oh…she writes using a lot of science, often botany, here fish and birds…a friend recommended her because I write a lot using medicine.” He nodded. Picking up the Stevens, he commented on how part of what he really likes about Stevens is that. . . poetry is one of the things he does, he’s not an academic poet, not trying to participate in the academic discourse of what poetry is, who, etc…(It’s funny to note that people often refer to Stevens as “an insurance salesman.” He was a lawyer who worked for an insurance company. Odd). I don’t know a lot about Stevens, but he did write about poetics, as well, some critical essays – but not much compared to his contemporaries. He went on to talk about poets who aren’t also English PhDs and who just. . .write…and do something else, too. How he likes/appreciates them. We talked about a few other writers. Then – “what’s your background? undergrad? did you major in…medicine?” And thus I reveal myself as aspiring to be, perhaps, a poet like one he admires – not-academic-but-that’s-okay.

***

Another poet/friend, today. We were discussing (“interlocuting”) what it’s like to write, for each of us, where poems come from, how they do, what we’re doing with them, what we’re reading and how that influences things…etc. He said, “Being a poet sometimes feels like being a homeless person, when you never know where you’re going to sleep next/next meal is going to come from…” It’s a curious analogy, but I think it’s okay because it’s not actually referencing or alluding to starving artists. Also not comparing the difficulty of either situation; more, I think, speaking to the unpredictability/ seeming lack of agency. I think. You don’t know where the next poem (or other artistic inspiration) is coming from, or when, or if. (With time, the anxiety of the “if” has lessened. A lot).

The “if,” though, has little remedies. Read poetry. Go to readings. It will come. For the ones giving the readings, then, it’s a gift they’re offering. Hoping, in fact, that will take, that anyone will take. If it’s a good reading, an amazing reading, I’m either writing lines down, madly scribbling ideas for my own new pieces, completely stunned and entranced by the reading, or I can’t find my pen and notebook. Any of the four are possible. (also – it’s not just the good readings that give ideas. In truth).

With another poet-friend of mine, after a reading we attended last week: he said he’d liked the second-to-last poet best. “The ones about high school.” (that writer is a high school teacher). “Oh...I don’t remember those very well…then again, that’s when I was writing the most, so I guess that means they were good?”

To a writer.

If someone is writing, they are thanking you. If someone will remember your words next week and not be quite sure where they came from, they are thanking you. If someone will put your line in a poem in a year and have no idea they didn’t write the line, they are thanking you. If someone will need to read your book, they are thanking you. If someone will pass that book on to another person, they are thanking you.

If someone will write now, tonight, tomorrow, next week, next month, in a year or in ten, they are thanking you.

Being an artist isn’t all about the art. The art comes from somewhere. It goes to somewhere. And you get to be the tenuous hands that have a part in that connection.

Why do you care about publishing, I’ve been asked. (“Why have a blog” is a similar/same question – or, actually, these days, I suppose we could debate the relative differences with other forms of publishing…) It’s sure as hell not altruistic to be an artist and to want to exhibit/publish your work. But even paintings should live off museum walls, and there’s a difference between printed impressions and the physical object. It’s what you see, how it makes you feel then and later.

If one person reads and wants to write, if one person uses a line of mine, if one person uses a line of mine, many years from now, because it’s been stuck inside them that long and they have no idea where it came from. If one person thinks I must have written about exactly what happened to them, because it is what it means. If one person connects to a poem, thinks about it later, keeps it, somehow, is reminded about it by an experience that happens later. If one person remembers reading my book and what happened at that time. If they reread the book (!!) and different things are more and less poignant, more and less meaningful.

(it’s poetry, it was never going to be about the money. Though the publications and the prizes and the fame and the money and the bookstores and the…would be nice…)

Enough.

~j

…red’s the only honest color, after all, we’re flesh and blood…”

- Rachael Sage, “Crack of Dawn” Smashing the Serene

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

***

I could turn Kevin into a metaphor for Americans, or really for many populations or groups of people or myself in (formerly) microcosmic med school . I will endeavor to not be that ridiculous. Or not.

So, to Geoffrey G. O’Brien’s Metropole. Geoffrey G. O’Brien was, at the recent Berkeley police-against-peaceful-community riots, beat up. Unceremoniously, per the article, was recovering from broken ribs the same weekend we were assigned to read his book. And discuss it. That was the same Monday I went to my first protest since the anti-war ones. (There’s a poem in there, somewhere, about all the places I’ve marched and demonstrated and protested. Somewhere). This isn’t a place for explication – suffice it to say – the title poem, “Metropole”, moves through politics and protests in America. Writing about politics without polemic. (There would be more to say about the poetry, but, not now, and I’m not the one to say). The following seemed almost eerily prescient – I don’t know if this had happened to him before. But as I was reading it, it was happening:

“Outside the bedroom buses stuffed with passengers pose family unawares. Pedestrians, commuters, worries pleased they’re happening, equivalent designs. The square completely filled then drained, a battle neither can afford to win. And banners, nightsticks, chanting, things with arms – from over either shoulder daylight knows the march as angry signs but crowds at night are demonstrations minus signs (portfolios). A struggle: fighting with an absent force. The rally’s unknown number when divided by itself”

This contrasts with Mark McMorris’s Entrepôt, apparently. Which I read in a Politically Irresponsible Manner. I did not read the lines, abruptly shifting between end-stopped and enjambed, as explicating the ambivalence of relationship to archive and colonial trauma. I’m not saying the former isn’t in the intent of the poet and isn’t in the explication and close reading. But. I didn’t know I was a Politically Irresponsible Reader until that workshop, after which, incidentally, I wrote the previous post . Do I hate being a poet when I feel like I’m not good at it or not getting it? More when – yes, I don’t understand and maybe it’s over my head and maybe it’s too much and maybe it’s over everyone’s heads – I’m not sure I see the point. I like the political poems. It’s damn hard to do well. Like painting in color or writing in rhyme.

***

Dear Kevin-in-the-elevator,

The second time, on the return trip, M was impressed I remembered your name. She was impressed when I mentioned your name to A, our supervisor, too. Who else do I know who lives in an elevator?

When we got on that time, a group of people with food got on. Some meeting somewhere. And they got off – two different floors maybe, with ours being the third ones. The elevator doors opened, the silver (jaws, to you, or quicksand) doors slid open – reminiscent of my cousin’s Delorean, perhaps – and there was a flash of another floor, beyond another set of doors. Whatever might have been there? Elysian fields, Madison Square Garden, Point Reyes, a sandcastle competition, the set of CSI (one of), hot air balloons in New Mexico, another group of cubicles and some with flowers, a very large kitchen making nothing but pâté…

Whatever makes your day more interesting. There is a finite number of floors – have you assigned attributes to each? Are they mutable? And what about the people who pass through – what are they doing with whatever large box or tray of sandwiches? Where have they come from? Etc.

Waza, Cameroun

***

There’s a story about Robert Duncan, in the H.D. book. He’s sitting on the grass at Berkeley, reading poems with some women. The bell rings for him to go to ROTC (mandatory in those days, whatever those days were, exactly). The women impugn (per his account) “You don’t have to go, “Stay with Joyce, “Rejoice with Joyce.”

And he stays.

Separating that moment from what ROTC was for, in those days, what going/being a conscientious objector might have meant…the point, more, as written, is about turning to the authority of a poem. Away from not just military but university and everything else. About poem as higher order. And how poets (in some views) cannot engage in politics and be both. That when trying to make poems do something in the world (can they?) they are defamed, somehow. That that’s not poetry. About this I don’t know enough. Yet – what I love about literature is its power to transform, transcend. But maybe that’s just it – if you focus on transcendence, then everything else is mundane. In a word.

And Kevin? The surreality, perhaps. That him being there seemed like it must be symbolic of something. The imagination in an elevator. More – you can imagine what’s outside the doors, without every actually seeing it. If you can sustain that. Less – well, no stimulation. Little.

I worry about poetry being inside the elevator. There are the conversations that take place there – whomever is passing by, whomever notices. And takes the moment to see it from that perspective – the elevator stops on someone else’s floor, and for a second, you imagine what might be there. Anything. A world that doesn’t have to conform to yours, and it could be an image, something whirling-dervish like (that’s a paraphrase of Ezra Pound – for another day) (and I have just thrown entirely too many poets into few pages). An engagement – or, an almost engagement – or, the infinite potential of engagement every time the door opens. Or not.

***

Dear NYC Department of Health and Mental Hygiene,

Kevin is in the elevator. I work on the Mental Hygiene floor. I don’t believe the elevator is very hygienic for his mental health, or for anyone’s. If you need a person to sit in the freight elevator – and again, I’m really not sure where you’re going with that – have them switch off. Like, every hour or two. And then do a job that involves running around the building. Or at least guarding something that is not the interior of a box. Let’s not be hypocritical, shall we? (Much like our syringe-return drop boxes (here – kiosks). You know we’re having trouble placing them in various places in the city, due to property lines, landlords, etc…is there a reason we can’t have them outside, here? It’s the right neighborhood. And there are certainly a lot of diabetics in the building – 24 floors? Yes. (…et al).

Maybe you’re worried because there is that big movie studio place (I’m assuming there are sets there) nearby? I mean, it’s easy to see, and I could definitely walk there during a quick break. I wonder what their security’s like. Or if they have anyone sitting in the elevator. If they do – okay, I’m picturing a fancy hotel – it should be made of glass and riding up and down in the middle of a lovely courtyard. There is a situation in which one can Sit in an Elevator. Much like subways, right? I imagine there’s a different in mental health and job retention between those on more above-ground lines and those on purely below-ground lines, right? I know several do go above ground, at one point. Take the Q. Those drivers are probably doing a little better than, say, the 2/3/4/5. You see the Brooklyn Bridge, downtown, etc. That’s pretty. And the Q – again – and the 7, etc, the ones that go over the Queensboro bridge. Okay. And I guess the A train drivers sortof see the ocean (do they?) on the way to the Rockaways.

You are concerned with my mental hygiene, perhaps. From my floor – the Mental Hygiene floor (only one of, I hope! but am not certain) – we have a panoramic view of four boroughs; with binoculars and imagination, we can likely see Staten Island, too. Across from my desk, I see midtown, the Citicorp building, and, craning a little to the left, the UN. If I go to the printer, I can see La Guardia, with fewer planes ascending/descending (visibly) than I would expect. I can see a lot of the Bronx, which is good, as we have many projects there. And, these days, I’m there when the sun sets.

BUT KEVIN IS IN THE ELEVATOR.

***

Dear Kevin-in-the-elevator,

Perhaps, next time, I will bring you poems. If you’re still there…

~j

(approx one week ago)

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.

I saw a friend from med school last night. And standing there, on a street corner, discussing the aesthetics of science and the unbelievable, incredible elegance of development, experiments that can show that… I wasn’t an imposter. Not then. Med school friends are coming through for residency interviews. It’s a view of an alternate life, the path I could have been/could be on…but even discussing that, the medicine, how absolutely incredible it is, the privilege, to be a doctor… feels right.

Right.

I’m supposed to be getting an education in poetry. I think. My tutorial (one-on-one) prof said to me last week that I should take her class next semester, on 20th century American poetry. Because my ignorance, my naiveté shows in my work. (True? sure). One thing – that would mean 3 classes with her this year, which is too much. Second thing – it’s the same poets we’ve been discussing in this semester’s workshop. Third thing – I just can’t make myself care, enough. Right now. There’s another course I could take, on more contemporary poetry – and this does actually include a number of poets I know and like. But then there are the comparative literature-type classes…*

*which explains that though I have a BS in Creative Writing, I have little to no education in poetry. I took the workshops, I did the one-on-one writing work, I wrote the thesis. I read a lot, I did. But I don’t have the background, and except for one course in France, I’ve never had that sort of formal study. Ever. And the one required course on the Western Canon, which is the only reason I’ve read (and loved) Milton. I wrote things with a lot of religious imagery, that semester – the influences, yes, are important. But I took comparative literature courses for everything else. It’s more what I care about. Literature in context.

So do I eat my poetic vegetables, so to speak?

I don’t want to.

I’m working 20 hours/week at the Department of Public Health, now (that’s DOHMH in NY – Department of Health and Mental Hygiene. I’m actually in the MH part. Haven’t quite figured out what the “hygiene” bit is). And it’s comfortable, easy to walk in, easy. I get how people are. I speak the language and I want to – I want to learn more, I want to learn so much more, I want to be part of that conversation, so to speak.

A few weeks ago, we did a training on buprenorphine, for doctors, so that they can prescribe it to patients. (It’s similar to methadone in that it can be used to help with heroin addiction, treatment, etc). I decided to go and help with it, though I didn’t have to – partly, yes, because it’s good form for work (to do semi-extra things), and partly because I was really, really interested, after I’d helped to put together the materials. (That’s another thing I really like about NGO/health dept-type offices – there’s no shitwork, no lowly intern things to do. If I don’t make the phone calls to remind people about the peer educator meetings? My supervisor does. We all – all levels – worked together to collate the materials (that took awhile…) Etc). And it just felt right.

Before this happened, I was describing it to my poet friends. It was a Friday evening, we’d gone to a poetics lecture, and then we were workshopping in a pizza place. (these are the truly wonderful moments – that – and that we care enough to do it, to hold extra workshops). One of my friends said – “What on earth can you talk about with methadone for a whole day?!?” I didn’t respond much more than the “Everything….” And I was thinking “How can you talk about line breaks for two hours?!?” That. “How can you spend a career studying Emily Dickinson?” That. It’s not that I don’t respect the above. I do. I do. But I couldn’t do it and I don’t *get * it, quite. A little bit. With a lot of explanation.

I used to think that doctor was what I did and poet was what I was. Writer, rather. Everything has become inseparable. Much of what I write, these days, is somehow related to medicine or medical language. More explicitly than before – perhaps on purpose, perhaps reactively, and perhaps as another way to re-engage. I haven’t, as previously planned, applied medical ways of thinking/examining patients to examining a poem. That should be next.

Looking at the graduate English course catalogues of three schools, I’ve found three or four classes I would take. Not more than that. Were it a public health catalogue, it would probably be the majority of the courses. Were it a medical school “elective” list – I would want to take almost everything listed under medicine and under psychiatry. As it were.

Problem is, I am a poet.

*******************************

And yet.

And yet.

Some days, I love being a poet – or, at least, I love poetry. And poets.

A few months ago, I first* read Cyrus Console’s The Odicy. This was before going to a reading he did with Omnidawn Press. And the first time I read it, I couldn’t stand it was over – I had to start again. I did this at the end of each of the five sections, too…no, no, no I wanted it to keep going. Breathless. Submerged. It had been a long time since I’d had that sort of experience with a book of poetry. I was expounding on how much I loved it to my classmate/friends, before the reading began, and before I knew that Cyrus Console was sitting behind me. At one of the breaks, I did have the nerve to talk to him.** I only get this way around writers. So I said – the above. I didn’t want the book to end, I didn’t want the sections to end, it was one of the best books I’d read in a long time. He said thank you, quietly, I think. It was a very quiet and seemingly awkward exchange. But, I’d said what I had to – and I had to say it. Too much to not. *** I certainly didn’t have the nerve to ask him to sign my book, then. It’s fine. It was fine. What counts is the interaction with the writer, the reading, etc… Later, at the reception, Cyrus Console came up to me. And he asked if he could sign my copy of his book. He said – thank you. For what I had said. Because that would make him keep writing, another book – hearing that kind of thing. That it meant something to write something out in the world.

He asked me if he could sign it. On the title page, he crossed out his name. And then wrote: “To Jenny, with thanks – Cyrus.”

Best inscription I have, besides the ones from mentors (different).

Even published writers – ones I admire so, so much – don’t believe in themselves and what the words can do for other people.

*I’ve read it 4 times since. Several more to go until I understand/see more and more and more… ** Cyrus is, perhaps, 5-7 years older than I am. At the most. Not intimidating at all – quite the opposite, quiet, unassuming, somewhat diffident. *** Similarly, I once told Li-Young Lee “you’re the kind of poet who changes my breathing.” I think he understood. He seemed to, anyway. But he is quite wise.

Poets certainly aren’t known for their self-confidence. I recently read Console’s first book, Brief Under Water. Same reaction. It was over too soon; I had to start again.

It’s the love-hate of poetry. In other (non-art) disciplines, you can finish things. There are infinite things, but you can finish one. Thing. Gain an understanding of something. Learn about a disease. Policy. Community programs and theory and epidemiology and pharmacology and pathophysiology and pathways. You can finish a book, you can finish a paper. But a poem? (as described above)

A “finished” product is one (often) I can’t bear to look at again. If I do, I’m likely to drown or light it on fire. In my undergraduate poetry thesis, there is a poem about just that - how much the poet wants to destroy the manuscript. A year later...it was better. Okay.

Anything, looked at too much – and carefully, down to each punctuation mark, spacing, letter – loses meaning. Like a word you say too much. A poem becomes – terrible. Nothing. Can’t see the forest for the trees, to use a terrible clichéd metaphor. And the work itself – hurts. It’s recursive. It’s never done – until the above happens. I spent six hours working on one poem last weekend (and many others on others; this, however, was six straight hours). One poem of 19 lines. And it’s passable, maybe, with several red marks and slashes (not mine) as of this afternoon. The poem was initially written in September, was then completely dismantled and rewritten, and, soon, it will be again. Unless I get rid of it entirely. All the work? Well, learning, becoming a better poet, better eye, more critical, etc… but to show for it? Lots of unused and failed files.

Our “assignment” over winter break is to write a book. And to fail. “May as well get it over with,” said our workshop teacher. Setting out – to fail. “How many failed books do you have?” “…All but three.”

And it can fail, and you might get one page, or one line, and that’s good! He says. I don’t know. Including us in that dialogue, though, included us in the discourse of published and future-published writers. Failure. Blood, blood everywhere (“writing poetry is easy; all you have to do is find a vein, and open it). Discarded paper everywhere (to be recycled).

Thus, simultaneously, public health program design, research, paper writing, article searching, curriculum creating - things that do feel satisfying. Partly in their ability to be complete, enough. For writing.

Start again.

~j

(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

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

I do the same in other languages, though – it’s either a function of being bilingual (since I’ve had language, lucky lucky) or just of being…strange. Speaking English with French people who have some accent in English, some significant accent, my speech softens slightly. Slightly. I’m not going to speak with an accent I don’t have, but...it changes. Situational. If I know a person’s first or native language, it’s hard for me to speak to her in anything else.

Thus, in Cameroon – Cameroonian-French and Anglophone.

When I went to Kenya, I started to speak what I think of as Anglophone – it was English-speaking Africa, after all… I got a few Looks. (What does the mzungu think she’s doing…) (Just like, when, in response to “I want to marry you” or “I love you” in Bulu, the mintangen shot back “Teke djom!” or “Ma vini wo!” (Never/I hate you).

In Kenya, they don’t speak Anglophone. The English in Kenya, yes, does have a distinctive Kenyan accent, diction, syntax, etc etc etc. But it is closer to British English, in some ways, than Anglophone sounds. Longer occupation and more in situ because there are good safari parks. It was hard to remember to speak English at first, actually. For me – Africa meant “speak French,” for the most part. In Equatorial Guinea (briefly), I had to remember to speak Spanish – Spanish mixed with Bulu, that is, as differentiated from the French mixed with Bulu that I was used to – same ethnic group, arbitrary border.

Arbitrary.

It makes the most sense for me to speak all my languages at once.

In Cameroon – as in many places, but this is what I know – there are 240 local languages. Country the size of California. Several of the languages are related in various groups, granted. But there’s the reason there is no African official language (as Wolof in Senegal or Malagasy in Madagascar) – there isn’t one. Not enough of one. (If Biya could decide that, on top of everything else, it would be a Beti-family language. Of which Bulu is one, actually). One village to another could be a different language. French and English are necessary to communicate in a country with 8 Francophone provinces, 2 Anglophone provinces, a German past, and 240 other languages…

Bilingual has a strict definition in people’s minds: French and English. I, then, am bilingual. Every Peace Corps Volunteer in country is bilingual.

And my friends who spoke 3 (least amount), 4, 5, 6 languages? Didn’t count themselves as bilingual unless English was truly amongst those. Every single person I know in Cameroon speaks more languages more fluently than I do. Most of them don’t count them as languages. They call them “patois” – dialect. Pejorative. Some are written, now, some have been, some are being codified by missionaries and/or linguists. In Bulu, there is Kalate Zambe – Bible, or “god book.” Books are Serious. Because I was often seen reading, people thought I was constantly working. Constantly. Always studying. It didn’t matter that some of the “serious” books I was always reading included books I consider equivalent to TV – passive entertainment – in a village where I couldn’t watch TV or movies.

But it’s not just that there’s not a conception of reading for pleasure (there’s not), for so many cultural reasons….* Books are expensive. Books are expensive and sold on sidewalks. There are bookstores in Yaoundé, the capital – two, I think. Small. Most things are copies, copies of copies for university, and it’s hard to get them (corruption/competition and otherwise) and it’s expensive. It’s not books. Even benches are shared – and paid for. Books are very expensive. Magazines, too. Anything that’s reading material, anything printed, thus gains value.

*I’m reminded of nights in my homestay in Bandjoun (perhaps written, 2005, the earliest posts here…). There was power. Technically. Low voltage. The bulb over the dining table was so dim that I rarely really knew what we were eating. For studying at night (in truth) or reading (in general) or writing letters, I needed an extra candle/kerosene lamp. This was probably (was) considered wasteful. My host sisters somehow sat, hunched, and did homework, after doing all the cooking/cleaning/taking care of the three screaming children under four. My host parents graded papers that way. But the TV and DVD player worked. In my room, with the light on, I read by flashlight. In Mvangan, until I got a table made (long saga and looooong time in production…), there were evenings lying on the floor with the book or letter, trying to get in the right angle with the light to see enough. (A headlamp, later, helped).

That’s both the importance of reading/writing to me – and the barriers that are set up just by the physical parameters. And no one but wasteful me (or other PCVs) would light more than one candle or use more than one lamp just to be able to see well.

But I was going to talk about language. It’s not the same language. And yet, the books are French-French. In college, I got to take a Francophone (Diaspora) literature class – actually, it was an intro to French literature, and the professor (Returned Peace Corps Volunteer from Chad), focuses on Francophone versus French. I’ve probably read more than most people in Africa have, of that canon. I can buy the books here. More easily. Writers are getting prizes in France, in the US… Africa?

I reviewed a book of Cameroonian poetry. The poet teaches and lives in the States.

Literature – the language of a people – should make sense.

*

And then there’s medicine. Words are always approximate. Always. Every art is approximate. The closest thing to anything, I think, would directly involve the body – and thus there’s singing (or any music not involving instruments) and dance. And medicine. We interact with this art form, shaping it and trying to understand it – I’m talking about surgery, I’m not talking about changing things through medicine, I might be talking about psychiatry, in some respects, but it’s not exactly that.

We ask people to describe and quantify things in common words.

Sharp/stabbing/dull Aching Where is it? Where? And what about referred pain – how do you actually know the locus of anything, as everything is “all in your head” – interpretation of pain. For many things, the body isn’t actually very good at that. I worry about this with the optometrist. What if I get it wrong? What if I can’t exactly record the nuances of the images, which is really better, or just a little bit better, or not at all better? (At my last visit, he assured me that I couldn’t mess it up – he used each image enough times, each diopter, and in contrast to other things that I should recognize more easily. This was slightly helpful – but still, I’m not completely convinced).

What about the power of suggestion? The review of systems. If I hadn’t asked about something, would the patient have thought about it or noticed it? (For some patients, this actually does become an issue – asking the ROS becomes a litany of issues they’d never considered or might be slightly off kilter).

We define these things and assume people understand.

Pointing is helpful – that’s the body speaking more directly – and yet, with anything visceral (in basic terms, organ-related) – the body isn’t good at localizing. Take the classic case of appendicitis: (this is textbook) Initially, pain is dull, maybe, and periumbilical (around the belly button). Vague, diffuse. (Is the appendix there? No. Not usually). And then it moves to a more specific location – McBurney’s point, 2/3 on the direct line between the umbilicus and the ASIS (anterior superior iliac spine). That’s classic. And the only reason it localizes, then, is that the appendix is so inflamed that it’s actually directly touching and irritating the peritoneum (wall of the body cavity). It’s not just the intestine anymore. And all of a sudden the body has a better idea of where it is.

The body, too, isn’t the best historian.

A friend (who just started med school) told me last night that his pain had begun at 6:30 pm the previous evening. “That’s precise…” “Well, give or take half an hour. Med students are good historians, aren’t they?” Yes, and sometimes hypochondriacs (I do think that improves with time, though).

What happens when you start to acquire the language of the body? The basics, as always, come back to pleasure and pain. And in order to communicate that to doctors (specified: doctors. Or any health professionals. Or people in a medicalized context). Do doctors care about pleasure in the body? Begs the question.

You could call importance of the patient feeling better as pleasure. Joy in resuming activities – or adding them, when things are truly “better.” When the patient-provider relationship has resulted in something positive and productive. There is joy in the improvement (or ceasing! gone!) of disease. (One patient called me “an angel” for helping with his cholesterol and getting him an expedient appointment with a surgeon for his hernia. Me – hardly. That’s the point of all of this, isn’t it? That’s what we learn, for? Behavior change communication, harm reduction, and then the medicines and then the surgery (order depending on the issue and its acuity).

How does the body – and how does the person – represent pain? The patient with metastatic cancer who says she’s in pain is more – terrifying, to me – than the five-year-old who is crying over a scraped knee. But?

A friend explained it this way. She was in the beginning stages of labor, with her first child. The nurse asked what her pain level was*. “Nine.” The nurse paused. Surprised. “You know…the actual birth is going to be a lot more than this.” “I know. But right now, this is just about the worst I can imagine. And now I’ve experienced this…so later, it’ll still be a nine.”

*This is a person who would probably be among the most stoic. This may have contributed to the nurse’s surprise. Also, this friend is in medicine.

Everything’s relative. The utility in measuring, quantifying, qualifying in common language is that we feel we can treat something, that we can communicate effectively with the patient. That’s why physicians like the physical exam and lab tests, too. But how much of the physical exam is truly objective? And for lab tests – much closer – as is imaging, certainly – but unless there are specific points of comparison, you don’t know what the patient’s baseline might be. (Patient. Person. Patient. Person).

Small small catch monkey

(offered to me as a present, Mvangan, Cameroun) Poetry is about specificity of language – actually, it’s about Vortex and Image (Ezra Pound), but that’s for another day. In medicine, specificity of language is crucial; it’s how patients tell stories to physicians (and we complain! it’s not specific enough, AND it’s not in the right words!) and it’s how physicians communicate with each other.

Epocrates isn’t quite a thesaurus, but . . . working on it.

(this is already far too long).

~j

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 avocation. 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

Why be a poet, and why not be another sort of writer? (many, many of us are, as well. These days, I’ll claim poetry-fiction-non-fiction, whether I have a “right” to or not).

“No one reads poetry.” “People are afraid of poetry.” “To say ‘poetry’ – to say ‘I’m a poet’ – has serious connotations. To say ‘writing’ or ‘piece’, rather than ‘poem’; to say ‘I’m a writer’ or ‘I write’ – that sounds different.” Less presumptuous? Less evocative of I’m-disconnected-from-the-world and I’m-part-of-the-tuberculosis-aesthetic, living-in-a-garret-aesthetic, surely-starving-artist who, well, teaches, because who can make a living at this, and who would do it anyway?

Among my coterie, among my new colleagues and friends and cohort, these are common discussions. Why do we do this. Who do we read. Who and what stops your breathing and heart and makes you gasp and reread from the beginning again, and again, and again.

To be a poet is not a choice. We didn’t choose this. People might choose to write fiction, in some sense (paperback? Things that sell? Even over and above that – it’s a different kind of discipline). There is discipline to being a poet, certainly. I was reminded of this in the poem that I have, perhaps, spent approximately 18 hours on – thus far. It’s not done. It’s far from done. It’s what absorbed much of last weekend, has kept me up until 3 am a few times (that and other new pieces), brought me to a café (“my office”) with my unabridged thesaurus, reminded me that being a poet is damn hard, and is unbelievably exciting. Why? I could articulate it, I know it – but to whom, outside of poets – and those who know me and try to understand – would get it? And why is that important.

I didn’t choose this.

One project, lately, has been rereading every poem I wrote since freshman year of college, when I first started getting serious about this poetry thing. When it went from being something I vaguely did and vaguely wanted to do to something I was really going to put energy into because it mattered. It matters.

Why on earth do that? There are the bad ones. So, so, so many bad ones. (The impulses and ideas for “bad poetry” are still there – I’m just better at self-censoring (we all learn to do this) and don’t write them down). But things are resurrectable – lines, ideas. Two of my recent poems, turned in for workshop, were resurrected – and severely edited – from pieces that are, respectively, 9 and a half and 7 years old. They’ve changed – they are something, now, maybe – but the raw material is that old. It needed time and maturity. So that’s why. There are things there that I just didn’t understand, before.

Reading this – yes, cringe-worthy at times, but actually less than you might believe – I have so much separation from most of the pieces (not all) that they almost feel as if someone else wrote them, as if I’m reading them for the first time, with only a vague memory – is useful. One of the poems – the nine-and-a-half-year-old – has been stuck in my head for many months. Just a few lines. And that meant something. That’s why I had to find it. Senior year of college, there was a line that was persistent, pestering all year. I tried to write poems with it. So many poems. And nothing worked. All were “bad.” In the end, that line happened to be the title of my thesis. That happened another time (another memorable time – but many, many more times – this was before I understood and had experienced the phenomenon frequently). A line came to me – I had no idea what it was, where it came from, or what it meant. But I knew it was “something” and that I had to write it down. I did. Turns out that it was the title of a piece I wrote three months later. Not on purpose. It was after I wrote the piece that I realized what the title was.

And thus Jack Spicer’s Martians (for the morbidly curious, it’s from the Vancouver lectures (starts in #1, but here's #3 - http://jacketmagazine.com/07/spicer-lect3main.html – or, in brief, http://www.poetryfoundation.org/harriet/2008/07/taking-dictation-from-a-martian-muse/ ). Others call them muses. Martians feels more appropriate, to me.

It’s reading these that I realize I am a poet, that there’s never been a choice, there isn’t one, and that taking time from med school for an MFA was, well, not really a choice, either. The MPH? Yes, later. But I can – and do – work on public health in the meantime (7 years, now. Much like that second poem, above). I’ll now be ‘working’ in some capacity with the Department of Public Health now. Fine. I know many, many people who understand my love, my passions for medicine, and how integral that has become. Ditto public health. Poetry? Harder to find them. And I have.

(Another commonality? We all hate Shel Silverstein and Jack Prelutsky. The "classic" children's "poets." Hate. Always did. This was a discussion the other night - Dr Seuss is a better poet. Certainly.

The poem from second grade: “The moon holds a beauty within itself. That beauty is called silence.”

A more recent line*? “The silence is palpable; I’m not.”

*completely unrelated to the project of resurrection. Interesting only in having some relationship, maybe. And in calling both "poetry" though they don't "sound like poetry." Education, too, is dangerous. Some types and some things in it. Powerful stuff. And the first doesn't have an "I", and the second has "I" as speaker - the delicate separations we make, earned or not. "I" could be the moon (really, too obvious an image for 'poetry', unless done well), or...whatever else. I just thought this was interesting. Curious. And anyone can certainly think that both/either are terrible lines.

It’s never been a choice. I don’t think anyone is a poet – not a “real” one – because they want to be. Want to hone, yes. Want to really work on and devote time to, yes. Perhaps this is reductionist, but you don't "become" a poet - you are or you aren't (apologies to some), and you can become a better poet, much. I wonder this while looking at the $#*%^ turned in as my portfolio for my first workshop - I got in on that?? There must have been something. A few lines.

And there are ways to write - read poetry. Go to readings. Be in workshops and around other poets. But the 'discipline' of poetry is different that that of fiction, I think. And others - you can choose to be a journalist. You can choose to be many things - and you can be a good writer, certainly, and you can work on that.

Realize the necessity, yes. But no one chooses to be a poet.

I wouldn’t have.

And last week I went to the ER (the next story) to shadow for a shift (no longer covered by malpractice, I can’t do anything hands on – it’s frustrating, in a sense, because it feels like many steps back). And yet – I read EKGs, I read head CTs, I helped do differentials and diagnose, I looked up criteria for admission, I saw physical exam findings and talked to patients and thought about things – I saw a stroke code (and could anticipate the exam and what would be done), I saw an intraventricular shunt placed to relieve pressure from hydrocephalus from a hemorrhagic stroke (i.e. – yes – the neurosurgeon bored a hole into a woman’s head and put a drain in it, and things came out. A little brain matter? How not?) All of this was rejuvenating and invigorating and exuberant and the time passed more quickly than time has in a long time. Similarly to the alone-work of a poem for late, late hours. Reading an EKG as reading a line. Thinking through how to put things together. How to get to somewhere. And the unbelievable, incredible nature of medicine.

That too is no longer an option.

Many people want to be doctors, initially – and maybe they don’t, for various reasons, because they didn’t understand what that actually means, the pre-work, the study, and then the work. And some do and become disillusioned. Others don’t and wish they had. Others do and it’s the absolutely perfect, right choice. Is it a choice? In some senses. I chose it – at least, I thought I did. Perhaps that’s not quite how it happened.

I didn’t choose to be a poet.

But no one asked me.

~j

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.

I was planning to try the Hungarian Pastry shop – almost everyone I’ve met has mentioned it, in a week and a half. So many writers have written books there, they said. Covers on the wall. Except – there is a hospital. And if the cafeteria’s anything like that at my home hospitals (ie, tables, chairs, space, half-decent coffee at times) – that’s where I could write a book, too. I’m not dressed for it. Yes, I was at a job interview, but it’s hot, I’m wearing flip-flops – though, the rest, I have worn to work in pieces. The Cameroonian skirt. Etc. There is a guard. He asks me “what floor?” and I answer lamely, pointing in the wrong direction, “the gift shop.” (having forgotten my initial coffee idea. It looks alien in here). I pass people in scrubs – some in the green ones that are my favorites. The yellow cord on that woman means size small. Someone passes me in a white coat. I gravitate. They don’t know I belong.

When I returned from 2 Peace Corps years in Cameroon, I would see groups of West Africans on the street (yes, I can usually tell), in subways, hear African French spoken, see West African clothes, and feel I belonged over there. Once, I chased a woman through a train station to tell her I had a dress of the same women’s day cloth (the bright pink one). If I dress like that, it’s a little clearer. Or on bush taxis with strangers speaking Bulu, I could surprise and make everyone laugh when I suddenly joined the conversation. Yep, ma wok. I understand. To me: “Ma nye wo!” My reply: “Ma vini wo.” (I love you!/ I hate you. Always good for a laugh). Or…the “marry-mes” (forgetting the Bulu words right now). Me: “Teke djom!” (Never!) Really, anything I said in Bulu was great for laughs. The mintangen (white woman) speaks Bulu! (some, and diminishing). Back in the States, it was easy enough to blend with Americans (any color) except it felt false. I could look like a visitor at this hospital where I have no patients. They don’t know me. I’m posing. In my hospitals, no white coat on, hasty ID still in the bag where the iPod earbuds have just disappeared, everyone knows I work there. We’re all obvious to each other and to everyone else. Ownership? Boredom? Concentration? Walking down the hall, checking email, entering stairwells (especially that) without once looking down? We walk faster. We are not, in general, crying (later). We carry no presents, no balloons. And especially in this county hospital (true), we dress differently (it is a level one trauma center, so those patients are undifferentiated – the patient with purposefully (expensive) distressed jeans stood out). I walked out. I wished I was wearing scrubs, maybe. It’s close to 3 weeks since I’ve been a med student (I’m ­­­____, one of the (a?) student doctors here) (have I forgotten my opening line?) and my stethoscope is on the wall in my apartment. Not stuffed in a bag. Swinging, swinging, swung around my neck. Nameplate facing out. It looks lonely, awkward. It’s only supposed to hang like that on a neck, my neck, and it twists. A stethoscope is never static.

From October 2008 to August 2011, the longest I ever went without seeing patients was 2 weeks.Usually one, usually 3 days. And for a year and a half, five to twelve patients a day, every day. Sometimes for 12 days stretches (or 30 hours). And after this, for the rest of my working life. Same-same. In the tradition of William Carlos Williams (the one everyone cites to me), I am a poet. “Somewhat writer,” I say. And I only claimed that after the first check came. (First one? $6. But I kept it because in the memo section of this university-generated check is typed “Writer”). Almost doctor (and I only claim that because, logistically, I have 6 months of classes – by which I mean mostly hospital work – left to graduate). And here I am, many, many miles from the city that’s become home and the hospitals that are home (people, places, patients. In a recent dream, the trope of someone intruding on me at home? Me, scrubs, hospital, waiting for an interminable elevator).

I’m an imposter non-med student, MFA student, and I could walk into a hospital in my scrubs and white coast (both made the packing list) – but I wouldn’t know where to go. No team and no patients. To people who run writing series, lit mags, are published-published-published, I, 7 years out from a literature class (or analysis), very under-read/educated by comparison, published only in lit mags-for-medicine, not knowing poets or literary movements or presses, am going to say I can keep up and have something to contribute? Doctor with a writing hobby? Writer with a doctor hobby? My college degree is in both, I defended a thesis in both, but MD will always precede MFA on the name badge, and I have fewer class hours in a week that I worked in a day. In a city I don’t live in, without any of my hospitals, I’m supposed to sit in cafés and – except for when I’m tutoring med and pre-med students (the aforementioned “job”), writing is not what I do between notecards and medical references. The journal, the poetry book are not what I add to what I carry. They are what’s supposed to be there, this is what I’m paying tuition to do and to learn, and no one expects me to pre-round at 5 and be prepared for rapid fire presentations and invective.

I don’t know what they want or what I can give. This school isn’t a job (paying for the privilege to work, guild system, hierarchy, etc). I call most of my hospital attending by first name anyway, but these poets aren’t doctors (and what, then, is acceptable formal address? Mr/Ms? Seriously?? They’re not all professors). People used to doubt I’d go back to finish med school after this. “I’m more than halfway,” I’d say. “I have to have something to write about.” “Besides, I can’t be a poet with med student-sized debt.” (the joke). It used to annoy me, the: oh, so you write about medicine? Well, when some weeks, months, all of my waking hours except 4 are spent at the hospital, what else might I much write about? And now? 17 days out and I consider communing in hospitals.

This imposter – Franco-American and bilingual, bi-passported, with Cameroon considered a home, grad school nested in grad school, keys for houses in two very different cities on my key chain – will try to learn to pass.

(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?”

Meaning, wear white coat + ID, even bring stethoscope, to show I belonged. Walking along with the team, though, and dressed as I was, I didn’t look out of place. Comfortable, except I don’t know these hallways. Even the cafeteria was comfortable with that coffee-bad-in-a-particular-way. Going on my good things about this city list? Hospital food was cheaper; apple cost 35 cents rather than 75.

There, I know what I’m talking about. “Do you know Pharos?” in rounds, we were speaking of medical publications that incorporate literature. “I’m published in Pharos, actually.”“Why do you still want to be a doctor, after this?” “Because it’s the best job in the world.” Nods. They know. They get it, too. There is no other reason to work so hard and not sleep.I was remembering the antibiotics – I knew, I knew, I took notes, I thought of the antibiotics cards I needed…and I still haven’t done the poetry homework for first workshop, the explication of the long poem.

This hospital is four stops from MFA school on the same line. Convenient. In any kind of metaphor, MFA school is the last stop on this line.

Three worlds and drinks at night with the one I’m least comfortable, have the least to say and interact the least – but 3 writers* – THREE! – were mentioned whom I know, personally, including my mentor and two I met last summer. I have signed copies of the books we discussed; I’ve read all of one of them.

*Promoting poets, the three are: Olga Broumas, college mentor and leading/initial writer in Calyx, Ross Gay, over whose poetry book I actually met a friend, last year, and Bhanu Kapil, whose work is indescribable.

I should see it like medicine. I was asked to teach a class on Whitman’s Brooklyn poems – I’ve barely read Whitman, and I certainly didn’t know he was from Brooklyn. The professor asked me to teach that day as the poetry “expert.” So, just like in medicine, I pretend to know. I’ll learn. See one-do one-teach one. See one-do one-teach one.

Medicine feels appropriately fast. In my head space, I am thinking through the body. Where are the offenders, the intruders, and who could they be? How do we find the intruders, how do we get to them, and how do eradicate them, and how do we make the patient better? Better.

In rounds at the hospital, this hospital, where I’m not a student, I take notes, whether I will need them or not. I’m remembering, I’m thinking, I’m trying to keep up and realizing how much in just these few weeks has moved to the back of my brain. Maybe that’s why we work so many hours in a row.

So there is poetry homework. I did buy the book, early, and I identified the poem and counted the pages. A poem to dissect, to explicate* (one of my favorite words). Can I approach with a differential? It’s a scalpel, I say. I call this. “Approach words with a scalpel.” (line poached from my poem).

*Explaining a poem. It is like dissection – the nerves/arteries/veins/lymph channels (NAVL we say for the femoral triangle), where they are in relation to each other and how they work together and what that means. What is the brachial plexus of the poem and what-leads-to-what and how; this is also the derivation and the allusions. What nerves mix to create what other nerves, and where do they go. We don’t make up dances or mnemonics for that in poetry, though. Unless it’s formal poetry and you’re talking about meter or shapes or rhyme schemes – each dance is different. A little different. And each author’s dances are related to each other, somehow, and the thread might be the voice.

It’s false. Everything I’ve said, this title, is false. I’ve been approaching scalpels with words. My MFA applications? About how I see medicine. How medicine is like poetry.

I wrote, I explained, I sold why-should-a-doctor-be-a-poet. Why, then, should a poet be a doctor? It’s why, perhaps, they want me here. Whatever that is.

I’ve approached scalpels with words.

I brought the poet’s eye, hand to medicine. And somewhere along the line, my old explanation ceased to be true. No.

“I’m a writer. Medicine is what I do.”

“Doctor” is who I am, too. Will be. Were I staying, I’d be applying for residency right now. And it’s not a brainwashing or mind-melding or beating-into-shape transformation.Writing, neither, is not my “hobby.” I hear that a lot.

But up until now, for the past several years, I’ve been learning about scalpels and approaching them with words.

Writer and a doctor.

Now is the time to approach words with a scalpel. To learn why that’s a good thing (assuming it is). The doctor will graduate more balanced – words with a scalpel with words.

And there’s a white coat in my doctor bag and two poetry books and notebooks, one of which has medical lecture notes – all that’s missing to make this “normal” is a stethoscope, many more than the one highlighter, and some papers. These have gone together for awhile. There is poetry inside the white coat at times. Maybe I should wear it to write. Maybe I should wear it to teach poetry, wear it to readings, and be subversive – there, it won’t represent the hierarchy it does in the hospital. In the hospital where I don’t like to wear it for reasons other than practical pockets. It represents who I am. Maybe the stethoscope would be easier to carry.

On the subway on the way to my first day on poet-campus, I considered bringing JAMA to read. For med school, I often had poetry with me. Close to always. Novels. I brought a poetry book(s) for boards – totems of good luck, things of balance. To my first workshop in college, I brought what was, at the time, my favorite book of poetry. You didn’t know until you arrived at the door if you had made it in. We had turned in the pieces – applications – the week before. I didn’t expect to get in. If I didn’t, the reasoning went, I would still and always have poetry.And then I got in.The first poem read in that first workshop – it’s Li-Young Lee’s “Words for Worry” – became my touchstone, after that. I started a reading I did with that one. I’ve started workshops I’ve run with that one. Any poetry class I teach should begin with that poem.So JAMA on the way to poetry school for balance? Maybe it should have been. Instead, the compromise, I read a book of ‘psychological poems’ – by providers and patients.That’s where I belong. And today I wrote in the hospital.

I’m not the writer who graduated with dual degrees and dual theses in college. I’m not the writer who returned from Peace Corps. I’m the writer whose signature has not degenerated, per se, but is often accompanied with an identifying code and a pager number. I’m the writer who uses abbreviations and bullet points in the hopes that maybe notes will be easier for others to read. And shorter for her to write. There are so many…

I’m the writer who could have been, would be, a doctor in less than a year. Who’s still trying to work on having thorough differentials with a consistent approach. A flow to the physical exam. To work with patients. To presentations. Conciseness. Meaning. What is said and what isn’t said.That’s what poetry brought to medicine.

Now medicine brings to poetry not-just-subject-matter. I don’t know what else that will mean, yet.

Use it.Use everything.

~j

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

We haven’t installed it at home yet (new apartment, new city, new life as a writer-med student rather than med student-writer), and so we’re stealing – pirating – where we can. There’s one network that’s usually close enough for us to get onto (have they realized? How much slower has it become for the mysterious Them?)It’s available at different points in different parts of the house. If that makes any sense – but there is a distance from the invisible (waves I don’t understand) that makes it easier and harder – and the distance is about 20 feet. There is, most of the time, a cloak or shield around my room. I don’t have it. And rather than take that as a sign that I should be doing other things, I should be reading, or I should be writing other-than-emails.Instead, I search. I go look for it. I move around.

I’ve been back too long.

My frame of reference for frustration in Cameroon:The summer prior to leaving, I was frustrated when our wireless internet wasn’t working and I had to go downstairs to plug in my computer.A few months later I didn’t care if there was power, I’d rather it stayed off than dimming the bulbs (yes, there, it can be cut by what seems like half) and flashing in and out.

I’ve been back too long.

(I’ve said this, I know). But there is cell service in the village, now. In Mvangan. I’ve gotten calls in the middle of the hospital from friends in village – things I can’t explain about how I can’t talk at work, I’m with a patient, I’m in the hallway, and I can run into the stairwell but I can’t stay for too long and I can’t really shout and if I’m heading into the elevator I’ll lose connection. Or have to cut it off.

I wonder how frustrated they get with me. And because I have to Skype I have to count the hours, be at home, and remember. And my excuse now for not answering the phone calls upon phone calls (it’s biping, for the most part – call and hang up so the other person sees the number and calls you back). Because there isn’t always internet.

In Cameroon, they can call me. For me to call – money less of an issue on this side – there are many, many other factors.

It’s the logistics here that are more complicated, and that’s what I have the most difficulty with. Logistics. Dealing with such. And having intermittent internet. Being in a large city in the United States, naturally, it’s easy enough to wander to a nearby café with free internet. Sit for hours with a table and a mug in the style (is it really first from Friends?) And even from there, it wouldn’t be couth to have a loud (necessarily, it’s both Skype and a phone call across sometimes-hesitant network to Africa).I’m pirating and it’s more difficult to communicate. Or that’s an excuse.

In psychiatry, everything is relevant.

(Even this)

Cacao drying, Mvangan

One of the interesting – and difficult – things to learn, in the beginning, was that in an hour you can speak with two patients who are very anxious. One is afraid of a recurrent heart attack, a recurrent theft, an attack, a nightmare.The other can’t access wireless internet and feels disconnected from the entire world* (yes, without ‘smart’ phone or 2/3/4 G).

*Not actually the case. Though, anyone who knows me does know that I don’t have an internet-capable phone.*

Another (perhaps relevant) point is that, when too tied to internet/devices and searching for internet/devices, you forget to pay attention. Attention to detail. To listen to everything around you – we block things out with headphones and ear buds (how much more intimately invasive can you get than actually blocking the ear canal directly?) Loud noises that drown out less loud ones. Right now, as I write, I’m periodically checking to see if I can access Wi-fi. If I could, would I be periodically checking email? Likely. I had learned at one point to turn off the internet capability of the computer in order to really write. Editing poetry is generally long-hand, on paper, with red pens and a paper thesaurus. That helps with the concentration. And typing that is stream of thought, something moving forward, at any rate, so I’m less likely to multi-task in the middle. (And this, compared to any sort of essay or assignment, is stream-of-consciousness and directed thought. And yet. I’m still searching for internet. I’ve moved to the part of the apartment where I’m more likely to find it…are they onto us? Are we cut off???)

The mental status exam, like writing poetry, is about using every sense.

Appearance.

The patient might say he doesn’t drink, ever. Or hasn’t had a drink in two weeks. Your sense of smell gives you a different answer. Write it down .We classify each other into subtypes – the ones most discussed in my life, currently, being hipster and hippie. High school was goth. Emo. Etc. These change, generationally. And they don’t at all. Incredible how people, even, are tropes. Would that be a shortcut to describing appearance? And how do you describe so that someone can listen to your presentation, someone can pick up your note and see the patient, exactly? A psychiatrist, any doctor, should be a writer. Is.

Behavior.

Who’s actually calm, these days? Behavior is being constantly connected. Behavior is what’s on your facebook status, gchat status (previously AIM – someone recently said I was betraying my age when I admitted to having an ICQ account, long ago). Behavior is having to tell people where you are, when you are, how to find you, your GPS coordinates, what you’re reading, where you’ve been, and who you know. I remember the Kevin Bacon game (preceding or co-existing with the advent of IMDB?) We do it to each other now, and not celebrities.Behavior is voyeuristic. (Photos of people you haven’t spoken to in a decade? What, really, is the curiosity, and why is that what becomes part of the procrastination routine? (admitted)). Finding out how friends are connected to friends of yours, from other parts of your life – connections necessary to know for curiosity? This is how the world is real. There are few people who do not, to some degree, know each other. Whatever knowledge is, now. Behavior is having to be online to work and thus being online for everything else. What’s “productive” and what’s not.

And because I am in a coffee shop – and I spent at least 15 minutes trying to troubleshoot why the internet was, initially, not working, though I mostly don’t need it – and because this is procrastination from working on a research article – and because this sort of rambling, this sort of unedited diatribe, is common in the self-promoting, self-actualizing world of blogging and online conversations without punctuation other than key returns becomes unbearably long – I will continue the mental status exam later.

Attention to detail. Attention to length. Attention to the icon on the bottom of the screen that, moused over, declares both local and internet connection. The shiny blue circle over the superimposed monitors, on my computer, looks like a little world of oceans.

~j

(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. + FCMSingle, intra-uterine pregnancyFetal cardiac motion

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

Every day for the past month I have been working in an abortion clinic.And three days a week for the past 4 weeks I have done abortions – yes, I, at least once on each of those days. And at times more (depending on patients – can the student doctor do it? Yes/no. Would I let me, if I were the patient? Yes/no). On the other two days, I’ve been helping to prepare for other abortions.

These are TABs or VIPs – Termination-abortion (as opposed to SAB, Spontaneous-abortion, commonly known as miscarriage).VIP. Voluntary Interruption of Pregnancy.

This is not a treatise on abortion. This is not political. This, simply, is.

***

I’ve been working in an abortion clinic – it’s part of my education. It’s my fourth year, now, so I chose this. I chose to work here. A clinic in a large-liberal city in the United States. Where we are, at this clinic, we don’t have to deal with protesters or laws forcing doctors to do things doctors shouldn’t have to do or say. Legalities interfering in even the conversation of the doctor-patient relationship.

There are legalities in every part of medicine. We learn medico-legal speak. We learn what to write, what not to write. How to cover yourself and everyone else.

And for billing purposes, I write “undesired pregnancy.” That is the reason for the ultrasound.

And I do ultrasounds.

***

It doesn’t matter what the stories are; I don’t need to tell them.My patients have been mothers of 3, high school students, animal trainers, women with master’s degrees (spoke 5 languages) now "without a home; if I have one more child my family is going to ...." Another, talking on the phone to get furniture delivered and 4 kids picked up from school… taking a day off from school + 2 jobs.

Twenty, three kids, here on a bus alone (can’t tell anyone at home), wandering around all night..and that’s why she showed up so early, and why I didn’t want to let her into the clinic, yet, when I was the only one there (protocols? Liability? Who knows. Or my laziness and wanting to finish breakfast, studying, and work for the day before anyone came in whom I had to talk to).

then the other one whose entire family lives on the same streetor the one with a two year old and a six month old – she’s 18.or the one whose mother is there to hold her handor the one whose partner is pacing, anxious, in the outside waiting roomor the one whose social work/case manager is the one in the clinic, in the ultrasound, in the procedure, holding her handit was a different one who came from the psychiatry floorit was a different one and a different one and another one who didn’t know she was pregnantit was another one who had had to cancel three appointments – mother-in-law sick, died, funeral, then she was sick, then something else happened… but today, she had a day off, and she could do it.(same for another, who luckily didn’t have to miss one of her summer school class days).

This is what keeps my day and my job alive, vibrant, constant, and me invested in what I’m doing with fresh (tired, tired, tired, red) eyes and hands, again.

Otherwise, it doesn’t matter.

Some are there for fetal anomalies (abnormalities? wide, wide range), chromosomal abnormalities (from amniocentesis; some, we know exactly what they mean – Down’s syndrome, etc. Others, it’s not clear, exactly, just clear it would be bad. Bad). Fetal demise (died inside. Didn’t come out. Could be an incomplete miscarriage, could be…whatever. Something happened. And something inside is dead and has to come out). And then there is every other imaginable reason.

But it doesn’t matter, does it.

***

As a future physician who will specialize in HIV/infectious disease, I shouldn't feel differently about my patients with AIDS-by-blood-transfusion or AIDS-by-heroin-shooting-up. (But are the babies different? Yes...) Health care worker? (yes, I identify more here). Unprotected sex, bad luck, the traditional birth attendant in Cameroon, the wife of the husband who was with the teenager and all those other ones...man in the same situation. Teenager (young). Before HIV was known about and how to protect from it. After. The medical treatment is the same. The clinical treatment, patient in the clinic, my patient in front of me, should be the same in that moment. I'd like to hope that one-to-one, ceteris paribus, it will all be the same.

But it doesn't matter, does it. The how or the who.

If I feel differently about the ones with anomalies or chromosomal abnormalitiesIf I feel differently about the fetuses that were absolutely desired pregnancies but, for some reason, the pregnancy can’t be continued – health, health, dying, fetus dead, health .

But no one’s happy to be here. No.The staff are happy to be in this amazing clinic, to be working together, doing this work, helping – counseling for psychosocial, support where there might not be any other in this woman’s life. Doing something small. Having a positive impact. And in this clinic, at least, family planning and contraceptive options are a big, big part of the counseling. Looking toward the future. No one actually wants to do this again - the providers don't want to see the same patients again. The patients don't want to be here again.

No one is happy to be having or doing an abortion. That's not the word.

Nothing is easy about this. In the beginning, it felt different – believing in, supporting abortion rights – and being the one who performs it. Is it? If I weren't in medicine and had the same socioeconomicpoliticalhealthcare views, I wouldn't be on the side with the hands-in-gloves, the mask on, concentrating on the procedure. But I am in medicine, I want to be in medicine, and that's part of the views, anyway. Getting to enact - getting to be part of extending health care, of making that a more positive experience for people who might not have those in a power structure. Respect. Just...being there. Like Peace Corps. Being there with whatever skills you have, working to learn as much as possible, always learning, and working because you care so much about it and about what you're doing. Lucky to get to do that. Lucky to be there, on this side. And that's all.

***

Before I started medical school, there was one procedure I was looking forward to learning:

This one.

I didn’t want to be a surgeon; I wasn’t looking forward to learning about appendectomies or heart transplants or venous grafts. I had no conception, yet, of so many of the things I would come to love in medicine. I didn’t know.

This, though – I knew. It had nothing to do with the procedure itself. This is, again, the privilege of medicine to me – and the responsibility, or what I feel it as. I’ve worked in places where abortion is illegal (though I haven’t worked in any of those places in the US, where everything is an unbelievable barrier). I’ve seen the sequelae, actually, a few times. And I’ve read about it (who hasn’t?), even back to my John Irving days and The Cider House Rules (book. better than movie). I wanted to be able to provide safe abortions. Safe. I wanted to learn how to do that, not just a safe procedure but a safe space to come for it. I want to fill in the gaps, in medicine. The things where there aren’t enough people (just need to be filled) or any at all.

Here’s a gap, to me. It’s a place I can fit.

Nothing is easy about this, and I don’t think it ever will be.

Nothing is easy about this. I'm learning. I'm going to keep learning. The skills will build. It won't be easy.

~j

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

Before I started med school, I couldn’t believe how lucky I was to get to go to medical school. I’ve had a lot of privilege in my life. This is one of the greatest, most amazing, most incredulous ones.What I’ve done, what I’m doing, what I will be doing.I was let into this hallowed profession – in some places, hallowed, darkened halls – in which I get to learn all about the body. Get to. And I get to interact with people in the most intimate way, at their most vulnerable – they trust me, let me in. I have to earn that trust.Starting, and before starting, I didn’t understand that sacred trust. It’s something I continue to learn, every day. And I am amazed.

After a day with patients, last week – any day – I left the hospital exhilarated. Exhausted. Beaten down, burnt out at times. But exhilarated.I will have no days this amazing as a writer. Or as anything else.I am unbelievably, incredibly lucky. I get to do this. They let me in.

When I graduate from medical school, I will have been thinking about becoming a doctor for about 17 years.

I am the luckiest.

When I hear about people studying for the MCAT, my first question – reaction – is why. It’s partly that I’m still not sure if I would do this again; there are other things I could have been very happy doing, and I wouldn’t have known, exactly, what becoming a physician means. Why. This is too damn hard if you don’t love it. Too hard. Not worth it. Become a lawyer, go into business, science, anything, anything, anything that is intellectually challenging/prestigious/hard/will make you money. Whatever the motivation is. This is too much work if you don’t love what you’re doing.

Perhaps I’m already nostalgic, but that’s why it’s important to write this now – so I remember, have it to read again, on the inevitable terrible days and nights.

I get to be a physician. I get to have patients.

When doing procedures that are uncomfortable/ painful. . . I give patients license to do whatever they want. Whatever helps, I say. Swearing. Call me names, I say – it’s nothing I haven’t heard before. And it won’t hurt my feelings - promise. It’s definitely not personal. You can talk on the phone. Whatever. . . If I’m holding a patient’s hand during a procedure that someone else is performing, I joke about breaking my hand. Go ahead, I say.

The unbelievable, unbelievable, incredible privilege.

It began with cadavers.No, before that. It began with getting in. Before that. The opportunity to do pre-med at a ‘very good’ university, with a lot of support, and enough liberty to really have time to focus on classes. Which goes back to high school, etc.

I was in the school bookstore today and I almost started tearing up, looking at the stethoscopes. Mine is coming with me to writing school. It’s part of me, at this point – it’s an extension of my ears, another way to augment my senses. And it hangs so naturally around my neck that I once picked up someone else’s stethoscope – same color – thinking it was mine, and didn’t notice I was wearing two until someone pointed it out.

I get to have a stethoscope. Mine. I get to listen to the inside of the body. And with this training, I learn to interpret what I hear. Sounds and silences. The natural unwinding of this caduceus. At one point, I thought I’d lost it – left it in a clinic, somewhere. (I know people who have lost them/had them stolen). And it wasn’t just the frustration/annoyance of having to spend money on another one.

It was the thought of losing mine. I can keep this one for the rest of my career. I’ve gotten to know it. In mine, there are still a few grains of sand around the bell from the time I put it in a bag I’d just taken to the beach…If I don’t use it, as a writer, it’ll hang on the wall.

The early med students walk around in clean white coats (I remember being told that was how we were recognizable), and the stethoscopes look a little awkward. The scrubs are almost a status thing, at that point – a little bit in awe of getting to wear them. (Getting to). And now… well, nothing used in that context stays white, and bleach barely works. The stethoscope that I used to wind carefully into a little bag, the one my sphygmomanometer (blood pressure cuff) came in – now goes around my neck, winds into a pocket, gets dropped into my bag. It isn’t fragile. And it’s mine.

I get to be a doctor.

I can’t imagine any job as incredible as this one.

This morning, talking about this with a med school friend –I, starry-eyed, was waxing poetic. I know it. And I’m trying to not forget the hours of exhaustion, “scut” (busy + mundane + worse at times) work, being grilled on the spot and judged on absolutely everything you do in a day, subjectively. And being graded just on that. And test scores. I got into this business for my patients. I want to be a good doctor for my patients. That’s the point and it comes back to that, it should always come down to that.

No matter what else is going on in the day – getting yelled at by an attending for something out of your control that you had no idea about – you get to be alone in a room with a patient. I do. And there are the patients who scream and throw things (more often, on psychiatry). There are the patients whose affects are so disturbing that you really hope the drug test comes back positive, to give you an explanation…There are the patients perseverating on things you really don’t need to know about and you have limited time and the story isn’t making sense and they’re ranting about things in the clinic or the health care system or life in general that are out of your control but they’re somehow being put on you. . .There’s that.

There isn’t anything that doesn’t happen.There isn’t a person, or a “type” of person, who doesn’t get sick and need to go to the doctor at some point. (Or they show up in the county hospital ER, or they need primary care but are marginally housed. . .) Or needs primary care/preventative medicine, which is generally not covered at all.

In the room with a patient, I am focused on that patient, and – the point is what the point is. I want to be a good doctor for my patients. And that’s most of what I have to think about, in those moments. That’s what I’m doing.

And I do it every day. Now, it could be a dozen times in a day. Different people, different stories, different ways lives are affected by the exact same pathophysiologic disease. But I have to do something different. The treatment might be the same, the procedure might be the same, but the way in which I approach it, talk about it, take time explaining (or not, as patient preference dictates) changes. The way I sit. The way I talk. What I talk about. Tone, volume, rhythm, posture, eye contact/facial expression – it’s not an act, it’s a mirror, and it’s finding how to be what your patient needs in that moment. Learning how to do that. You’re not changing yourself – you’re accessing all of yourself in different ways. You use the patient’s language and metaphors.And then there is the science, some of which is supposed to become second nature. Pattern recognition and understanding the underlying conditions, the physiology, what is going on in this body at this time.

I get to do all of this.

I am trusted by the physicians around me – my colleagues – and by my patients. I get to go in, alone, and do all of this. And it’s the trust on both sides that helps me need to do it right, or as “right” as I can with the training I have.

There are the times I’m frustrated with the thing (or the patient). The vein is rolling or they have no veins left… the cervix is wayyy anterior and it’s hard to find/access. The tonsils are large and obstructing the intubation. The heart sounds are muffled. The patient will not get the concept of taking a deep breath (“in through your mouth, out through your mouth). And I still have difficulty (a lot) finding the optic disk…

For now, I get to take time as a writer – a writer who misses medicine and patients and remains involved, in ways –

But I still can’t imagine a job as good as this one (perspective).There are days I left my internal medicine clinic almost skipping across the parking lot. My patient’s blood pressure was better. Another one’s insomnia was improving. Another was seriously keeping track of his blood sugars. Another brought his three-year-old in to meet me (not all the same day).

My job. My future job, my future, and the present/future job of so many wonderful people I know. We – no, they – no, we – are going to be incredible doctors for these patients, because that’s the “why” in this privileged position.

Lucky, lucky patients?

Luckiest – us.

~j Kribi, Cameroun

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.

A medical license – just a general one – requires five full days of testing, over 3-4 years. A lot of time is spent studying – during school, after hours from the hospital. A lot of money goes into each part of the exam, from the question banks to the tests themselves, with the requisite nothing-but-the-ID-check-in and checks inside of your sleeves .Eventually, 5 years after starting medical school, many more years after starting the process of getting into and moving toward medical school, you have a license.

On the most basic level, this allows you to prescribe – that’s helpful for your patients, your attending (who no longer have to cosign your scripts), and potentially for your friends and other loved ones. All it takes is your name and license number – the person you’re prescribing for’s name, birthday, and allergy-to-medications status, and any pharmacy will transcribe it over the phone .

But a medical license – and the steps to obtaining one – implies more than this sort of power (and responsibility).

Doctors can pronounce death – we learn to know when someone is dead, or alive, and to say it officially. Saying it makes it true.Doctors can teach other doctors. There’s no teaching certificate required, here, but the way medical students, in the clinical years, and residents and fellows learn is by teaching each other. On down the food chain. The main source of information, actually, is the teaching on the wards. There’s no training in that.Doctors can run businesses – what else do you call a medical practice? No business acumen or training required (technically, not optimally).Doctors can work in public health without an MPH.Doctors can get a loan for a house – even med students can, sometimes – while 100s of thousands in debt. “Future earnings potential” they call it, not taking into account whether your career choice within doctor-dom actually has much of that.Doctors can run labs without having PhDs.Doctors are more likely to get published as op-eds or letters to the editor – “MD” looks pretty official and officious, tagged onto whatever-name.

And doctors can tell patients to focus on self-care, sleep, the importance of healthy eating and exercise. Well, we do get exercise on a service that runs up and down the floors of the hospital. Even on one floor, you’re constantly dashing between rooms.

I don’t have a medical license. I have ½ or 2/3, depending on how you count it.

And I hurt people on a daily basis.With license.


I hurt people, by which I mean I cause pain.”Discomfort.” I don’t lie to patients. “Will it hurt?” “Well, it’s not fun. It shouldn’t hurt, but it’s not comfortable. It’s different for everyone – you know, I had a patient the other week who was talking on the phone the whole time.” (Now I can count that as two . And I’m not even counting the texter).I don’t lie to patients. The one who, somewhat suspiciously, asked “how old are you?” I told her. She’s three years older. And she decided to trust me – I can say I’ve done this (dozens) of times before, that I’ve only been in this clinic a few weeks, but before that, I was working other places (…in other areas, not doing this particular job, but I can hand-wave a little about that).“How much longer do you have in school?” In truth? Six months of coursework.

I like procedures. I like working with my hands, having those physical skills. And on this rotation, I did just a few procedures but many, many times. You can get good that way – or, closer to good. Pretty good. To the point that, at least, I can carry on a conversation the entire time, smoothly, while doing what I need to do.One Filipina patient – her entire family lives on the same street (in the US). Everytime someone leaves, they buy up another house.Another patient is a horse trainer and travels around to county fairs.Another works as a security guard.Another is majoring in environmental studies.Another’s kids are at Disneyland.The list continues. And this is what we talk about.For some, it doesn’t help so much – but others are so distracted that they have no idea what I’m doing, and they’re surprised when I tell them I’m done.We’re done. “Great job!” I say.

I say.

I tell them about books I’ve read, if they bring that up. If it’s a commonality, what I majored in, in college. If I lived where they do now, know the area. If my friend is moving there. That one of my patients lives on the same street as her entire family. For a Procedure, there’s a whole other set of shtick. “I swear, I think I spend half my day fighting with this lamp…” (it was actually somewhat true, but it made patients laugh). “Hopefully, this will be the longest part!” I say similar things about computers. Math, etc. The light self-deprecating humor works pretty well.(My doctor self is really, really good at small talk).

“Do you like your job? Do you like doing this?”“Yes, I do. But the part I don’t like is when it causes people pain.”

~j

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.

I stopped touching her when her blood spattered over my face.

There was a second year medical student in the room – she saw. I motioned her over to me. She grabbed a paper towel and started dabbing at my face, my neck. I gestured, half whispering, half mouthing the words without moving my lip – here. My mouth. Finally, she slipped the paper towel between my lips and the one blood spot, the one, might have been wiped off and gone. “Go check in the bathroom later,” she said. I was almost finished, so I finished the procedure, had the patient sit up and made sure she was okay, then I left the room. Walked, walked to the bathroom, rinsed my mouth, saw a few other spatters. Tiny, tiny red spots. I might not have noticed right away if I hadn’t known – someone who wasn’t right next to me might not have noticed. The debate then, was whether to tell anyone.It wasn’t a needlestick.

And blood to skin…yes, mucous membrane, that one spot on my lip, but it’s not like I was bleeding, too, and had a cut there. None to my eyes. The risks of transmission of anything…thinking, thinking, thinking. Nothing. Nothing that wasn’t curable and easy. And probably nothing.

I did. Tell. I told the charge nurse, she told me to call needlestick (“exposure”, it was. I had an exposure. I was exposed to a patient…). After a series of call-backs, call-back-laters, and why-are-you-calling-this-number-and-not-that-other-ones, I described what had happened. I’m a med student and I’m interested in infectious diseases. I’ve studied/worked in HIV for almost 7 years. I know the risks, I know them, but I wanted to check I wasn’t being cavalier.The woman on the line said the only thing she could have worried about being transmitted would be heptatitis B – but I’m not only vaccinated but immune, as proven for school. Anything else… HIV, hepatitis C being the major worries – was next to impossible. Next to, since nothing is.We discussed testing the patient – she was coming back the next day, anyway, and we had no labs for her. If it won’t change your clinical management, don’t do it.

We learn that. It’s rational.

Were she positive, would I go on PEP? (post-exposure prophylaxis for HIV, a month worth of antiretrovirals, making you retchingly, wretchedly tired and sick). No.For Hep C, there’s nothing to be done anyway.And anything else – well. Both close to zero possibility and curable.(End Infection control and disease transmission lesson for the day) .

Universal precautions? Not applied universally. No one wears a mask for this.

We love to use the word “discomfort.” “This shouldn’t hurt, but it might be a little uncomfortable.” “Pressure… lots of pressure.” “Is that pain or pressure?”

(Discomfort: acutely feeling each drop, real (real) and maybe imagined, each spatter-point. Hyper-aware. Discomfort: the mask over my face, eyes, that alien-like barrier from the patient, frustrated with breathing, sometimes, and not fogging up the eyes).

What I used to consider a sort of torture instrument (tenaculum), I’ve used to manipulate with ease – and as much force as I can muster. It’s a clamp you put on the cervix to straighten out the uterus, essentially. In some techniques, you inject lidocaine first; in others, you don’t. Is the tenaculum-discomfort worse than the lidocaine injection-discomfort – should you just get it over with? With these procedures, it’s injection first, tenaculum second, and then two more injections for the paracervical block.

The tenaculum is there to help straighten out the uterus by pulling on the cervix, which makes it easier/safer to manipulate anything in there, instruments, etc. And if the patient isn’t flinching, I’m pulling. It’s my counter-traction. And I’m pulling hard.

If the patient isn’t flinching or saying anything to me or tensing her legs – she’s not feeling it. True? Yes, or at least, I’m not causing any additional discomfort. There are varying theories on this – do the block first and tenaculum second? Or just the tenaculum? Ie, pain of injection, anxiety of longer procedure, versus just pain of tenaculum and over more quickly?

The patient, the patient’s blood, the blood on me.

For this procedure (consider: tenaculum. This was a pelvic procedure, involving the cervix. It was frank blood, fresh bleeding, from something that I had caused – normal, normal, when any instruments touch it. It’s friable (delicate, in brief).In Spanish, “cervix” is boca de la matriz. Mouth of the (mater, mother). In English, the opening of the cervix is the os. Latin for “mouth.” We could call it “mouth of the womb.” Bright red bleeding per os, this was. Fresh from vessels I had micro-lacerated, in space, to me.

No one wears a mask for this. But there was blood pooling in the vault, in the fornices…(in the next, or the next-next, I will describe what I was doing, why I was doing it, and what I’ve been doing this month. For now, the patient, and her blood).

On my ob/gyn rotation, third year, a patient’s blood spattered at me – but I was wearing glasses. I only knew later, taking them off, seeing the dried flecks on the glass. It was unusual for me to wear them. It was the first time there had been blood.

Another time (there are many times), a patient’s blood dripped onto my skirt. I was wearing red that day, luckily – and I don’t say this just for staining purposes, but because that way the patient didn’t do. I didn’t want her to – I never do with this. There’s no reason for them to feel badly about it. They apologize enough for having bodies and for reacting to things within and outside their bodies.

No apologies for what those bodies might do, might interact with me. I don’t tell them. Unless it’s a question of real disease transmission – a needle stick or way I really could have contracted something – they don’t need to. There’s no purpose – there’s no therapeutic purpose in them knowing. As long as they don’t see, I don’t say.

Patients apologize for the state of their bodies, for what they say in pain – in-between bouts of complaining (we say everything they say is complaining, and everything they say “no” to is denying) and yelling and sleeping and getting pain meds and getting off of pain meds and feeling better. I’ve had apologies after pain meds wear on, after patients feel they’ve been listened to, the next day, in clinic a few weeks later… The patients who mutter under their breath, apologizing for the language they feel slips out uncontrollably while I’m doing some procedure that is quite uncomfortable – no apologies, I say, say or yell whatever you want. Call me whatever you want, I promise I’ve heard it before – and I won’t be offended. (True and true).

They apologize enough for having bodies.

~j

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.

Now, I’m on psychiatry at the county hospital. This is exactly the sort of hospital where I want to work – underinsured, uninsured, every problem is more complex than medicine and medications. It’s not about thinking you’re saving anyone, at all – it’s math. There aren’t enough doctors working with these patients. Patients with more insurance, patients with more money, patients with fancy papers and jobs and luck at some level – they have doctors. Math. Simple.

So this is where I’ll be. I’m learning, everyday, what it means to be a doctor. What it will mean. And there are the practical issues like having to clear the pages from my pager, sometimes several times in a day. (Disbelief, the first day that happened. That’s what happens to residents) . Being first call for a patient – this is what that means. Any issues, I get called. By everyone.

It’s about teams – trite, maybe, but true. At the university, tertiary care hospital where I was for palliative care and pediatrics – teams might be like the Congestive Heart Failure Team, the Liver Transplant Team, the Restrictive Lung Diseases team. I had no idea how deeply you could specialize. Patients may have multiple failing organs plus a rare rheumatologic disease and a mitochondrial disease and something neurologic going on. Presenting with an endocrine problem. (For one of my patients in pediatrics, the team coordination I had to do literally consisted of pediatrics, child neurology, child endocrinology, molecular genetics, and then psychiatry) . Not uncommon.

Here? One team consists of ENT (ear-nose-throat) surgeons + psychiatry + social work + nutrition + pain management + social work + nursing. + psych-consult nursing (separate from the psychiatric consult service I’m on, for some reason) . The patient needed surgery, complicated surgery, for the second time. And soon the fifth and sixth and seventh. There’s the CT, the MRI, the X-ray, the lab value version of what happened to him. And there’s the homelessness, alcohol, other drugs, history of child abuse (to the patient), family estrangement, language and cultural issues and differences, a country that isn’t recognized as a country, everywhere, and doesn’t want him back. . .

That’s a team. The surgery note, every day, says “appreciate psych input.” And I end up calling the resident every day, for some issue/discussion about Our Patient.Our Patient.

This is what I say when I call outpatient providers: “calling about our mutual patient. . .”

The people in the hospital I’ve developed working relationships with in my short time here? (aka, those who recognize my pager number. And voice) . That surgeon. An emergency department social worker. A psychiatric social worker. The charge nurse on the geriatric floor. The residents for my patients (more obvious) . A patient’s therapist. A patient’s psychiatrist. A patient’s social worker. Patient families.

A friend once asked me if doctors think about their patients, outside of the office.

I’m in the hospital. I see the patient at her most acute. My patients, right now, are there for suicide attempts, suicidality, drug overdoses (intentional or not?), altered mental status from alcohol or drugs, assault related to homelessness, dementia related to HIV, dementia not helped by alcohol, everything related to social situation, to past factors, to family history, to childhood, to marginal housing and relationships and proximity to their birthdays. . . everything.

I’m in the hospital, and with permission, I call the out-patient providers.Every single one has been glad I called – many, relieved in a sense, to know their patient is being taken care of, and that it’s by someone who cares enough to call them to let them know about it. And to get more history. We call that collateral.I call many times. Maybe we need more information, we need clarification – I’m seeing the patient at her most acute. They may have known her for years. And I promise to call back with our plans. We coordinate.

That’s not billed time. It’s after hours, between patients, during lunch. From home. I don’t think medicare or insurance companies count that.

And these aren’t short conversations. There are the half hour conversations (almost an hour, with one patient’s husband) . And then we call each other back. And back. I give updates. They ask me.Nothing is static here.

And the license I have, the incredible, humbling license to call my patients’ medical and psychiatric care providers, to learn more about their relationships with these providers, to know my patient a little bit better pre-hospital and to figure out what I might be able to do. Maybe.

Many of my patients are on holds. The first one is 72 hours - held. In the hospital. Danger to self, danger to others, or grave disability – inability to find food, shelter, clothing, medical care (essentially. And homelessness doesn’t count – technically, if they know about and can access shelters) . There have been holds for danger to self – the ones with suicidal intent/overdose – and for grave disability – the ones with dementia. Yesterday was the first time I saw what happened when a patient on a hold tried to leave – security came. She was restrained – soft restraints. Is it safer for her? Arguably, right now. Maybe. Can we do something for her? Maybe. The problem larger than the current overdose, though (which she says she’ll repeat – and better) is the living situation. Money, drugs, and how to get that money. Other people on the street. Everything that’s happened up until now and before and after. And this patient spends hours at the library, online, reading about the pharmacology of various drugs. The particular enzymes.

Then there are the 14 day holds. And the hearings – the patient presents his case to the judge. Accepted – patient free to leave. Denied – patient stays until we say go, within fourteen days. Law, medicine, minds.

The new interns have started. These are the people who are a year ahead of me in school – weeks ago, they were medical students (as I’d always known them) . Now, the IDs say “, MD” and the ones in psychiatry have license (with supervision?) to hold people in the hospital. Danger to self, danger to others, grave disability.

Grave disability. Inability to provide food, shelter, for oneself. But “homeless” doesn’t count, as long as you have enough wits/facilities to find shelters, to find food kitchens, to know where freer things are.

Four years of school and we get to pronounce death (time of. . .and the certificate that must be signed). We get to pronounce life (time of. . . and the certificate that must be signed) .And we get to decide who can’t take care of themselves or their own lives, right now.

"Death" is easy to pronounce. "Danger." "Grave."

~j

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

As I explored poetry and science in parallel, organic chemistry flattened molecules into boxy lattices. I couldn’t see their relationship to even the scientific study of life. At the same time, I wrote a paper on Sharon Olds’s “I Go Back to May 1937.” First look, second look, I loved the poem. As I delved deeper, I discovered the structure – the tendons, ligaments, and fascia – subtle scaffold for this exquisite organism. I see the body as a poem to learn, but early medical training spends years on anatomy, physiology, and pathology. It’s like learning to read and write poetry by counting epics in syllables. Every two beats must be an iamb. But the iamb echoes the meter of the healthy, human heart. Exactly.

The poet is better at listening. The doctor is better at discerning what to listen for. Dr. Rafael Campo’s Desire to Heal circumscribed the locus where I want to exist: narratives of illness, stories of medicine, exploring the palimpsest of the body. Diseases are stories that have been written over and over through history, and yet they continue to engage us in the same basic plot. I had the opportunity to work with Dr. Campo both as a writing workshop teacher and in his medical practice. My first steps in clinical medicine were alongside a poet. I started learning the practice of medicine by listening and asking for stories.

Batoke, near Limbe, Cameroun I find the narratives of medicine everywhere. In AIDS in Anthropological Perspectives, a college course, I read the history of AIDS from the first descriptions of a strange epidemic in San Francisco and New York to the scientific papers, anthropological dissertations, national statistics, and the poetry and fiction by those infected and affected by the virus. Here altogether was public health, literature, medicine, global health, and an opportunity to work with underserved populations. In college, I volunteered in AIDS outreach and activism. In Cameroon, as a Peace Corps Volunteer, I directed a rural health district’s HIV programs, trained HIV counselors and counseled patients, worked with high school students, and wrote curriculum. In Kenya, I did public health research on HIV. As a medical student, I work in HIV clinics. I am reading the literature as I learn to write it. Every connotation and different cultural metaphor is critical to my understanding. And this is just one disease. HIV poster in Migori District, Kenya When I was a community health volunteer in Francophone Cameroon, no one understood me for a few weeks. I was technically speaking the same language as they were, but African French is a more oral language than French-French, with different and mutable vocabulary. The natural storytellers I worked alongside and who became my close friends were raised in a poetic culture of call-and-response. To be an effective volunteer in my village and in the larger health district, I had to re-learn to speak my first language. Words, though, weren’t enough. In Cameroon, people also communicate with clicks from the back of the throat. These clicks mean assent, empathy, “I am listening,” “I am here with you.” They express more in a single sound than can any combination of words. Every language requires the tongue, larynx, and jaws to move in varying configurations while air expelled from the lungs charts a slightly different course. It was difficult, as an adult, to learn to shape a sound I had never made before and could not write down. I spent many hours practicing in order to be able to say what I was learning to hear. Back in the United States, I find that I want to use the clicks just like I want to use French while speaking English. Having to communicate without access to my full range of languages is challenging and, at times, feels stilted and stifling.

in Madagascar (sign in Malagasy) I have spent three years formally learning to read poems of the body. I turn now to MFA programs to learn to write them. I want to be equally a physician and a writer, so before I continue a clinical education that will not allow deviation from a strict path for many years, I feel it is time to explore poetry as rigorously as I have medicine. Scientists are just beginning to study human history through mitochondrial DNA. Living in contemporary poetry, I want to study literature’s attachment to the earth.In my career, I plan to work as a physician in global public health, and as a writer. I will continue to explore experiences of the body across cultures and demographics, working with underserved and under-heard people. The poets writing about AIDS in the 1980s had no small part in raising awareness of the epidemic. Writers lent humanity and narrative to disease, working in concert with and giving imperative to the medical fight for progress. Theirs was a revolutionary act, in showing that even the ill body, ravaged with disease, could be worth loving – and thus – human.

*(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

There are the diagnoses I’ve made because they were so “classic.”(The people on the subway I’ve wanted to/have diagnosed at glances because I can’t help it. That part of the brain doesn’t always turn off.)When a friend’s telling you a story and the diagnosis isn’t the point of the story but all I can think is – the diagnosis – the one he was given, the one that makes everything so hard – isn’t right. (in the end, it turns out, I am right. Turning point. I solved it)

I hate when it’s the ones who are dying. I get it right.

But then – that’s the point, isn’t it?

Some patients have been so happy to be part of my education

There was the mother of one of my patients –Maria, my patient, was pregnant with twins. I was there for the delivery – and I delivered the placentas, but I didn’t get to do the birth because it was complicated, one was breech and one was vertex (normal). Anyway. Maria’s mother was so excited that this was my first delivery, that I would always remember them for that, and that they got to be such a special part of my life.First? No. Delivery? Well, placenta, and I did lots of those. Not very exciting.

Remember them? Yes. I remember Maria, her friend, her mother, her grandmother, the twins…her in labor, her coming in twice prior to being in labor, the preeclampsia, her friend’s cell phone ring. I remember. And that was a year ago.

I don’t remember because of this, though maybe partially – Maria had preeclampsia. She was the first patient I took care of, personally, who had preeclampsia. So when I think about that process, I think of her, and then I think of Shonda, my family medicine patient who had had preeclampsia and was still dealing with it, weeks after giving birth. I remember her daughter’s name, and how her uncle died and she still came in for the appointment with me but she was late…And because of her, I remember the medications you give for preeclampsia.

Belize City, Belize And then I think of Melinda, who had (NOT trichitillomania) and was losing her house and I called to remind her about the appointment and she was crying to me on the phone… and that’s how I remember that condition. Then I remember the night I met Melinda, in the ER, when she was in for evaluation of DVT versus cellulitis. I remember the work-up we did, and the differential then and later, when she was in my primary care clinic. I remember – family history – her son had a blood clot (genetic bleeding disorder?) – but mostly I remember that he died when he was 15 and she was saddest to have her house foreclosed on because it was where he had lived, with her.And that’s how I remember the tests we run for problems with clotting, too.

What drugs people like for what

I remember how serious pseudotumor cerebri is from Cristina, how her symptoms were, how they affected her life, what the treatments were – and in order. What she looked like – some classic features, too, in how they describe the cases, and that she preferred dialudid for pain so they called her drug-seeking.

Make me a better doctor? Could argue indirectly that I’ll get into a “better” residency with “better” scores – though, other than the quality of teaching (important), access to multiple hospitals, including tertiary care (important for breadth of learning) - prestige won’t make me learn. My teachers will – the other residents, the fellows, the attending, with me teaching med students and later interns/residents as I move up.

But this is about pattern-recognition (so is medicine) – the African-American male (or boy) or African-American woman in her 30s or white woman in her 20s or Asian man in his 50s or obese young woman – for the test, anyway, they’re consistent, insistent, and repetitive with epithets. Those will, in general, mean very particular things.This is about getting things right (isn’t medicine?) Medicine, though, isn’t multiple choice.

How I’ll always remember what Crohn’s does to a person. Seven years on a college police force and how many days he had to take off from work. He hoped this surgery would work for a longer period of time. As I was about to leave the room – history, history, physical, and me listening in to the gastroenterologists as they explained the condition and what would happen from the operation to him – he stopped me. “So, what does laparoscopic surgery mean?”Somehow we’d missed that point. Words that become commonplace. So the CO2 insufflation, the little camera and TV screens and tools through small ports – something I’d seen enough to describe. And I remember what they did with the tiny instruments operated by larger hands, and why.

Serena, twenty-five, aching joints, weight loss, fluid around her lungs, fluid around her heat. Getting married because of a diagnosis of lupus – and all the symptoms of lupus – she had most of them. She had all the lab values too – those get tested a lot.

Tikal, Guatemala Myxedema – what happens when hypothyroidism goes to your head. That was the Portuguese-speaking patient, Julia, who hallucinated numbers she drew into her hand. Everyone thought it must be difficult to communicate with her, with the language difference – that and her tongue, so big from the matrix deposits from Hashimoto’s hypothyroidism, not quite fitting in her mouth. She and I discovered we could communicate in Spanish. I wonder who had tried that.At any rate, the changes in personality, per family, her forgetting things, and her dreams and dreams and dreams of numbers that she drew on her hand and on the back of my patient list – I wasn’t carrying any other paper.

COPD* exacerbation vs pneumonia: that was one of my first ER patients, and it’s a common distinction to make. I got it wrong in him (the resident got it) . And that’s how I remember. The disease and how to distinguish. Mostly I picture him where I met him, on that gurney in the ER hallway (busy day, that was Yellow Hall bed J, or something), long hair sweaty around his face, uncomfortable, leaning forward, trying to breathe better, pausing between every few words. That and how he couldn’t afford his medications anymore because he got a job that didn’t pay enough to cover them but mean he had more than zero.

*Chronic obstructive pulmonary disease: emphysema, chronic bronchitis

A classic hand fracture and how I effectively used a hand musculoskeletal, cardiovascular, and neurologic exam. The snuffbox fracture and how I was more worried that the patient would reinjure it because basketball playoffs were the next week (this, to me, wasmore of a reason to cast it, poor kid) . If we didn’t? He could lose blood supply to that part of his hand and end up with a permanent injury, nerve damage, etc. . .Good kid. It was right after his birthday, too. He understood. I remember the treatment – the spica thumb cast – because everytime I called radiology they were either not in the office yet (too early for them) or about to go to lunch (I win!), they’d read the X-ray over the phone with me, and then I had to call the orthopedists to make an appointment. Again. Or call the patient and tell him to go to urgent care. Again.

The angry little girl? Her condition comes with very rare infections. I remember the bugs and I remember the drugs we used, they showed up in my repetitive progress notes every day. I know the treatment regimens from talking with her and her mother. She showed up on boards.

There was the kid with the rare immunodeficiency and brain abscesses, on IV antibiotics at home (devoted, attention-to-detail mother) . He came in for appendicitis that we knew he didn’t have, but anyway, he’d had these abscesses in his brain and his lungs. And he didn’t have appendicitis. But I met him and I met the family and I read the chart. That kid showed up a lot in boards practice questions – the disease he has, at any rate.

How to remember genetic inheritance of diseases encountered. Who in the family has it? I pin diseases to people, in my tenuous neuronal connections. One disease is a friend-and-her-family-tree. I’ve read about it. It’s interesting. It can have a lot of features that she (thankfully) does not have. But I care because of her. And she’s how I remember it.

I’ve seen a lot of patients this year.

Side effect? getting questions right on a nine hour multiple-choice test.

Effect? Learning how to take care of the real ones.

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 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.

I’m on the palliative care service, now. One week gone with one week left. I’ve been here before, with dying patients – even before I was on this side of the medical line. Cameroon. Kenya. I’ve seen babies die. And this year, I’ve had patients die in other hospitals, on other services (this year of medicine – everything I’ve written – actually takes place in 7 different hospitals, thus far). None of my patients who died, previously, were seen by palliative care. They may have died after everyone involved had decided to stop working on curative treatments. Possibly curative treatments or impossibly curative treatments.

It’s hard to not feel like the angel of death, sometimes. I’m learning how to talk to patients about death. They know, I know (doesn’t make it easier for me to say it). I’m not announcing the news – though I’ve been a part of announcing cancer diagnoses, in the past. Fear of death but not death – not yet. It may be new news, it may be old news, it may be something they’ve known instinctively for a long time, they haven’t wanted to know or realize, or they’re no longer able to communicate directly and it’s the families that are communicated, being communicated with, making decisions.

Coming in on a consult, the first visit with palliative care, explaining what the service does is tricky. It’s not about death, not exactly. It’s about supporting patients’ goals of care, what they want from the hospitalization, how to treat their symptoms, and what they need now – physically, psychologically. It could be near death, it could be farther death, it could be a new, chronic, serious diagnosis – likely one that will result in degenerative disease or a somewhat hastened death. It’s patients who are very, very sick and potentially going to be cured. Potentially. Being on chemotherapy, ventilation – the proverbial “machines”, the “lines and tubes”, the “machines keeping you alive” – not contraindications.Not usual.Unusual.

For patients who’ve recently been told they’re dying, which may be in the form of “not eligible for further chemotherapy” (the “nothing else we can do” – which isn’t nothing, but isn’t a cure) – it’s hard not to feel like the angel of death. That, I’m not used to.

One patient’s family told me that they were frustrated and that they knew the oncologist (cancer specialist) was frustrated, as well. He had nothing else to offer – so he called the team that isn’t ever going to talk about a cure. Doctors don’t like the feeling of “nothing else” – particularly oncologists, I think, though/since it may happen to them more than to some others. But stopping trying-to-cure treatments is part of “do no harm.” That’s the best known part of the Hippocratic (now Lasagna) Oath – but it includes, also, “do good.” Balance of action/inaction. And “do no harm” may include, at times, not giving medications, not doing surgery, not doing, exactly, what a patient’s family may ask for (with an ethics consult).If harms vastly outweigh the benefits. If, as a surgeon, you know that the patient is vastly more likely to die on your table than to live and helped – you shouldn’t do the surgery. If you know that further rounds of chemo are going to be just poison and not medicine – you shouldn’t do it.

Good medicine isn’t always about giving or practicing or employing modalities.

I don’t have so much medicine. Not yet. I have some, I can contribute, and I can care for patients. What I have the most of is time. It’s fourth year now – there is less time than in third year. And/or, I’m supposed to be more efficient. Less scared, less intimidated. This past week, I’ve had four patients. (Third year, I never had that many). Granted, on this service, they take less time – medically. And some want or need more than others. Take Mr. P, the patient who invited me to his funeral. I met him on my first day. For various reasons, he has no particular place to go, no money, and no chance of taking care of himself, anymore. He does have a supportive daughter, who is close to him. And his daughter is pregnant. Communicating through a translator (he’s Vietnamese), we talked – at first, this seemed stilted. The fellow on the service told me she didn’t think he was depressed (in patients with “terminal” diagnoses, weeks-to-months-to-years, this still surprises me). He’s not hopeless, she said. He does want to be around for his granddaughter’s birth – even though he doesn’t think it’s going to happen. Meeting with his daughter, later, she said she’d asked him to write a letter to her future daughter – and he hadn’t wanted to. There, there something I might be able to do. So I mentioned it. And again. The chaplain mentioned it. And again. I went in and mentioned it, again. He said he wasn’t sure what to write, but he’d think about it, and then four visitors walked in, so I left.

When I returned, the following morning, he was sitting up in bed, wearing glasses, writing in a red-bound notebook. He had already covered many pages.

In the afternoon, through the translator phone, we transcribed it in English. He read it into the phone. The translator translated to me – and I wrote as quickly as I could (Mr P used a very good speed, pausing to give me enough time for phrases) .The translator, as she spoke, was crying. She’s a medical translator – used to translating exactly and impersonally. This was different. I was writing too fast to feel as much – wishing I still remembered short-hand, from the brief class in 5th grade, and making up my own as I went along, planning to type soon so I wouldn’t forget the semi-legible words. I didn’t tear up until I was typing, later, and I read the phrases in order. “My dearest granddaughter,” he began, telling me he wrote that because he didn’t know her name. But the letter was full of love for her – this future-dwelling letter girl. And full of love for her mother, his daughter. Scribe, not narrator.(one thing I’ve learned – what sounds like a lot of words to me, in Cantonese – isn’t. Maybe I’d feel that way about a lot of languages I don’t understand a word of (no, I have approximately one now) – but I always think there are more words than there are) .

He told me he’s going to keep writing every day.

Unbelievable, incredible, sacred privilege. I was entrusted with this. And it’s a job anyone could do – all I did, technically, was write down what the translator said. But I was there because it’s a hospital and he’s “my” patient and this is what he needed, what he wanted for his health and comfort and the health and comfort of those he cares about most. “Legacy work” they call it, “the dignity of dying.”

I have barely-can-vote patients who are dying. I have have-been-living-with-disease-for-decades patients who are dying. I have patients who don’t want to “live like this” – they can say – or they expressed it earlier and it’s up to their families to say.

It isn’t, necessarily, a glass-half-full thing. If medicine is about life – and it is – than we’re not helping patients die (even euthanasia, arguably, could be related to quality of life. But that’s an entirely different topic) .

We’re helping patients live – how they want to live – with the time they have that we’re terrible at predicting (doctors notoriously over-estimate how long patients may have. Patients may not want to read this – and if they do, they can say it’s not their doctor. That’s fine) .

The point is and always was about the patients. Do no harm, do good, to… and for…And when the scientific knowledge has reached its limit – do good is what we can do, anyway, and do no harm is not doing what we can’t do or can do but that the patient doesn’t want.(In my French etymological dictionary – the entry for medicine starts with “Art that has for its objective protecting health and healing illnesses.” Art. Certainly isn’t a science).

...

"Writing allows you that. Approach

words with a scalpel.You reopen scars without newwounds, or lengthening.

The firm white line – a rope that binds you, if not to this life,to the living."

~j

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

*Bacteremic means bacteria within the blood stream, meaning they’ve escaped the confines of wherever the initial infection was. Bacteria aren’t supposed to be there, nor fungi. Viruses can be – but this should be more antibodies to than antigens from. Once bacteria escape – and this includes the good, normal kind who are supposed to live in the intestine – they wreak havoc. This becomes sepsis. (Interesting word relationship/derivation to “septic tank.” In medicine, sepsis means shock. It’s a terrifying emergency.)

Then, septic. The body can attack infections where they are. But if the infection is in the blood, it is, by definition, swiftly moving everywhere. What to attack? Itself. The immune response is upregulated and storming through the blood vessels. The blood vessels, in response, are dilating like mad – and things are leaking out – and blood is rushing quickly, quickly, quickly, but there’s not enough pressure and it’s not actually working – and the body is attacking itself because the toxins are spreading, spreading . It’s the one kind of shock where the patient is warm, flushed (with other types, pale and cold) . The blood is moving everywhere but nothing is working.

So the clinical lab scientist in her jeans and sequined head band, mechanically incubating bottles with blood and other bodily fluids (anything that might grow something, whatever might be the initial source of the infection) – is looking for sepsis. A light goes off on the machine if something grows (so much is automated) . But then that gets plated onto various types of agar, separated, separated, then checked by gram stain and color of growth and look of colonies (shiny? mucoid? smell like fruit?) to figure out what the actual organism is and how to treat it.

Meanwhile, the medicine team is throwing every sort of antibacterial, antifungal, antiviral at the patient; anything, anything that might be suspect. When the organism comes back – after days – they can narrow the treatment (and this part is important, too) .

The question becomes, then, how does the patient look.

The pathologists don’t know. I appreciate it when they ask. Pathology rounds – the micro kind, anyway – consisted of petri dishes. Walking around to different stations, looking at them under the microscope – what’s growing, how do we know. Is this actually making the patient sick. And that’s why the ID (Infectious Disease) team is there, to answer. They know the patients.

There are things like the infection control meeting – patient with suspected bacterial meningitis (emergency, fatal w/in 3 days, often. Highly, highly infectious/transmissible. And, like plague, easily treatable with antibiotics. ) . The issue was that the six firefighters who had taken her into the hospital, stuporous, on the ground, hadn’t worn masks. So were they exposed? Then their families? . . . and everyone else in possible contact.

It’s problematic (maybe) that I want to go into ID – to be a “global fund doctor” – HIV, malaria, TB, on to yellow fever, dengue, dysentery all causes, filarial, schisto. . . etc. But I don’t want to be stuck in the lab with the petri dishes at any point.

Rat glioma, nuclei (blue) and mitochondria (red)

Digression.

Pathology gives the answers. We trust them. Particularly for oncology, they’re the ones who say “cancer” or “not cancer”, and, if cancer, what kind, which dictates what treatment. How bad is the cancer. How far does it spread. Much of this is directly based on what the cells look like – and, yes, there are some biochemical markers and non-subjective measures of this, now. Take prostate cancer, though – the grade of cancer, related to prognosis given, is 100% based on what the cells from the biopsy look like – that plus how far it’s spread, where else it might be in the body. Radiology, pathology, and surgery will tell you that.And medicine is left with the patient, and with treating the patient.

“It’s a good lifestyle,” they say. Pathology’s not officially part of the ROA(U)D to happiness – radiology, ophthalmology, anesthesia, (urology), dermatology. The specialties that are very, very lucrative, particularly compared to work both in residency and in practice. (For urology, this is generally true in practice, but residency is similar to a general surgery residency) . And there are people who pick a specialty based on those letters. ER counts sometimes as “good lifestyle” because it’s shift work, you don’t have work to do at home or follow-ups on patients, and you can cluster your shifts and then have other weeks to do other things that are important to you. (It doesn’t match the lucrative or less work parts, though) . Pathology – can be very lucrative (one resident remarked to me that his goal was “to make as much money as possible for as little work as possible.” I had nothing to say to that. I only wondered what he’d actually said in his interviews) . Psychiatry is sometimes grouped with these. “Lifestyle,” people tell me, “lifestyle,” as if that has anything to do with anything, for me, in choosing what to do. (Medicine, out-patient medicine, county hospital or international NGO, + public health, is essentially the opposite of all of the “positive” things above. Except that I love what I’m doing. That’s the lifestyle bit) . With other interests (writing, public health work. . .) it would certainly be convenient to like a field with more straightforward hours that allowed more room for that – emergency medicine, for instance.

There was a night I realized that, without a doubt, I’m not a ER doctor* (besides the medicine bits, ER doctors are probably the coolest specialty, and most of them own kayaks and/or go rock climbing a lot) .

* We speak of this in terms of personalities, too. “Finding your people.” “Who are your people.” Mine happen to be internal medicine HIV docs, or medicine working in public health/county settings.

Rhumsiki, Cameroun

Tomorrow, I start on the palliative care service. It’s mostly (as I understand) for patients who have chosen to not pursue further aggressive medical care. There are chaplains (specific and non-religious in bent; whatever the patient wants), medical doctors (pain of all sorts), social workers (perhaps) – we’ll see. It’s not something I could do as a specialty. I have to balance death – and many of them do; not many could do this all day, every day. Pathology has weighed in and no longer matters. Or that’s what mattered in the first place. Or they’re the ones who made the patient (person. person) decide to continue* with treatment – or not. *I wrote “fighting” and erased it. I try, conscientiously, to avoid words that are negative metaphors in medicine. Medicine as war. Disease as enemy. Is the word “survivor” empowering? Does it necessitate the winning of a war? Is a victim someone who was weaker, or didn’t fight back enough, or let the guys on the street with guns take his wallet because, in the end, it wasn’t worth what the consequences might be otherwise? The chance? That means, also… women who (here and in other countries) get blamed, explicitly or implicitly, in part, for attacks. Can they be compared to smokers, then, who get lung cancer? (and heart disease, etc). IV drug users for hepatitis C, alcoholics for liver failure? (These are ethical issues that come up in transplant committees. We had a discussion about this in class, a few years ago. There were many differing opinions). Former alcoholic who needs a liver versus person with a genetic disease that destroyed their liver. Perpetrator versus victim. Same thing for HIV transmitted from mothers and blood transfusions, versus sex and drugs. Victim. Perpetrator. Same disease. I don’t think the metaphor is fair to either side.

Susan Sontag’s Illness as Metaphor, and the updated AIDS and its Metaphors. Every generation, the culpable disease changes. It was tuberculosis. And then cancer – people were thought to be at fault for that, somehow. It was shameful. And now AIDS is becoming somewhat more normalized – or maybe that’s my socialist working-in-county-hospital-in-liberal-city perspective. What next, then. Meanwhile, for the next two weeks, we are told to – not – think as much about death and how that will be, or about delaying it, but about what the rest of the life should look like. To that end, and to learning it.

~j

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.

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? none of this).

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.

If I hadn't gotten into medical school the first time, I would not have applied again. It would have been, I think, a year of something then two years of MPH. There are so many paths to the same thing – these are not Frost’s diverging roads.

Hopital de District de Mvangan

I digress.

Different ways to get at the same thing.

Sustainability, ecstatic. Things I worked on – sustainable/sustaining. Me – ecstatic.

When I – when we – took over the homeless clinic, almost two years ago, it was not, in my viewpoint, functional. My basic stance was either we turn this into a real clinic or we shut it down. The clinic operates within the largest homeless shelter in this city. (But this is not a story about the clinic). It was tied to the Department of Public Health (DPH) – sortof. We took supplies from their supply closet (ah, the delectable power of having that key on my key chains… the thrill of wandering and finding new things for the clinic, new ideas for how to expand and what we could do with them. This is a story about that). We had the same patients in the same clinic space as two health care providers from the DPH. We had files, sortof. They had files. We gave them copies of our notes, the billing parts that were not ever filled out correctly. The “billing sheets” went to the DPH for their statistics, which help determine state funding. And every year, the clinic leadership turned over to a new group of medical students. Medical school is short and fast. Four months into starting first year, three months – or less – into starting clinical volunteering, students have to decide if and who is going to lead next.

African Development Bank's unbelievably costly hospital, Amvom, which has nothing but expensive walls and nothing to sustain it

This is not sustainable unless there is a standardization of clinical practice.

This is not sustainable unless this clinic is a direct part of the DPH.

This is not sustainable if there is no public health group incorporated as part of clinic leadership, running monitoring and evaluation.

This is not sustainable if there is no cohesive clinic structure, cohesive and streamlined clinical practice, standard of care and operating protocol – because – the clinic coordinator is not the same, every night (though, in the end, it rotated between about 4 people, every week, who were there at one or both of the clinic nights).

Without the above, this is not a clinic.

This is not a story about what I did, or about what we did – it’s a story about how we made something function.

At the end of a year, less, the clinic was a clinic. Maybe a shaky one – we weren’t sure. It was part of the DPH. We were continuing all the relationships we had cultivated. The way to create sustainability, or the illusion of a functioning structure, is to present it as if it has always been that way, and that this is just the further iteration of institutional memory. So we conned them – the new group of students – into thinking this was a longstanding procedure, a longstanding part of the DPH, that their job was to continue and continue to improve. We wanted it to be an illusion – or was it, or did it need to be? – that these were time-honored and strong foundations, that they weren’t brand new. We inculcated our new recruits with new procedures.

Prior clinic in Amvom, which functioned for a long time How?

A checklist.

I just finished reading Atul Gawande’s The Checklist Manifesto. And I just returned to clinic for the first time in a little over a year. It’s functioning exactly as we hoped –moreso. The same structures are in place, the relationships are stronger, and the foundation we left was firm enough to be built and improved upon. Many things we’d wanted to do, but had not had the time to do – have been are being done. And then I realized how we’d done it.

It’s called the Coordinator Checklist. It hasn’t changed; basic procedures really haven’t changed or obviated the need for change (the contact info is the same for the same four of us who were running it then, actually). We went through and tried to create a standard operating protocol; the things that needed to get done and how we did them. According to Gawande (and in truth), it’s too long, too complicated, with too many full sentences. It can serve more for troubleshooting, then, and the most motivated ones, early on, do read it. It references an entire binder of SOPs.

I went back to clinic last week. I was nervous and excited – how was it functioning, now, (and how much better would it be/how little had I worked), would I remember what and how to do things.Clinic is there.Clinic is better.They’re more a part of the DPH. They’ve kept the same positions/core group structure that we created (ie, made up) and have built on it. They’ve created more SOPs than we did – things we’d dreamed of, somewhat, and not had time to do. Better structure for patient education handouts – and using them more. Domestic violence screening practices. Etc.

And the coordinator for the night told me how the best thing we can do for patients is get them into primary care through the city programs.

He told me.

I started that. (Having a large/main focus of our clinic as getting our patients into primary care and training everyone else to know how to do it. And to track what we were doing.).

Things that feel tenuous when you “make them up”, when it was built on an idea and a few students in a windowless small group room … aren’t tenuous. What is real, then? (Anything). This is not an NGO, this is not something that’s going to transform health or homeless health or a shelter. It’s not going to revolutionize anything. But it’s something. It is something. All it needs to be maintained are interested, motivated students (no short supply in any conceivable future). It’s incredibly lucky that we can count on that. We rely on free labor from people who are doing this because they’re passionate about it – and who, realistically, don’t forget that all this goes into residency applications (and for the pre-meds, into med school applications).

Closer to two years ago than I’d like to think about, I was on a bus from Yaoundé to Ebolowa, and we’d just arrived. The woman next to me asked me where I was going, and I told her I was going to Mvangan, that I had lived there for a few years as a Peace Corps Volunteer (did I even say PCV? Maybe I said American. Maybe none of the above). “Ah!” she exclaimed. “I know Peace Corps Volunteers in Mvangan and Ebolowa, they taught me about nutrition, it was a project with growing soy.”

She told me about the soy nutrition project, the teaching, the health and agriculture and business components.

I started that.

And now it’s infinitely better, and more, and makes more sense, and has done more than I would ever have imagined/could have done myself. I am unbelievably, incredibly lucky to have been able to (already) see not one but two of my most beloved projects grow and become sustainable. Take on a life of their own beyond me. Were these children, they’d be walking, and maybe talking, a little.

Fields in front of Hopital de District de Mvangan Writing about the bits of public health that really excite me, the things that create programs that can sustain themselves (involving motivated people, obviously) – would not be, may not be so exciting. Monitoring and evaluation. Quality improvement. KAP studies (knowledge, attitudes, and perceptions). PACA – the Peace Corps one (Participatory Analysis for Community Action. or similar. I still use that). Behavior change communication.

Where There Is No Doctor. Helping Health Workers Learn. (Hesperian foundation). I still use those. Patient care, though, is only sustainable in out-patient, longitudinal practice – if that. Building they physician-patient relationship, working on stages of change. Etc.

With writing, I suppose this would include being quoted or included in someone’s personal anthology. Publishing has other attributes, unless the point is advocacy. Or something. But even that has a self-promotional aspect. There are writers whose words are always in my head – and this includes some people I know personally, who are not published but are some of the most talented writers I’ve read. I used to be terrified of not writing again, that “it all” was gone. This was hardest when I was writing my undergrad thesis – if I went a week, almost two once, without anything writing itself – I was afraid there was nothing left. And then something would come, and for the time being, everything would be okay again. There’s a solution, actually – reading. Reading and going to readings. I was working on a book review, recently, for a book of Cameroonian poetry (The Oracle of Tears). It was difficult/impossible to get all the way through on an initial read – I kept putting it down to write. Anything that inspires others to write/think/read, then, is the sustainability bit. That more muses and Martians will be translated and expressed, that words will continue.

Lines that have been over my desk for many years –

“…open the notebookand drunk with inspiration commencedescribing.”

~Franz Wright “The Lemon Grove”

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

Sometimes, in progress notes, admit notes, presentations, we put this more delicately. Call it “pertinent.” What is the pertinent past medical history, pertinent family history, pertinent social history. “Go do a focused history and physical.” Then, present, giving the pertinent positive* and negative* findings.

* “Positive” is something in the history or physical that would support a particular diagnosis; “negative” is something not present that could have supported the diagnosis/could refute it by not being there. Or, in the case of some things things, including a diagnosis as generally benign as strep throat, not having a cough makes the case more likely that it’s strep. Pertinent negative.

Is his appendectomy 25 years ago relevant? No. (unless there was excessive bleeding or some other unusual reaction) .

Is her mother’s breast cancer at age 84 relevant? No, not to her health risks. (but did her mother die recently? Was she taking care of her mother? Did she live with her mother?)What about my patient’s son’s other mother’s history of joint problems – was that relevant to his twisted ankle (broken or not?) after jumping down from the bed? No, the other mother (the mom sitting with me – her wife, she called her) wasn’t his biological mother, though it was her brother who was the sperm donor. (But in asking that one question of family history – lax joints/bone problems/connective tissue disease? I learned about the family structure, the genetics, the relationships in this child – my patient’s – life) .

Is the patient’s chest pain relevant? Well, we’ve effectively ruled out a heart attack, but there are a few other physical conditions it could be. (But, has he had any life changes? New stressors? Anxiety attack?)

The patient with insomnia doesn’t just get ambien – he gets asked why. And you should screen for physical conditions that could be contributing. And you should ask about depression. Relevant.

Doctors redirect because patients don’t know what is relevant and what is not. There’s something learned over time – the right questions to ask, and how to ask them. And in presenting, what's necessary to say. There are patients who ramble.There are patients with whom I dread doing a review of systems.

Technically, there are 12 points to go through. (How often are all really covered?)Any changes in your health?There are the favorites. We ask in one breath – as if a patient can remember them all, or anyone who doesn’t anticipate the list can answer them in order. These can be abbreviated by one letter each, usually, written with slashes in-between, after a +/- or denies*/endorses**.

*As if the patient might be lying**As if the patient is selling a particular product: her body? how her body functions?

Fever, chills, weight loss? (No, you don’t have cancer) . Changes in appetite/Nausea/vomiting/etc? (then I won’t worry about that system)Any changes in your skin? (What kind of changes? Too many to enumerate, so it gets short-handed. Changes. Anything you’ve noticed (and if there’s something that you didn’t notice, what do I imply?)More bleeding/changes in bleeding? (Are you losing more parts of yourself? Is there more blood inside your skin, or out of it?). . it goes on.

Anything else I haven’t asked about or that we haven’t discussed? Anything else you think I should know?*

*What should I know? What do you want me to know? I hear about divorces, children in jail, someone sick at home, someone dying or dead, a house being repossessed, an upcoming trip, evening plans. I hear family history and favorite colors, I hear how much they like my shoes (especially all the bright red ones) .

As we move ahead in medical training, we have to move faster. It does become easier, to take less time, elicit the needed information, and establish a relationship with the patient. I don’t have to write everything down right away, I can chat as I do the physical exam, I can remember. But I have to move faster.

I want relevance-to-right-now. There are the patients who will tell me about the one episode of indigestion a week ago, how their ankle hurt last week and there was that one day they couldn’t sleep very well and there’s one bruise they got 3 weeks ago, they’re not sure why but it went away. . .and then a few days ago he felt like he had a fever, but maybe not, and maybe it was a little warm at night. . . oh, and then his tooth kinda hurt in the morning, and he kinda had acid reflux after eating spicy things, but that just happened the one time, and then. . .he gained two pounds in the last 6 months, should he be worried about that? And actually right now he’s a little bit tired, and maybe his foot is sore again. . .

(am I still listening? half. I’m also writing at the same time. Trying to pull out what I think I need to know. And I’m interrupting and redirecting, a lot. It’s necessary. The story – even if it’s a medically relevant story – is convoluted and confusing and I need to understand it in order) .

This is a patient who, in the ER, was told “he says” that he had the largest habitus they’d ever seen! on abdominal ultrasound. (Everything with him was largest/worst/shortest time to live any doctor had ever seen) . Habitus means space inhabited by the body. (Ie, in this case, abdominal fat seen on the ultrasound.) At least, here, I could assure him without a doubt, that, no, it wasn’t the largest habitus we’d ever seen (I tried to explain what it was. He kept insisting it was something pathologic) . Fine. But I promise we’ve seen larger habitus and that it’s not dangerous to him right now.(Am I exaggerating? No.)

Problem with the above.

The patient (saying it’s one) actually has had a heart attack and actually has a potential mass on his liver. But who is going to listen, who is going to sift through the irrelevant for the relevant.The patient doesn’t know what I want to hear. He doesn’t know what’s most important to me or what’s most important to his health. He wants to tell me everything – it’s what he perceives, and some is frankly medical. Some is not.

That he’s living in a trailer in his brother’s backyard and his brother might kick him out? Relevant, relevant, relevant.

And not just in psychiatry.The head of the psychiatry department actually told me, “You might start out as something else. You might start out as an internist, and that’s fine. Eventually, you’ll be a psychiatrist.”(do I think so? unlikely, but he’s a professionally perceptive person) .

He said to me, “If you don’t do psychiatry, there are whole parts of you that you won’t be accessing.*” In psychiatry, you bring everything that you are and all of your experiences into your practice. Everything you’ve done is important. Everything is relevant.” Everything you are reverberates. Reverent.

*reference to writing, arts

Relevant to patients: where I’m from? I’d venture yes, but also allow debate on that point.

My religion? I move that back to the patient. The “it’s important what you think. What matters to you.”

My politics? – there’s one I may cross the line on, sometimes – I can’t help but speak my mind. Only in relation to healthcare and immigration status. (And this one isn't generally asked).

Are these irreverent? No. There have been almost no questions that I did not feel comfortable answering.

Diabetes, high blood pressure, high cholesterol, “lifestyle modifications”, medications? Most patients could care less about these, most of the time. But these (stress/tension) headaches. . . (I can’t do anything about) . Relevant to me. Irrelevant to the patient.

People look at me funny when I say what I’m doing next year. Pause. “and. . .how did you think of that?”

Relevant.

To end on a point that makes me irate everyday –in many clinics, the patient’s insurance/insurance status is noted on the chart. Physicians have to prescribe by formulary, which is decided by each insurance company/Medicare and Medicaid.Yet a lot of patients (my patients, past, present, and future) are not eligible for any of those programs. We’re deciding who might get to have a better quality of life or even live longer. I had a patient who was not deemed eligible for a kidney transplant because his wife, not him, was a polysubstance (drug) user, and you’re supposed to/required to have support to help you after the transplant. This counts for the transplant committee. He was deemed "futility of care." Nothing else to do.

Relevant? Yes.

Who are we prioritizing, as all the disqualifying factors are so complex and socioeconomically linked?

Should be irrelevant.

~j

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 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.

*

For births, these were only the ones where I performed the birth, where my hands were on the body that became a child. I didn’t include the ones where I just watched. These were also the ones in the newborn nursery where I took care of them, I examined them moments after birth.

For deaths, these were the ones who were my patients. These were the ones whose families I had met and spoken with. And these were the ones who died in the hospital – that’s how I knew. I don’t count the ones who were discharged and who have likely died this year, as well. I don’t know for sure. I don’t count them. I don’t count the ones on my team who weren't my patients.

These patients are represented by beads on a thin, silver, malleable silver wire. Blue are born. White have died. It’s a small string, now, with knots and twisting between each bead. I keep it curled up in a box, and I plan to maintain it throughout my career. This small remembrance, this small tribute. Each time, I take the moment to think about the person, the patient, as I add them. This started one week into my third year, the first time I was on labor and delivery. The last bead was a few months ago. None of the patients I directly took care of, on surgery, died. One is now in hospice, though, and has declined further treatments. Since I’m going into internal medicine, and maybe I’ll do another labor and delivery elective – but likely not – I won’t have new blue beads in the future. Maybe I can count babies born to my patients. I have to find some way to balance the white.

*

The first K I saw every day for two weeks, on my in-patient internal medicine rotation. It was July. She never complained of anything. She was wasting away. Everyone who walked into the room knew she was dying. And that it would be soon. Chemo and cancer made her look like that, made her so sick.She wanted to keep going with treatments. She wanted to see her three children again.In the end, she couldn’t do both. And she died in the hospital. And the last days, she was unconscious. When I saw her, she knew everything.Her last days, when she died, I wasn’t there.I heard about it after. I hadn’t seen her in a week, at that point.This is when I learned, first, to be afraid, to keep checking, to see people when they were in the hospital, to try to find out when they were there again.

*

K wasn’t the one who first scared me into this.It was another patient – and he isn’t counted, because he didn’t die in the hospital. He likely died this year. But he likely died at home. It was a Friday. My patients were K, Mr L, and a third one, young, new diagnosis of a very serious, chronic illness. After rounds, my senior resident commented that Mr L probably wouldn’t be alive on Monday. It was like I had been struck – I knew he was sick. I’d never heard anyone prognosticate like that. I asked the resident, later, how he dealt with the death of patients. He said, a little surprised, “…I don’t think about it.”I had class that afternoon, briefly, but I ran back to the hospital afterward. I had to know who my patients were – I had to know them as something, someone else than the sick and dying person I’d never seen out of bed. (Over the year, this has become much more natural and a regular part of my day – until surgery, when doing this would mean I was at the hospital more than 15 hours per day, and, after getting up at 4, I wanted to go home).

I went first to Mr L’s room – and my heart stopped when I saw it was empty. Frantically looking for his nurse, I was finally told that Mr L, per his wishes, had gone home. He would stay there. I was relieved, at least, that he would get what he wanted; I still didn’t know if he would be alive. (I didn’t count him).

Next, I went to K’s room. I was afraid when I saw the sign on her door “no visitors per patient request.” It was the first time the sign was there. So, now, again, besides my daily abdominal exam, cursory heart/lungs/edema/mental status, check of lab values and recommendations for more platelets – I didn’t go.

I did go see the third patient – the one who is and will be sick, but chronically. I stayed with her and her mother for over an hour. There was something vibrant, then, about that day.

The resident said, offhand, that I didn’t need to follow K anymore – we didn’t even need to see her on rounds, not really. Nothing was changing. There was nothing to do.

*The second K.The second K was sick, for a few days. My formal presentation for that rotation was on the reasons she might be sick. She got better. I spoke with her parents several times, got to know them a bit. I met her mother’s friend and her mother’s mother, tiny and not-English-speaking.I saw them again in clinic, the next week, with the intern who is their new pediatrician. They were more relaxed, there. Nervous, older, first-time parents.

The first K and the second K.It’s an uncommon, beautiful name. The unbelievable odds of having two patients with this name, of the not-so-many on my wire (I haven’t had any others with this name. I’ve had, and seen on teams, close to one thousand patients this year. More? More. )

I know exactly where each K is on the silver wire.

The first K had only boys (three) . If she’d had a girl, I doubt she would have named her after herself. But it’s a beautiful name. Maybe someone in her family will name a child K – in memoriam, in memory, in homage. One of her friends, maybe. A sister. It’s not a completely unlikely thing to happen. Especially for someone who died so young. The first time she had cancer, she was 26. They thought it went away. The second time – same cancer, now everywhere – she was 29.

I wanted to read the obituary. I wanted a small idea of who she had been in life – I didn’t want to remember her (as I picture her now) as wasted away,sinking back into a hospital bed, clearly dying. I never met any of her family. I know they came. She was beautiful. Vivacious. Loud, it looked like. Bold. Extroverted. Loved.

*

I was invited to a patient’s wedding this year – I didn’t go, because I didn’t get to speak to her right before she left. I was hesitating (I don’t think I would – hesitate – now). I sent a card, though. A patient brought in his daughter to meet me – he’d shown me her photos, before. Other patients kept me updated on their children’s plans and relationships. Where they’re traveling. How another patient’s son was doing in school – I met him too. Patients’ children and parents and spouses – I met lots of those. Often, I could name them before I met them – I’d heard the stories. And sometimes they already knew who I was. The patients I joked with – we ended up making fun of each other. The patients who broke down and cried. The real reasons they were there. The patients who got better, a little bit, by talking about it. The patient who is (I hope!) getting a day job, after his night job, which will help with his anxiety and his insomnia…I think, too, about the ones who were “lost-to-follow-up” – the ones I didn’t see again, or who didn’t make the next appointment. And I don’t do enough to follow-up with all of them. There is so much more I could do that I – don’t.

Patients I’d see almost every day for weeks (in the hospital that long). The patient I saw one time in clinic – and he left, angry. Marginally housed. I couldn’t do anything for that. And then I saw he was in the ICU. I saw him there. I read the chart. I checked the notes and labs and radiology reports. When he came back to clinic – he made it through that, miraculously with how sick he was – he mentioned to me what had happened and how miraculous it all was. I told him I knew, because I had been there. There’s the patient who deeply disturbed me. We (the preceptor and I) almost hoped one of the drug tests was positive, it would explain things a bit more, his affect, something. . . the tests were all negative. I haven’t forgotten him either.I can picture the ones who died – most of them, some of them. I can picture the ones who were born – most of them, some of them.The morning after the first baby I helped be born, after I’d been working for about 26 hours, I went to sit and think about him, on a beautiful overlook. Softly, ‘Happy Birthday’ to him – even though we didn’t know, yet, what his name was.

*

The angry patients, the happy ones, the ones who are frustrating, the ones who are frustrated.

This year was one of the harder and better ones. This year. The third year, the first year of the rest of my (medical) career – the first one that is spent, entirely, in the hospital and in clinics. (years leading up to this, actively working toward a career in medicine? 9. Years since I’ve been thinking about going into medicine? 16) . Of 48 weeks of work (and four of vacation), three weeks were spent in the classroom and in lecture. Three. And counting the weekends and nights we worked and the 60-80++ hour weeks – that’s still more days than you’d usually consider in 45 weeks.

And this is what it means, to be a doctor.This is what it means.The rest is a lot, a lot, a lot of learning, and a lot of practice, and a lot more terrible and wonderful things, and a lot more responsibility. That will happen, that’s ahead and on the way.

A friend asked me recently if doctors think about their patients, outside of the office.Is it possible not to?I’ve learned, this year, I’ve seen so many doctors go above and beyond what I ever knew for their patients. It’s an incredible privilege – all of this. And the conception of the third year, the necessity to be a part of so many specialties at shifting times, means learning about what it means to be a physician more than what it means to be a particular type of doctor. There are qualities of physicians that transcend their particular work, and those are the ones I want to be, in whatever I do.

You learn how to balance things. Each birth and death since the first ones has meant something to me, has had its own space – but not in the same way. You learn to incorporate things together. An amalgamation. All of these matter, each has to matter every time, but it can’t overshadow everything else, it can’t overwhelm the space of a day or an hour.

But you remember. You worry about the biopsy. You wonder about the labs. It isn’t just that. If a patient gets sicker – but there are so many kinds of sicker.If a patient gets better – but there are so many kinds of better. All of them matter. We know that.

This is what it means.

For the first K and the second K.The first K and the second K.If there is one thing about this year that is right, it’s that.

Forget you?

No.

~j

*This was written as an oral narrative for a Peace Corps anniversary story telling event*

It was a village without a wedding. Two years, no wedding.

In the south of Cameroon, there aren’t a lot of ceremonies. Much of the “traditional”, what might have been there, was obliterated by missionaries of various types. The chiefs – installed as part of the government, partly, though still in inherited positions – call cobbled-together army uniforms their “traditional” costumes.

In the south, almost no one gets married. In Bulu culture, girls have to have a baby before they can get married, to prove that they can. And marriages, for the most part, are traditional. The couple who gets an official ceremony is seen – revered, almost – as serious. Probably a bit higher social status, too. It’s rare, in the south. (I knew maybe 3 couples who had, all “big men” in town)I’d been to funerals. I’d been to a lot of funerals. I’d seen babies die, I’d known a lot of people with advancing AIDS. Malnutrition, malaria, TB, onchocercosis, measles, residuals of polio.

Before I left, I wanted a wedding.

I met Carine on my first site visit, before I moved in. She was president of the Tantines association for teen mothers (GTZ). When I met her, she lived with Alino, her boyfriend of some years, and her five-year-old son Willy (not his). They owned the largest bar in town, and the only one that felt – to me – like a comfortable place to hang out during the day. In the beginning, I talked with Carine about projects with the Tantines. I went to a meeting, I met the other Tantines, we talked about projects, family planning, HIV. . . But then, like many baby projects in village, this one fell apart as most of the women moved away – to other villages or to town to go to school (or just had other babies with more other men). For the next two years, I visited Carine – often – as a friend.

Carine’s Alino (to differentiate him from the other one in town) was/is one of the best men I knew there. Good-looking, smart, enterprising, friendly –a friend to me – and truly a father to Willy. Alino did 2/3 of a college degree in biology, but then his father died and the family ran out of money and he had to return to village. Typical story. Alino does Kung Fu, started the Kung Fu association in town – and on festival days, he and Willy (yes, age 5) would perform together.

It was two years and I wanted a wedding.

Anyway.June of my first year in village, Carine had a second child. (It was another reason she couldn’t be president of the Tantines, again). I was away from village the week their son was born. “Le Prince,” they called him. “The prince”, including, “the.” The happiest, roundest baby you’ve ever seen – at six months, he looked a year old, and more like a sumo wrestler than a future martial arts star. Alino couldn’t be prouder – of both of his sons. (And le Prince learned kung fu, too)As friends came to visit me – other PCVs – we would always hang out chez Carine and Alino. My close PC friends got to know them well. And le Prince was a crowd favorite. I took my counterpart when we went out to eat. He was hard to convince sometimes – Carine had fish – he wanted to go where there was more bushmeat. Whenever we had conferences or meetings at the hospital, I would order food from Carine.

Middle of my second year, Carine told me they were getting married. Real married, she said. Civil married. Status. She was planning the wedding for November – I would be leaving at the end of November. I told her that, hoping, hoping she would arrange it so I could go. . .and she did.

(You’re still wondering about the rooster. I’m getting there)

In Cameroon, the tradition for weddings is that the couple chooses a pagne that everyone attending the wedding has to buy, and then get clothes made out of. Everyone, then, is dressed in the same fabric, but in so many different styles, supporting the couple and really coming together as a cohesive unit. We talked about this. We talked about picking out the other things for the wedding, the bright pink and shiny bridesmaids dresses for the part at the mayor’s, the dowry (from Alino’s family), the invitations (I made them, printed in color in the city, took the picture of them for it) .

And then one day I went to talk to her – a light day, something out of the more difficult bits – to just sit and chat with a friend about her wedding. But it wasn’t that kind of a day. I didn’t understand, for awhile. “Régime, régime, régime. . .”

(In French, in Cameroon, this means – bunch of plantains – diet – or type of marriage).

When you get married, in Cameroon, there are two official choices – monogamy or polygamy.Alino is Bamoun, from the West province, and Carine is from the East province but has grown up in the South. Two very very different cultures. The West is steeped in different traditions, polygamy. (one of my friends, from the West, became a chief (small one) after his father died. He had one wife at the time, but then had to take more, also inheriting – symbolically – his father’s 36 wives. It was supposed to be a secret, how many wives he took on after that. He wouldn’t tell. Until the day I said I was so sad to leave Cameroon, and he said, don’t worry, you can stay, I’ll marry you and you’ll be my 12th wife, and you can work and do whatever you want!”)

Alino’s father was a polygamist. There, monogamy – the official kind, the kind that means a man can’t officially marry another wife – means he’s weak, and that his wife is, in some sorts, trying to be his equal. He can’t expand his family more (civil marriage means more in the West. It’s more common). His family was putting the pressure on him, and how. . .

And Carine was upset and wanted to call off the wedding. Alino tried to console her –“ just say polygamy, it’ll make my family happy – and then I won’t marry again.” She didn’t want any of that. There was no certainty in it for her, no security, and he would be able to hold it over her. . . and his family could find him a second wife and make him marry her too. . .no, no, no.The wedding was getting closer, and nothing had been resolved.

His family made the very long trip down for the wedding, first time they'd been in the rainforest.I had four Peace Corps trainees and two other PCVs at my house, including L, my closest friend and one of Carine’s.

Day of the wedding, things were tense. Alino wasn’t smiling, mostly – though that’s part of the aesthetic in formal poses in Cameroon (not smiling, short ties, photos that include shoes, and possibly holding cell phones). The traditional part, incorporating the south/east and the west, multiple languages, and the “important” people sitting inside while others danced in bags of rice and wine and fish, went well – except – the families were barely speaking. The official wedding, the civil one at the town hall, was scheduled for later in the afternoon.

They rode in by car – the doctor offered his for the 2 minute ride through town, the white official pickup strewn with pink streamers. Everyone filed into the town hall, dressed alike, except for the shiny pink bridesmaids. For this part of the wedding, Carine was in a very Western-looking white dress. The mayor went through the lines. When it came to the part about régime, he asked Carine first. “Monogame où polygame?” She waited. Dramatic or deliberating? We were holding our breath. Everyone was craning forward. Everyone knew what had been going on. And then she said it. “Monogame.” A sigh and a cheer went through the crowd – still quiet – but obviously supportive of her. Alino was next, and he had no choice but to repeat her words, softly and a little miserable-looking.

The crowd erupted outside. It was dark – the pictures I have aren’t in good light. It was a day (like 95% of them, in village) without electricity. Still hours to wait before the reception. Alino’s family withdrew. I don’t think they were talking to anyone else, much, at that point.And there was no power. That, they had planned for. They’d rented a generator for the community space, they’d bought gas, everything was hooked up and ready.

And it wouldn’t start.

No matter what they tried (and the generator had been tested the night before), it wouldn’t start. Nothing. And then the rain started.(It hadn’t rained in 2 days) . And walking into town from my house, we had encountered the fourmis mangeantes – the ones that ate a child in The Poisonwood Bible, migrated through town on occasion (with a path straight through my house,) and hurt like burning hell. We went to the bar to see what was going on. Carine was panicking less than I’d imagine. Candles on there, kerosene lamps. She’d figured out what to do.

“It’s the Bamoun spirits. We have to find the rooster.”

“The. . .”

“Rooster. It’s the ancestral spirit. It ran away and we have to get it back. My brother’s going.”

L and I looked at each other. One particular rooster. In the pouring rain. At night. . .Like anything else in village, we sat, and we waited. . . and we had another drink. . .three hours. Three hours after they’d started trying to start the generator, Carine’s brother came back with a rooster – the rooster, apparently. He had to sacrifice the rooster, and it had to be him.Behind the house, with a sharpened machete. . . this part was fast.And then they tried the generator again.

It worked. On the first tug of the engine, it worked (!!)

At the reception, the emcee asked who had gifts for the couple and wrote us all down on a list. Then, in order, each person/group was called up – and a different song was played for each – and we had to dance the gifts up to the married couple. Then we danced with them to the rest of the song. I was learning these traditions – it was my first wedding, after all. L and I danced to the front, holding the Peace Corps pagne (among other things) that we’d bought for them.

Carine’s mother-in-law told her, later, in private, that she was proud, and that Carine had made the right decision. She was one of multiple wives, and she didn’t want that life. For months and years after a wedding, you see the clothes around town, as well.

So for Carine and Alino – who I got to see when I went back, a year and a half later, who now have the little girl Carine had hoped for, after two boys, and a larger house than the room behind the bar where they used to stay –

I’m wearing this for you.

~j

“Don’t faint.”“Don’t worry.”“Seriously, don’t faint. Maybe you should stand back.”I grinned “I’ve been looking forward to this for years.”“Still. That might be worse.”“I’m fine.”

And then he cracked open the chest and we could see the patient’s heart.

It had been slow and methodical up to that point. The skin incision, stem to stern – the open heart incision people are used to seeing. Someone has been inside you. Someone has touched the part of you that makes you alive. It was the usual things. Careful splitting of fascia. The muscles that separate willingly, that sometimes spring apart under your fingers. A lot of things in surgery are done with fingers, actually. We call it “blunt dissection.” For many things, no instrument is best.

He spread the muscle off the ribs – these, these are the ribs. Attachments of muscle left. These bones are alive. These bones are full of marrow – we saw that. It’s how they heal and why they – parts of them – do bleed. What protects the heart has to be already full of life.

Anyway. Ribs, sternum, everything we’d felt from the outside. Large, huge actually xiphoid process (bottom of the sternum) – we already knew that. Careful, careful cleaning for this things that must remain alive (they will), and then R, the fellow, took up the sternal saw. And then the sternum – the chest cage – was open. And then the retractors, and then we spread it.

It happens on ER, it happens on Grey’s Anatomy, everywhere. “Sternal saw.” “Rib spreader.”We spread the ribs. The retractor, the tightened screws attached to the table, held them apart.We were watching the heart before we saw it. The anesthesiologists were doing a continuous transesophageal echo. The typical one, the one you imagine ultrasound to be, which many people think is just for fetuses (I think), is transthoracic – through the chest wall – looking down into the heart.You don’t see as much that way.The esophagus is directly behind the heart. So the probe for this one goes through the patient’s mouth (patient is asleep), down, down, down and stops before the stomach. You are directly behind the heart. We are watching the grainy black-white-gray in real-time, on a TV screen. You can see the valves moving, the suggestion of beautiful, intricate leaflets. If you turn on the Doppler flow, you can see where and how the blood is moving, and if there are any holes in the heart.

Kribi, Cameroon - waterfall into the ocean

It was just me and R, at that point. He had to dissect the pericardium. That’s where the heart lives – it’s not unprotected within bone. It’s the shroud, the cocoon. I held it up with forceps( ‘pick-ups’, they’re called) so he could cut down the middle. With scissors.

You use these for delicate things. We also use fingers.

And it seems like it should be harder, that this shouldn’t work.The bypasses – veins from his leg – are sewn into his heart with teeny-tiny thread on teeny-tiny needles. It seems like this shouldn’t work, and the shortest part of the surgery is actually connecting these veins, and arteries from the chest wall, from the outside map of the heart to aortic blood supply.

But before any of that happened.

We stopped his heart. When I helped to open it, it was still beating. It’s not the heart you even see in realistic photos or drawings – there’s fat around it. It protects it. Depending on the patient, there is more or less. The body, though, puts cushions where they are needed most. Otherwise, it would swing into the ribcage.

Pericardium opened, we saw the heart better, the attending came in, and I stepped aside and was twisted into a corner. They sewed – temporary – artificial tubes into sides of the heart, grafting them. Temporary. They turned on the special solution – cardioplegic – that stops the heart, that cools it down. Cold. You could use this to kill a person if you weren’t careful, if you weren’t using the machines.

And he was exsanguinated.

Blood to a machine. Bypass. Spinning, spun, oxygen put back in, returned to the rest of the body. The heart wasn’t beating anymore. We had turned on the clock to time this. His blood was cycling outside of his body. Patients can be on this for weeks or months. Nothing more dramatic than being kept alive by this machine. You don’t need lungs (you’re under anesthesia. There’s a tube down your throat. If the anesthesiologist stops pumping oxygen into it – they do – then your lungs don’t move).You don’t need a heart.

Every time something like this happens in surgery, there’s a gasp (from me), an incredulousness, a wonder and absolute disbelief that anyone would dare do this to another person. The gall. The arrogance. The power. The saving of people, sometimes, by stopping their hearts. By clamping their aortas. By taking veins out and moving them. By cutting into their brains. While removing parts of their spine and grinding them up with pliers.

Anyway. His heart was stopped and restarted again. And in the middle, with tiny thread and tiny needles, human hands – no better, no worse – sewed new vessels into his heart.

Open heart surgery is why I’m in medicine.(Not that I ever wanted to do it).I was always afraid of blood. Little, I was more squeamish than I can even imagine or remember. Even the sight of meat that was a little rare made me sick. And then I decided I wanted to be a doctor. I had to get over it – no choice. At the Science Museum, in the human body bits, there was a video of open heart surgery. Just the chest open, the heart, and the surgeon hands. I made myself stand and watch it twice, all the way through.And that was it.

I remember the day I first held a heart in my hands. It was my cadaver’s heart – we had been through much of the body at that point (it was November), and we took out the hearts. Back then, everything we did felt slightly anathema and extremely bold. Removing the intestines. Cutting through and exposing each layer of skin and muscle. Opening organs. And this is for a person who didn’t need them anymore, who had gifted them to us so we could learn.

That day, we took out the heart. It was election day, 2008, Tuesday, because later that night, Obama was elected. Earlier that day, I held a heart.

My cadaver had had a valve replaced. Even before getting to the heart, we knew she’d had surgery – there were the obvious scars.It was one of the most beautiful things I’d ever seen. The valves have two or three leaflets. Delicate. You can imagine them fluttering. This, this is what keeps us alive, keeps blood moving and not moving in an ordered fashion. They can be replaced. They can tear. But for the most part, they do work, and forever (as long as that means something). I was cradling it for awhile, with two hands. It was heavy. I couldn’t put it down. I couldn’t believe that this, this was the heart.

*

(excerpt from a letter/poem I wrote to my cadaver)

Your heart.

Your exquisite heart. Aorta, fleur-de-lis. Scallopededges of left ventricle flutteredopen. Butterfly chords. Parachutes.Staples in the louvers of your chest – you had been opened before.You had been reconnected.

*

Later this week, in surgery again, we took out a man’s esophagus and reconnected his stomach to the top end of it (for cancer). It’s amazing that this works. It’s amazing that patients have, essentially, normal swallowing and digestion. At any rate. The incisions are in the abdomen and in the neck. The stomach has to be pulled up in-between, to be the new esophagus. The stomach has to go behind the heart. And we don’t open the rib cage. The surgeons are dissecting “blind”, with their fingers, separating the esophagus from surrounding tissues. Gently. In typical med student fashion, I was holding the retractor, hard, needing both hands, holding one with a light on the end that pulled up the area where they were working and helped them see deeper inside. It’s painful to hold something that way for a long time. When I could relax – when they did – at first, I thought the pulsations were just from my hands in their very tight gloves. And then the pulsations started to bounce my hands, up and down, up and down, with a vigorous, exuberant force. I knew, but I asked anyway. “Am I on. . .”“You’re on the heart.”

~j

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

When I see patients in the hospital, they’re in bed. The note, in fact (assuming the patient is doing well) will include something like this in the General subsection of Objective findings. “Comfortable, resting in bed, NAD (no acute distress).” If it’s a psych note, it will also state “dressed in hospital attire,” and I might make some comment about the state of dress (disheveled?) or hygiene – as indicators of state of mind, situation, possible delirium, connection to the outside world - or supposed to be. I might say “looks older” or “looks younger than stated age.”

(I rarely do this, but I had two patients in clinic the other day – same disease, basically the same operation. One was 62 and one was 82. Having read the charts, then going into the rooms, I had to double-check the names. The 82 year old looked much younger). Same for the 87-year-old who plays 18 holes of golf everyday and catches very large fish – he had a huge abdominal aortic aneurysm, without any symptoms, and by all rights, he should have symptoms, or have been sick. He wasn’t. It could kill him, so it had to operated on. Otherwise, he was very, very much alive.

Yaounde

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

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

Sequoia national forest

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

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

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

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

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

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

~j

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

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

So many large movements of the earth, natural and non, right now. And during the day, I can and do just concentrate on trending my patient’s pain level, hemoglobin, electrolytes, vital signs. On surgery, they always, always want to know the “ins and outs.” Report as totals then break it down: in: IV fluids (what kind), p.o. (oral), medication infusions, etc. Out…also…has several forms. All are meticulously recorded on 24 hour balance sheets.It’s a vital sign – and it does give you the best indicator of fluid retention/dehydration/kidney function. Patients can be “fluid up” or “fluid down” – you just subtract. You know exactly where the extra or the deficit is, and there are ways to work on fixing both, and there are particular things you start to worry about.Fluid balance.

If there’s a major, major earthquake on one side of the vastest ocean on the planet, the waves move all the way across to the other side, and quickly. Fluid balance.

*

Conservation of energy

“Japanese nuclear safety officials and international experts said that because of crucial design differences, the release of radiation at Daiichi would most likely be much smaller than at Chernobyl even if the plant had a complete core meltdown, which they said it had not.” – The New York Times, March 12,2011

“Most likely be much smaller than at Chernobyl…”And this just passes by uncommented in the article. Chernobyl was 25 years ago and it’s a ubiquitously known word/event. And Chernobyl was 25 years ago.

Here's something that won't, can't spare anyone.. though there is the small wonder of what employees were actually there and what the real estate is like in the direct vicinity.

But there’s no way to understand/wrap head around this type of thing. Not for me, anyway. If in 10, 20 years I have a patient who was around Daiichi and develops thyroid cancer/leukemia/lymphoma/melanoma/etc… it’ll take on a different meaning. On the public health level, they’re giving people iodine. (scanty, scanty, scanty evidence. From what I can find). And - it's Japan. They have iodized salt. And they eat a lot of fish. And this is on the coast. I'm not sure how much more replete with iodine they could possibly be.

Prevention is a hard sell; you don't see things if they don't happen, and you can't be relieved that they didn't. Current death tolls are countable. Japan, though...knows. This. What it does.

*

The doctor-head and the public health-head

My patients would never want to hear about the second one.

The public health head wonders about cost-efficiency and allocation of resources – not monetarily, necessarily, but medical resources, including personnel.

And yet it’s done all the time. That’s what tumor boards do – they decide, together, what the best course of treatment is. That’s what transplant committees and UNOS do – they decide who’s the best candidate and at what rank someone should be placed on the list.

Many months ago, I saw a patient in the ICU who had been labeled “futility of care.” He was…perhaps…39, in kidney failure. Or liver failure. It doesn’t matter. Whatever it was, he needed a transplant to survive much longer. Otherwise, he was healthy enough, and his health status would have qualified him. He might have had decent matches, I don’t know. But his wife – not he – was a polysubstance user. Because of that, because they deemed he wouldn’t have enough psychosocial support after the transplant, to help with recovery and anti-rejection regimens and all matter of things – he didn’t get to have a transplant. Futility of care. Two physicians have to agree. Nothing else to be done. At this point, harm exceeds benefit of treatment. Comfort care. Thirty-nine. Could otherwise have received a transplant.

Then there’s the patient who’s had multiple, multiple, multiple coronary artery bypass grafts (CABG. Open heart surgery). Multiple multiple stents, multiple replaced valves. He’s fifty-five. It’s atherosclerotic disease 2/2 (secondary to) smoking, maybe to drugs, too, that have caused heart infections. Does it matter? It could have been congenital. Maybe it was because of high cholesterol, and/or maybe the high cholesterol was a familial, genetic thing. Tobacco and other drugs are addictive. There are chemical propensities for addiction. And everything has psychosocial factors.None of this should matter, theoretically.But at this point – it’s the fifth operation – they’re still operating. And I can’t help but wonder about this allocation of resources. Someone else who needs surgery, one, any surgery, and can’t get it for lack of resources, ability to pay or access a hospital. All this time and energy into someone so chronic, because, at some point, we can’t do this anymore.No one will say when that is.Doctors are the worst optimists when it comes to predicting mortality. Two, three, four times the “actual” lifespan. I’m not saying he’s dying right now. He’s not. And this patient is a lovely person. I enjoy talking with him. Not that that should matter anyway. I wish him the absolute best and I am engaged in taking care of him and working to find and provide the best things we can.

But yes there are starving children…everywhere… and so many conditions that could be completely averted, and not enough vaccine access, and not enough medication access or access when things have presented far too late, or going into bankruptcy for life saving interventions…

The public health head wonders where the line is. One patient versus hundreds versus thousands and millions. Physicians in out-patient practice, these days, have 1000 to 2000 patients in their cohort. Not that they see all regularly; some may never have come back. But this actual “thousands” of patients, added to the hundreds/thousand in medical school and thousands in residency – is how we actually end up seeing extremely rare conditions.Each patient is an individual and a single data point. In the encounter, I am focused on the one person. That’s why physicians who are perfectly well-skilled in epidemiology are still referring for mammograms at age 50 and pap smears every year for everyone. That’s why they’re still doing PSA tests for men over 50. Rationally, these things have been proven to not make sense and be inefficacious. Public health looks at things in “numbers needed to treat” – the NNT is part of how you decide whether to do an intervention for everyone (screening) or not. How much money (yes) but moreover how many needless complications for one person found with the disease, one person treated, one person saved? There are no absolute thresholds. But this is part of how guidelines are decided. The cost of screening isn't just what you see (mammograms, blood tests, Xrays, et al). It's what you don't see, from the outside perspective. It's the many, many individuals who had false positives and then the anxiety of thinking they had cancer (not insignificant), unnecessary biopsies, perhaps surgeries, each of which comes with risk and side effects and consequences. Radiation, risks and consequences. The NNT is a question of what level of unnecessary harm (and how bad is it) is worth it to maybe find and help one person. It's still an individual question, on that level, if you think about the prototypical wrong diagnosis (false positive) who might go all the way to surgery for no need. It is an individual decision (if the patient's insurance will cover it, or if the patient will. And some "insurance" does not even cover screening based on US Preventative Services Task Forces guidelines (USPSTF. They make the official recommendations). Is the risk acceptable?

But on a population level, somebody has to make the decision. As a society, what can we accept, and what is reasonable.

The public health head cares most about the population. And the doctor head might do everything possible for the one person in the exam room. Even if it doesn’t actually make sense. You can’t not. But the public health head is always there.

In disasters and in chronic states of health/baseline rates of disease, it's about allocation of resources. With increased risks, you have to re-and-re-allocate.

If patients knew that a lot of what (surgeons) worry about is their ins and outs, spreadsheet balance, it might seem horribly impersonal. Voiced concerns are taken into account - pain. Everything. But it's the tight spreadsheet columns that help the best, sometimes, to know how the body is coping, especially after surgery. It's basic accounting. It's checkbooks or second grade math.

When calculating maintenance fluids (to keep at baseline/not dehydrated and not fluid-up) for patients who can't drink and regulate their own fluids (or whose balance is thrown off for another reason), we talk about "insensible losses."

"Insensible losses" means water you lose through evaporation (sweat) and by breathing (we breathe out water vapor). There's a way to calculate the basic amount and to take that into account.

Calculating ins and outs, we know about insensible losses. That's in the background. (and we call them 'insensibles.')

Fluid balance. Insensible loss.

~j

(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 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.I’m one of the luckiest ones – I was placed in exactly the right village with exactly the right work for me with exactly the right people. That doesn’t mean things didn’t work, it doesn’t mean many (most) things fell apart or happened in different ways. I couldn’t imagine being in any other post, though. In the later parts, I was happy and relieved, coming home, to be away from cities. It was the same when I returned in 2009. It will be the same, I think, next time I go.

I’m one of the luckiest ones – what I was doing in Peace Corps is essentially the work I want to do for the rest of my life, but as a physician. One of the hardest parts was having to leave in order to go back.

I’m one of the luckiest ones – I was always safe and supported in village, and I had so many families there. Families I am still a part of. Peace Corps security (at that time) didn’t really care that my door didn’t actually lock, and that there were holes in the walls. (I didn’t either. Foolhardy? Yes). There were days I left the house without locking it – I forgot.

Drying cacao in the sunI’m one of the luckiest ones. Things did work out, with my projects, better than for many volunteers. It’s always part luck.

For the fiftieth anniversary, I went to a house party where many of the RPCVs had served in the 60s and 70s. I don’t know if I would have, could have joined them – going into the complete unknown without any communication. Countries that had just gained independence. It was different. And yet – every country, every situation, even now, is completely different. And every Peace Corps experience has certain commonalities, and every R/PCV can understand. Simpatico.

Manioc (cassava) leaves...for pkwem

One of my comparative literature professors taught in Chad in the early 60s. In those days, they trained out of country; to teach in Chad, she trained in Montreal (as if there was anything similar). She wasn’t really considering teaching, before, and now she teaches and writes about Francophone literature, largely from Africa and the Caribbean. Diaspora, Francophonie.

Lion indomptable d'Ebolowa

These are short pieces I wrote after returning. Snapshots.

This is where I lived.

***

It isn’t a green that comes out in photographs. They’re all wrong. It defines green – living, breathing, life-giving, all-encompassing, overpowering, plan to inherit the earth green. Oxygen green. Encroaching on the human footprint green – mostly green from orbit, Yann Bertrand photographs and mostly dark on electric use imaging green. Hiding green, swallowing green. Barely trodden, almost erased footpaths green. Vines curling across and weeding sweeping up and over to make tunnels on the water source trail green. Taller than you green, thorns in your forearm and dotting your hems green. You can’t distinguish most species green. The shy grass – leaves – blushing at a fingertip and closing like downturned eyelashes – some draw blood from imperceptible skin pricks. Others don’t.

Mvangan, road past hospital/to my house

7 am, end of marche in town center (surrounded by forest).

(Yvonne, hospital pharmacy tech, in front)

***

What matters, remembering, are the nights – 19 mai – I didn’t go out with the guys and sat on Mama Fran’s veranda – hers, not his in those queen of the manor, lady of the estate moments – she’d make a good queen. It’s about the women. Dicing tomatoes on a tray? Grinding stone? IN a bucket or bowl filled with mostly clear water, knife’s back edge pressing into my hand. Marks. (She still has my first good knife. I wish I weren’t anxious over vaguely disappearing possessions. I wish I’d left her more baking tins).

Part of Regine's kitchenStage (training), Bandjoun. The one night Carine and Chantal let me really help make dinner – usually done while I was in school, or escaping the pent-up-unhappy house for bars with friends, internet in Bafoussam – wherever. Open air markets. They handed me tomatoes and a half-slope knife, plastic handle molded around the edge and coming off. No cutting surface or board.

Sunset view from the hospital veranda, where Cecile and I would sit and cookLater, in my own home, I’d poise the plastic cutting board on a bucket or my unstable (none of my cement floors were flat, sloping down from the wall joining) varnished wooden shelves. Pantry.So I cut into my hand, like they did, cradling the oblong and slightly blemished, small tomato in my left hand. Cutting it open like a flower, turning up for symmetrical incisions. Diagonal slashes – deeper brown, not cut but like blood called to the surface – stayed on my left palm for months.I continued, holding my breath with each slice, me still nervous around cheese graters and unskinned knuckles – until the knife fell deeper into my index finger. Blood and tomatoes. I thought the scars would stay. Those are gone, now.

~j

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 don’t generally talk politics in clinic…except over health insurance sometimes when I can’t help my angry outbursts at what I can’t provide. So I don’t know as much about that. In Cameroon, I learned more about European politics than even BBC World News told me – my friends in village knew. They discussed ministers I hadn’t heard of.

And I was listening to BBC, at least, on the bus to clinic in the mornings, until I discovered itunes had free pediatrics podcasts. If I can count the morning commute as studying time, there’s less to do later. Theoretically. Or sleep. Or music I’m not even listening to. Those are the ways of dissociating from the world. I remember the proximity of holidays from storefronts and clinic waiting rooms. Nursing staff scrubs, that’s actually another way, sometimes. Spending days in the ER, you never see light unless you’re standing by the ambulance bay or going to the roof to accept transport from a helicopter. At the end of 8 or 12 hours, you walk outside and are surprised… either that it’s night or that it’s day. Whichever. Maybe in that fast-paced environment of immediacy, current events would be more on the tongue, as everything is constantly changing and you’re not getting into longer-term conversations or relationships with people there. Then again, you’re always focusing on checklists, gestalt presentation, and minutiae of learned instinct to tell you which patient is going to decompensate quickly, and which one is not. Patient by patient by patient, minute by minute by minute. If it’s not public health, there’s not a larger picture, and if it’s emergent treat-‘em-and-street-‘em care, all you might have fixed is the very short-term problem. If that. Clinical medicine is still about bandaids, though some of them are large enough and strong enough to keep a heart or a brain together for five, ten years. One person’s heart, one person’s brain. And there’s nothing negligible about that. In most offices and hospital floors, going room to room to room, you do get glimpses of outside. It’s mobile. During things like the World Cup (I haven’t yet been in a hospital during elections), clinical staff will pause just a bit longer in doorways, or as long as possible. Patients have TVs on. On the wards, I would sometimes learn larger bits of news from patients, either that they told me or that I saw on the TV as I sat down to chat for awhile. I can’t be the only one who garners bits of the world in this way. These days.

Clinical medicine without public health, without any focus on larger outreach (national or international), is like a room with a skylight (lets light in, does something luminous) but without a window you can see out or in. In the ER (or spending all day, every day in a surgical suite), you’re so internally focused for 12-30 hours at a time that you have no physical connection beyond the walls. I can’t choose a career without windows.

~j

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.

Then there was Little E – I won’t call him Baby, because he’s 13 months old (not quite walking yet, though). Little E wasn’t even in the office to see the doctor; his mom had brought in his big sister (age 4) for an earache. The ear was a little red, not bad, and the attending on that day was one of the ones more liberal with antibiotics (most wouldn’t have treated at all). Then the attending noticed how fast Little E was breathing. He looked sick, ish. His mom asked, offhand, “oh, could you listen to him, actually?”His lungs were crackles everywhere, little tissue paper-popping sounds. Bronchiolitis – also usually caused by RSV. In the office, though, he was RSV negative. He was breathing okay, just a little fast, and the oxygen saturation (fingertip probe thing) was fine. We sent him home with, as they say, “strict precautions.” We phone followed up the next day – doing about the same. On Friday – doing a little better, but temperatures of 100F (still low). Seemed to be on the upswing, no one was worried, have a good weekend, have a good weekend, and that’s that.And the next day Little E was also having trouble breathing, also came into the ER, and got admitted (he went to the regular floor, at least, and not to the ICU). And when I went to see Little E, he was on oxygen and still too low in oxygen. RSV, now, was positive.

Kids aren’t little adults. They can go down fast. Fast. From something that seems minor by all other measures.Two other kids in the office, last week, developed symptoms while they were there – good thing, because, when they first came in, they weren’t diagnosable with anything significant.

That’s another thing about pediatrics, though – a lot of the time, you have no diagnosis, and, ohwell, most of the time kids will get better and you still won’t know exactly what it was. A kid with roaring sinusitis won’t have a headache. A kid with a terrible kidney infection will have no pain with urination and no back pain. A kid with an earache will come in for vomiting, not for ear pain. You could call everything “atypical,” just as we call “atypical” symptoms of heart attacks those that occur more often in women and diabetics and African Americans…

*

Is there a giraffe in your ear?

The art of medicine here is the art of distraction.

My new “standards”:…depending on chronological and developmental age. And how much sarcasm they have developed (also part of development, I think. One father thought I was fabulously funny; his 8 year old sarcastic son seemed to have the same idea).Where’s your heart? Where should I listen? (good for little ones)(and, yes, sometimes you start out by listening to a hand or a shoe or a forehead or a doll. Then they’ll let you listen to them…)…goes on to…Well, how am I supposed to know if you don’t?

For the little ones (haven’t used this in awhile, actually). What am I going to find in your ear? Is it an elephant? Is there a dinosaur?

There’s the basic school ones, sports, commenting on princess shoes and racecar shirts and spiderman jackets. I was relieved to learn from one mom that kids are still watching Sesame Street. And she was reading Berenstein Bears books to her daughter! I have no idea what the new things are.

Even with high schoolers….

I had to convince a 15-year-old to let me get a nasal and a pharyngeal swab. Flu and strep throat. “Come on, please…. I did this with a three year old this morning…” (yes, I told him that). I showed him the materials. I had him practice before I actually got the swabs. I did what I always do, too – honesty – told him: “I can’t imagine this would be fun, either. But if I needed this, I would let you do it to me.”

Shining light directly in the eyes and they wince – “I know, I don’t like this part either.” (True).

Tip the kid backwards over parent’s lap to get them to open their mouth wide enough to see.Restrain the kid for an ear exam – you put their legs between the parent’s legs. Clamped. “Now give him a big hug…” puling both arms and side of head into the parent’s chest. Tight.And now I brace one hand on the head and the other hand between the otoscope and the head, to make sure the instrument moves with the head that still might jerk a little, so I don’t accidentally puncture the tympanic membrane (ear drum).

Those heal right up, anyway. In kids.

Nlobo river, near Zoebefam

I didn’t get how this worked. Learning to feel bodies, to know what’s “within range of normal” (wnl. Better/more PC/more accurate than saying “normal” or “nl.” The note is covered with “wnl.”)I have no idea how many patients I’ve examined at this point. Not countable; a thousand is a very low estimate. More like 1500, maybe? 2000? I don’t know*. But the point is that the other day I felt a spleen that was just very slightly enlarged, and I was confident enough that I knew it. I’ve done that with livers now. With murmurs, I’m starting to know how to grade the intensity – I,II,III,IV,V,VI - it’s another of those gestalt things. They can’t/don’t teach exactly how loud merits a II, III, etc. We were told that medical students couldn’t hear anything less than III, so I had been grading most murmurs III/VI. Then I realized that was wrong. There have been some I-IIs and a lot of IIs.

*A little incredible to think about. This has varied a lot by rotation, and when I’m following patients in the hospital, I examine the same people several times. On a rotation like this, though, over 15 days I’ve seen about 6 -10 kids per day. Medium estimate, 8x15 is 120 examined. In three weeks.

An attending taught me the liver exam on an infant, and how to run your fingertips lightly over the abdomen until you feel the change in consistency. It’s subtle, but it’s there. In newborns, the liver normally juts out very slightly from under the ribs. Later in life, the liver shouldn’t be that far out. For adults, we press in under the ribs. Hard. “Take a deep breath….” (patient inspires) “and let it out…” The liver might slip against my fingers. Might now appreciate the edge, and might not. Even with this, you can use multiple senses to find it. The “scratch test” helps localize the border of the liver – part of a full exam is measuring it. With stethoscope in ears and on the abdomen, you lightly brush a fingertip up, up, up the patient’s abdomen, vertically, until you hear the change in sound. Without the stethoscope (and with perhaps more talent/practice), you do this just by percussion. Tap one finger onto another finger on the patient’s skin. (abdomen, lungs/back, sinuses). Everything that is hollow makes a sound.

Twice, now, I’ve accurately appreciated hepatosplenomegaly*. It was one of the first times I had felt a spleen that was neither grossly enlarged nor had already been signaled to me as an interesting physical exam finding. Feeling the spleen tip, I had no idea what it was, exactly, but knowing it wasn’t quite what I had felt before. Range of normal. WNL. And for the patients who aren’t, yes, a group of people might parade through to look or feel. They’re asked, first. * In medicine, we say “appreciate” when we mean “feel.” We also run liver and spleen together into one word, as if they were inseparable and not physically placed on opposite sides of the abdomen.

Generally. It’s explained that they would be contributing to education (true). I’m not sure I’ve ever heard anyone say no – interest in doing it, versus hesitancy of contradicting anyone in a white coat. These days, kids with chickenpox get treated to seeing every resident, student, and possibly attending in the clinic. The not-so-old practice of taking kids to be exposed on purpose is replaced with vaccination and freaking out over symptoms/placing in isolation those who aren’t immunized. The entire cultural context is changing.

Nurses walking through the rainforest to deliver measles vaccines. Cultural context: disease never thought about/only recently re-seen in the US with "fads"/"campaigns" to not vaccinate...

Neurologically, working with children proves the circuitousness of health and experiences. The normal reflexes of the newborn are pathologic if they occur later in life – reflexes that means an infant is healthy and neurologically “intact” means an adult has had a stroke, has ALS, has MS…something pathologic. A few weeks ago, I was doing a newborn exam in front of parents. Scanning through my methodical checklist, I tested the Moro reflex. Moro is the startle reflex – the infant is lying on his back and you pull him up by his hands. Just a little bit. And then you let him drop. Yes, the head hangs back a little while you do this. And yes, you are…dropping the baby (from a slightly raised torso to back onto the table). The arms shoot up straight into the air and the tightly fisted palms spring open. “DON’T DO THAT IN FRONT OF PARENTS!” the attending admonished me. “Or… at least, not so high.” (I was doing exactly what we do out of view). You get more cavalier, this way. Things we can do. Things that are indestructible.

~j

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?

It’s the way I learned to read PPDs (TB skin tests). That, too, was the first procedure. Sliding the needle in under the skin, shallow-angled, so superficial to the surface that you could see the metal tip gliding in. Inject and you see the wheal rise, or you should. (I placed so many. The wheal wasn’t always there as much; it wasn’t always perfect. How much did this end up mattering?) And two days later – 48 to 72 hours, we say – come back and we’ll check. Are you positive. Are you not. It depends on your risk factors – average risk, >15 mm is positive. High risk (includes living in a homeless shelter), > 5 mm is positive.The spot is often red, two days later. It’s nerve-wracking for patient and for young provider who doesn’t know any better. But the redness doesn’t matter, apparently. Just the induration. The hard mound that mimics the wheal you injected in the first place. The best way to not confuse yourself is to close your eyes. Run your fingertips lightly over the skin of the forearm. Stop where they are stopped. Run back and forth, back and forth until you are sure.

Children are both afraid of and comforted by touch. The touch at the doctor’s office might include needles. Approach some children at all and they start crying. To get infants to stop crying, we gag them. Functionally. A gloved finger reaches into the mouth, up towards the palate, just as during breast or bottle feeding. And once you pass the lips and reach up and over the tooth-hard gums to the palate, the mouth clamps around your finger. It’s a neurologic test – this is an infant reflex. (We learn to survive). It’s a pharyngeal exam – is the palate high or low arched? Is it cleft? What about the tongue? And it’s a pacifier. One baby was so strong that I felt she was almost cutting off my circulation. Touch is reflex, exam, and bribe. Somehow, even the (must-taste-terrible) latex glove counts as something comforting.

In the nursery, we scrub once in the morning. Ritual. Because after you scrub, you dry your hands with paper towels, and you go about your day. Touching everything. We use the alcohol before and after touching babies. But other than that, I walk around the hospital, I go to the cafeteria, I wander by the lounge, I hug friends in the hallway, and I go back to the nursery, rub the evaporating alcohol on my hands, and I go back to touching babies.

The ritual of scrubbing in the nursery is the same as it is for the OR – I don’t know how to do it another way. I wonder if this is as ingrained in surgeons as bike-riding or writing or driving are for other people. Post-stroke, during dementia.

The little package, the little flat-curved plastic stick for under your nails, the brush/sponge that you soak in soap from the foot-activated dispenser. I forget how many times you’re actually supposed to count on each surface. I may only be doing five, now – should go back up to ten. Not sure. Each finger, including the finger tip, becomes a three-dimensional geometric object that you view in terms of planes. Equal attention. Up the wrists, the arms to the elbows, the other hand. The ritual of running each arm under the foot-activated water so the water drips down your hands; whatever you’ve scrubbed off goes away from you. It’s dance-like and graceful; we reach elegantly in diagonal directions. And then (this is for surgery, not for the nursery), you turn off the water with your foot and you back into the OR, hands up and out in front of you, dripping water onto the floor. You go where the scrub table is, and someone sterile lays a blue towel over one of your arms. Everyone has a different technique for how to dry your sterile hands with which side of the sterile towel. I can’t deduce the evidence-basis. There isn’t one. You might then drop the towel on the floor, or, if there’s a linen container close enough that you can open with your foot. Gown is next. You can’t touch yourself or anything. The scrub nurse gowns you – ritual in that. And anyone non-sterile comes to tie the gown on in the back. I like this part; I like doing it for others. It took time to feel comfortable maneuvering in the OR and not being afraid to be yelled at (still happens) or to unsterilize something or someone. It’s a gentle way we help each other, and it’s wordless. Someone is being gowned. You go tie them.

Next are the gloves. You dive one hand in, and then the other. You can’t touch your hands to anything before the first layer is on. Your fingers stay hidden and hesitant, until the last minute, within the sleeve. One glove, two gloves, and for the second pair you can actually help a little – now, you can touch things. Settle them on. The last part of the dance. In your right hand, you take the color-coded card from around the waist of the gown. You hand it to someone – sterile or not, here everyone is equal – and they grasp the other half of the card. You spin to the left, they tear off the card, and you tie the gown in front.

Every time.

It takes awhile to be comfortable in the sea of blue. It’s not the view-of-the-ocean blue. It’s not the even-if-it’s-not-summer-I’ll-enjoy-being-outside-in-sun-today blue.

It’s don’t-touch-if-you’re-not-blue-blue.

Don’t touch.

“What you want to be when you grow up…in medicine.” Different theories: how do you learn best and why? What do you want your life to look like? Who are “your people”?

What part of you do you want to be using all day?Maybe that’s another way to decide a specialty.

There’s so much talk about surgeons’ hands and how they insure them. Tens, hundreds of thousands. Millions. In surgery, scrubbed hands are encased in two pairs of gloves. Often, the half-size larger pair is underneath, sealed by the smaller pair. You want it to be as tight as possible, while your circulation is still good. I started off with 7 ½ size gloves. They do fit comfortably. And then I tried to tie suture in the OR. Next surgery, I went down to a size 7. I tied off sutures on the next case. And now I wear 6 ½. On the wall, I reach for the small gloves. It has to be a second skin. There can’t be extra movement. I brought home a pair of sterile gloves for practice – tying knots isn’t enough, but being able to tie knots in gloves, and then tying knots in wet gloves…

They have to be tight.

The point is that I’m actually far from my hands when I’m in surgery. They’re one of the few parts of me that, scrubbed and gowned, count as sterile. And they’re the only sterile things that aren’t blue. (Some inner gloves are blue. more are green). The white hands stand out, stretched over the white cuffs of the disposal blue gowns. The sterile window of the body extends from collarbone to navel, approximately. Hands and arms, technically only up to the elbows. My hands are mobile, they’re fluent and fluid and flexible and nimble, but in terms of actually feeling things? Not much.

~j

Zen, Part 2

(Trigeminal nerve, CN V1,2,3: 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. The events coordinator walked quickly up and down. Hassled and unsure what to do. He said to the gathered (unseen-to-me) crowd “I can open up the larger room downstairs, but it will take me about 15 minutes.” Solidarity among readers – done. “You’ll have to carry your chairs down.” Those of us lined up on the steps started to follow him down – “WAIT!” Patience, impatience. There were things on the walls and free newspapers enough. And it couldn’t be true that we would get to be in front this time…or would it…

He was ready, he went back upstairs to the invisible room, and people started to walk down with their chairs. And we followed as they passed by. Three, five, ten chairs were set up and someone asked “can we all just stand? There will be more room…”The few who needed them, kept them. The few others who needed to sit, sat beside them on the floor. And I stood in a corner pressed into so many people that both the requisite sweaters came off and I was almost held up by the crowd. The writers, even, were sitting on the floor next to the single podium as they awaited their turns.

Standing. Room. Only.

Pacific

Deborah Treisman introduced them, once she was introduced. Maybe she’s not famous to everyone – maybe not everyone had slight chills, an extra-attentive connection with the moment when she began to speak. Deborah Treisman, fiction editor of The New Yorker, narrates the monthly fiction podcasts. For over a year, Deborah Treisman in my ears, walking, running, driving, it’s Deborah Treisman introducing the author, discussing literature with the author pre-and-post story. And here was Deborah Treisman. And here were the writers. I was eight feet away and standing, drawn in by her same-as-on-the-radio voice.

Writers are my fan-worshipped idols. Had I been this into poetry, younger, I might have been somewhat akin to the famous Beatles fans. And since famous poets aren’t very famous (I’m paraphrasing Denise Duhmel), I’ve met a lot of my idols. Of the triad of muses of my development (Li-Young Lee, Louise Glück, Sharon Olds), I’ve met two (and had a workshop with Li-Young Lee). And many, many others. I can’t remember what I stammered to Louise Glück after going up to speak to her after a reading (did she sign my book? Did I have the foresight to bring one?) I remember what I said to Li-Young because I’d practiced it. “You’re a writer who changes my breathing.” I assumed he would understand what I meant – after all, he’s Li-Young Lee – and I left it at that. I did think his quiet nod and thank you meant that.

This is one instance of poetry becoming visceral. When I read his work – and when I read Sharon’s, and that of many other poets – and when I read the middle section of Jeanette Winterson’s Written on the Body – the words and the rhythm enter and my breathing patterns actually change. It slows, I think. I’m controlled by something exterior-to-interior. Whatever effect writing has on the brain (and meditation has been proven to do this. Yoga. Poetry is my meditation), it infiltrates the autonomic circuits and changes things. I’ve never counted a change in pulse, but it’s probably there. Good writing changes my breathing. Good writing is breathing. And good poetry is blood.Poets sound very metaphysical-y sometimes. Perhaps too ‘new age’ or whatever (which I’m not. At all). But the visceral analogies make sense. Finding what parts of a poem are actually the poem? “Put your hand over it. Feel where it’s warm.”It works, if you let it.You can hear when a syllable is missing, or if you have one too much. I say this as one who very rarely writes in meter. It doesn’t matter. Things either fit or they don’t, and the reason is encoded past a readily-accessible place.

Sunrise, Masai Mara, Kenya

Chris Adrian read first. Deborah Treisman introduced him. And her introduction was based around his other life – how impressive, how amazing, a pediatric hematology/oncology fellow (incredible and incredibly sad, the way his stories integrate children with cancer and fairy tales). How amazing, in medicine, and a writer, so many hours, so busy, so busy, so talented in multi-directions. She said almost nothing about his writing.This reminded me, in my very small way, of how I was introduced at my senior thesis reading (poetry). I had been waiting for this – a moment, a few minutes, to hear what my mentor truly thought of my writing, and how she would describe it. (The year before, a poet (now published!) a year ahead of me said something about knives. The sharpness of my words. I wish I remembered exactly). At any rate, I had been looking forward to this. It was part of the culmination of years of work, for me. Being introduced by someone I look up to so much, as a mentor and as a poet.And what she talked about was science. How I do both. How that is special, just that viewpoint. Not even what I write about science (now medicine), I don’t think. I felt cheated. I felt like…that must mean I’m not a good writer, I’m just… good balance, good breadth for the program, or something. It wasn’t about me as a writer.

But what Deborah said about Chris wasn’t about him as a writer, either. (which made me feel so much better in a 6 year retrospection)… What stands out is how this other side stands out. Everyone uses both hemispheres, I think. Science is incredibly creative. Computer science is creative. Engineering is creative. (Math is…art and philosophy). Studying literature is analytical and systematic and difficult. History is the study of patterns. Sociology is the study of human patterns and how to, perhaps, move forward with them and enact change. Dancers count rhythms and have to figure out how to be exactly within them, with deliberate figures. Visual artists use scale. Study and application; everything requires creativity. If a job doesn’t – which is maybe possible – then the mind is wandering, and the direction it goes is probably to the right.

So why is the junction and science and art perceived – by people on both sides of the spectrum – (think: Kinsey. I can’t believe that anyone is completely either a 0 or a 6) as something so amazing and unusual and novel? These days, physician-writers have known-names. Atul Gawande. Oliver Sacks. Jerome Groopman. As to poetry, everyone likes to bring up William Carlos Williams. It’s rare that people mention Michael Crichton, come to think of it… maybe they don’t know. It’s not amazing or anomalous when this is just the way a brain happens to be wired. Maybe the corpus callosum looks more like swiss cheese, I don’t know. But a physician should be judged on merit as a physician and not for other accolades; a writer should be judged on merits as a writer, and whatever else informs the writing…informs the writing because it’s an innate part of the author. Period. Okay, so Junot Díaz sometimes writes about life in the D.R. And Chris Adrian sometimes writes about hospitals.

From a Chihuly exhibit. Scientifically exacting...and completely abstract.

So I was standing there, in the crowd, watching rapturously. As I always do, I closed my eyes to the beginning of the reading, to focus solely on the words, and then I opened them and I was within the narrative stream. I was within the collective…something. It’s a feeling. There’s a calmness that exists in that space. It’s the calm of exultation. It’s the calm of something larger in the room, a deeper connection, a collective unconscious connection (Jung) to a form or a muse or a Martian (Jack Spicer).

And I realized that it’s the same feeling as in African dance. Good writing means letting go, giving up and being completely open to whatever words come. They might not make sense for years. They might never make sense to anyone else, but they’re there. There aren’t drums dictating this, not exactly, but there’s…something. My selfish reason for going to readings is because it makes me write. Sometimes the words I write, there, are triggered by what’s being said, and sometimes they aren’t.

It’s the same feeling, and, as in dance, if you let it overtake you, let it in openly and willingly, that’s when the best, the truest things happen. I don’t have a better way to explain it, not right now.It’s the same feeling. The zen, without a better coinage. Being within and becoming part of the music. Being within and becoming part of the words.

~j

…and both literature and medicine are/can be insular worlds, while physical and virtual connection in the world is making things explode with a forward motion.

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…

And it’s the junction of the lumbar and sacral (L-S) spines.

L4, L5, S1.

The bulging, the herniating, the compressing discs. The seat of the sciatic nerve – where it starts, from whence it courses all the way down the back of the leg. If your back hurts – chances are – this is where it hurts. It’s the most common musculoskeletal injury in America. Second cause of clinic visits. Chronic pain. Pain killers. Sick days. Most common cause of job-related disability.

Different cultures use different signifiers for the body. In France, pain in the back is “kidney pain.” It’s the same in Spanish – and now I explain to patients that “your kidneys are actually much higher up.” The left is protected by the rib cage. The right is…partly protected (pushed lower down by the liver. The things we live with that are not symmetrical).This doesn’t particularly matter. In France, there’s also “spleen pain” (la rate). How many Americans could point to a spleen? “Gall” we use for arrogance. “Bile” for anger (interesting relationship).

Actual back pain can be a harbinger of serious things – prostate cancer. Cauda equina syndrome (medical emergency). And just below is S2 to S4 – the pudendal nerve roots – locus of pleasure and of reproduction (in part. neurologically, these are not completely entwined functions. sympathetic and parasympathetic play different roles – the “fight or flight” and “rest and digest” systems).

And the ones who tend to hurt the most are the ones in professions that stand and bend all day. But there aren’t as many studies on farm workers, minimum wage jobs, drivers. The ‘known’ epidemic is the one of cubicles, of delineated squares and desks and noise-unchanging partitions. The sedentary society. This two, becomes a symbol, of being hunched over a computer desk. We make special chairs for that. We make special keyboards. We don’t…move.

Doctors stand. Doctors in the hospital walk, a lot. Rounds mean…walking around, around, around. Pediatrics for the past few weeks has been much less exercise than usual, because our patients are only on two floors. In general, they’re on about ten floors. And we’re always walking quickly. And we’re bending over patients. A lot. And there’s really not an ergonomic way to do an eight-hour surgery. And you can’t move much when you’re scrubbed in. And…and the special-researched shoes for people who spend all day standing are expensive and made for doctors (and other healthcare professionals. I use “doctor” as proxy). Our health “matters”, we invest in it, and there are stores with stylish options. Often located near major medical centers.

Sciatica is perhaps one of the most latinate and difficult-to-pronounce medical words that is spoken colloquially. That it derives from the sciatic nerve is possibly less well-known. That it describes a common type of radicular pain and that there are specific physical exam findings to test for it… it becomes just another word for back pain. At a certain age. At the age of the aging population.

Looking up sciatica and Africa, I find 18 papers. I get HIV and schistosomiasis. And again, the health care providers. A quick pubmed search elicits studies of mostly dentists and nurses with low back pain in Africa.

Of course there are biases: research done in Africa? little. Research done in US? lots. 156 papers. One review paper, looking at research mostly in South Africa and Nigeria, states that rates of low back pain are similar in prevalence in Africa to those in ‘developed’ countries. Fine. I know this very unlikely takes into account anyone in villages, farmers, etc – it’s city people. So maybe I’m wrong, and maybe there’s actually no physical difference, and maybe it’s not developed any differently. Watching the loads of water and laundry that children carry, my wooden furniture friends carried to my house in Mvangan on their heads, and my own improvement in carrying water home without spilling it and with barely touching the bucket…this is difficult to believe.Carrying water, or carrying anything on your head, you discover the sweet spot. It’s much farther back that you would imagine, or than I did. It’s not midline. It balances the kyphosis of the lumbar spine. Carrying that many kilos on your head actually helps you stand up straighter, because otherwise, it’s painful and it’s almost impossible. It takes confidence and a leap of faith in your axial skeleton to put something that heavy that far back on your head. It’s not going to fall. Your neck is not going to snap. Once you learn, it’s the most sensible way to carry everything. (Imagine: city street in residential-ish area, you’re walking or driving, and you see someone who has picked up a free wooden nightstand and is carrying it the six blocks home on her head).

Maybe it really is different in Africa. And maybe it’s not. Maybe, with constant development from childhood, the lower back doesn’t herniate and break and ache. Maybe – just like they’ve shown that smiling more actually makes you happier – standing stretched from the center makes you stronger, more confident, and less prone to injury later. And maybe this is an area of strength that is fading.

Point being, it’s the same locus.

The locus of joyful, free-flowing, natural and difficult-to-accomplish movement is the part of the body with the greatest tendency to injury. In adults. In the US.

Whatever it is has been lost. Or is losing.

~j

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.

Stop being self-conscious. Stop counting steps, stop the 8-counts so many dances are given in, stop marking and thinking “right..left..left.” If you let go of everything, absolutely everything (and this is going to mean a lot of pain and stiffness in ensuing days, for a few weeks)..then you’re doing it, and you’re approximating it if not already there. It’s not about you. It’s not about counting. There is no counting. To dance, you listen to the drum, the drum tells you what to do, you do it, and you become part of the music. If the drum keeps going with a particular rhythm, and you only did that particular step four times in the practicing bits – it doesn’t matter. You keep going. And you keep going and you keep going until the drum changes rhythms. The only way you know what step to do, what to do next, and when to do it, is because the drummers and the drums tell you.And that’s why I stopped going to the other classes. The counting bits felt too artificial, and the dancing itself felt too stiff.

African dance means letting go.

(This will have something to do with writing and medicine. Really. And it’s not even contrived. But if I write all of that at once, it would be far too long-winded for even me. So, I wait).

I needed more dance than the weekly and sometimes bimonthly classes. In the city, there is an amazing place with adult, drop-in classes of every type I can think of quickly. Six, seven studios. African dance – Senegalese, this time – was on the top floor (is, probably). Four to seven drummers, windows open, studio pounding. There aren’t a lot of West African dance classes in any city, not enough to really differentiate levels – or it’s just not part of the culture of it. I don’t know. So this class, the Saturday 4:30 class, was mixed. Professionals – so many of them – on down to me. It was hard. Every week was hard, and then there would be a few steps I already knew, and a few more, and a few more. I went as much to dance as to watch the other dancers. Unbelievable. I learned there that there are infinite ways to do it “right.” Watching. In awe. And learning. It’s joy with drums pounding so loudly and so viscerally that you have no idea how to hear the teacher or to respond to the calls that go with the dance.

I kept going, Malian, Senegalese, sometimes Ivoirien. My last year of college, we performed for hundreds-of-some-number. That must have been the first dance I fully memorized, rather than individual steps.I had wanted to go to Africa since I was young: six, seven, maybe. One major life goal, accomplished. Now, the goal is to go every year that I can – and since (and including) 2005, I’ve been in Africa every year except 2010. I have hopes for 2011. At any rate, dance, and the culture of the dance may have influenced my decision. I don’t know anymore.

Class tonight was hard. The women there have been going every week, at least once a week, for years. They know the dances. For the last two we did, the teacher didn’t even really show the steps, just marked them, and then we were off… and I followed as best as I could.

But then it was the end. The end of every African dance class is a circle that includes the drummers. Everyone, anyone, can go into the middle of the circle and do anything they want. You go with the drums, and the drums are follow. The teacher saw that I was still in the music. She nodded at me. And I went.These are the minutes of zen, of absolute engagement with sometime so much larger than the self. During the class, as much as I try to forget everything, I’m working on learning the steps, on improving, on adding to the repertoire of what I know. But in that circle, everything explodes. Things I remember from – what? where? come back. It’s exuberant. It’s the energy of the past hour and a half of everyone in the room and it’s not me, alone, in the middle, but it’s the total energy propelling me up, into the air (this often involves a lot of the jumping moves. I think several of those must be Malian; they’re the most ingrained. Thank you, Joh). And at the end, she said “you made everyone have to dance tonight.”Everyone made me have to dance tonight.

In the beginning years, I was intimidated by the circles. I was part of the energy, I loved the energy, but I had no idea what to do or what I could do if I ever ventured in. Now, I always go. It’s the homage to the music and the dance and the drummers and the dancers and the connection across time and culture and country and… yes, it’s ridiculous and melodramatic and sappy.It just happens to be true, somehow.

Last night, I went to a Malian jazz show with several Peace Corps friends. We’re from different countries, though all in West/Central Africa. One of the drummers for my class today happened to be the kora player last night. I couldn’t sit. This is often true of me and music, but this was African music, there were drums, and if I’ve learned anything in these 8 years-going-on-9, it’s that I listen to the drums, and I do what the drums tell me to do. So I got up, I went to the back of the room, and I danced. It wasn't all out, because this wasn't a dance class. I was partly marking things, but mostly, I wasn't thinking at all and just doing, gently, what the drums told me to do. For me, that is the honor and the homage that I not only can give but am obliged to give.

(This must have happened during a dance class some years ago, because I wrote it down.)

*

Joh says in Mali we like objects. People, we lovewithout exception.

I know the custom.I kneel, kiss my fingertipspress them to the ground.

*

~j

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 liver* 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…

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-six-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). “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. I leave. Only when I return in the morning and am greeted somewhat grudgingly (she was busy) 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 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. But I did 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.

Anna reminds me exactly of my cousin’s daughter (in France). That one, Catherine, is a little younger. She’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. 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. 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, if only she’d let people….)They’re pretty similar, these too. They don’t speak the same language, not verbally, but I know that wouldn’t matter. If C had a hospital room it would look exactly the same. And her mother would stay, too, and leave when I was in there, and sit and talk to me while her daughter ran around the room. We’d do that.But one is sick and one is not. Anna looks like…well maybe one of those characters in a 19th century novel. One of the little ones with TB, so little, long hair, eyes a little sunken, pale, pale, pale. Those little girls didn’t run around the room and throw things – though probably they did – it just didn’t seem like the thing to write about, at the time. Maybe Beth in Little Women. Maybe the girl in Jane Eyre…what the heck was her name… when she was young. One of the orphans in one of those books, around this age. I’m reaching, books I haven’t read in a decade and a half? More than that, but not quite two. It’s been awhile.

So here’s the writing bit. I realized that she is the little girl from the novelette-bit from November. She’s the girl I didn’t know I was writing about. And now I can write her…Writing does this, somehow. I didn’t even know that girl was sick, but it doesn’t really matter that this one is, not really.

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’s 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.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. 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 while I can write notes, they all have to be read over by the interns and residents and co-signed and posted. Which means that has to happen after I’m done. 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. The ones who are there more often – like the therapists for various things – don’t get that anymore, and don’t get things thrown at them, I don’t think.

These are the good parts. And then I – it might be much easier for me than for her or her parents, perhaps. Probably. – can forget for a bit that she is sick, chronically, and that the rest of them are.

My angry little girl. Not always so angry.

~j

(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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And this is why there’s an incredible sort of intimacy in writing workshops. It’s different than anything else I’ve experienced. The poems are not about the specific thing they are describing are 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 recognized 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

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 1/30th 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

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 – 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.

sketch of Rodin's "La Cathedrale" - my vision of healing hands.

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 year ago, my first clinical experiences. 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

Ok, it’s official, I didn’t win NaNoWriMo this year. (and by win, I mean write 50,000 words in November).It may have been a bit ambitious to take on, alongside third year of med school and concomitant hours in the hospital/studying. Then again, I have been spending an hour – two every day writing; it’s just been poetry or essays. Or researching writing.

I did start. Like last year. I was planning to not write something new – I was either going to revise and finish last year’s novel (now at 65,000 words), work on poetry, or do…something. Else. But I sat down on November 1, taking one of the many, many breaks that are scheduled during anesthesia (seriously. The attending come into the OR every two hours. “Want coffee?” “Want more coffee?” “Have you had lunch yet?” Etc. No other specialty does this. I can imagine the surgeons glaring or snickering behind their masks, after they’re been standing for 8 hours without relief. At any rate)….

And a voice was there. So I started to write. It made me feel a little bit smug about my development as a fiction writer, as the voice arrived in first person and she is most definitely not me. Last year, I had started in first person and had to switch to third to keep myself out of it.It’s an interesting story, maybe, though I don’t yet understand what’s happening, at all. I’ll finish it someday. The characters are: the main character, a little girl (nameless so far), the president (maybe Obama, probably not), and a few three-headed, wooden dogs. So far. I appear, as well, as a bystander at one point; I’m not sure if “I’m” going to be a recurring character. (At least, it’s someone who looks like me at a very particular point – ie, in Zoebefam when I was building the water project there. Only time will tell, I suppose, if it’s “me.”). This was a very different experience, in terms of writing – last year’s came to me in words. It’s very fluid, very poet-y prose, perhaps Jeanette Winterson-ish (if I flatter myself. All my influences are somewhere, after all). This year was all images, like I was flying/gliding somewhere and just writing down everything that I saw and encountered. And it makes no sense. This story takes place in a world that is magical realism, perhaps, in another time period, perhaps. It seems to be some sort of speculative fiction – a genre I’ve read only small amounts of and do not know much about.

A sample of this year’s story, somewhere beginning-middle-ish: (Context: I have no idea).

The girl looked strangely familiar. She probably lived in a candlestick. She walked toward me with a bounce, little flaring navy dress over transparent knee socks. Looking back at the president, his hand came off in her hand and she continued, unconcerned. The girl started floating a little, like the hand was attached to an invisible balloon without a string (and what do we need strings for anyway except cheese and hamsters?)

Looking into glass, she bit my ears. “This isn’t a wishing well,” the little girl said, “but I’ll throw coins on you anyway. Are you made of stones or salt? I’ll try not to melt you.”“How would I know if I melted?” I asked her. This sounded concerning.“Do you carry an umbrella?”I looked at my elbows, Nothing there except some trailing ribbons.“Then probably you don’t. “

Compare with last year’s random sample:(context: Sera, main character, just smashed her finger into a wall, and she’s watching the skin change colors. This is from the middle/end of the scene).

Prisoners, tower-locked in membranes. Not the ones filling her skin. Catabolism – sanitizing catastrophe. Reversal of what is expected, from katastrophein down and turn. Strophe like ballads. Body like dead.

Delicate cleaving, coordinated cycles. Green comes first, biliverdin (Verdi like spring), carbon monoxide floating into tissues. Silent killer. Verdin turns to rubin, darkened red stone, breaking cells – monk-like chambers - into light. The white carriers, protein, to eat and build and break, albumen from alba, docks filled with too much color. In bodies red and green makes yellow, turning eyes and skin to gold.

Insensitive, unseeing to the slight new crook in the bone, Sera went to X-ray to earn more narcotics. White on black, gray for fat, water that wasn’t water. Photographing bones. Calcified proof of how long it would take you to dissolve.

The mind is strange and fascinating.

...And then the patient who does not have schizophrenia (who I thought, previously, likely did).

This is relieving. I’ve been seeing him most days for the past few weeks, over which time he’s come to think of me as his psychiatrist or similar. – No, I never told him that, and he does understand I’m a student/in training. I am the one who recommended staying with the first drug regimen and adding one, though. I am the one who wrote the initial psych note and the follow-up notes. And somehow, somehow, this is counseling. Therapy. What I do with him, what we do. There was a study that did a case-control (not double-blind, but…something) on therapy with trained professionals versus therapy with other sorts of professionals masquerading as therapists (ie, architects, scientists…whomever). The patients did decently well. I’m not saying the discipline is useless – I believe the contrary, these days, actually. It is specialized, it is important, and the drugs can and do work.

Point being – part of the whole deal is just having someone to listen to you, who cares and is all-in. Who’s unbiased – as much as any human can be – because the only context in which they know you is what you’re telling them. They might get collateral (friends, family, previous physicians). But in general…

So I sit, in the yellow disposable isolation gown, with gloves on, and we talk. He talks, I ask questions, sometimes. The narrative bit is amazing. I have the agency to ask And then what happened? It’s an unfolding story to me, and somehow, in the telling of the story, he feels better – he says, at any rate. And I don’t think he has schizophrenia. Something, certainly, but it doesn’t seem to be that. One of the psychiatrists who taught us a few years ago called it the “cancer of the mind.” True. Not for everyone – some people can recover from an initial episode of psychosis, and that’s it, or maybe they’ll have another one far down the line. That’s not what we see as often, though – but working in the hospital is its own bias. We only see the people who are sick.

(banner below is from AIDS Action Committee's website. Because I think they're really cool (used to volunteer there)).

......And I’ll segue into World AIDS Day, a thought debate on does-this-sort-of-“visibility”-help-anyone, and December.

Addendum on the One Campaign – as far as I could understand, in 2005, their main message was “Africa is poor. Africa has AIDS.” Both of which are DUH, as in, clichés in language, at any rate, empty of meaning, digressive, pejorative, and oversimplified. Take that. But THEN, you get celebrities to play concerts around the world, bringing together tons of liberal, left-leaning, world-loving young adults to chant “Yeah!” to that sort of a message. And you don’t harness the energy. At all. You don’t use it to raise money. (“Awareness” in that arena is… what. Meaningless, in any manner I can see. Maybe someone with far more vision than I could create something spectacular). So, money. Volunteer hours. Donations of other sorts. ANYTHING. Millions of people there for free. Nothing happens. Except they buy rubber white bracelets, maybe (are those still in fashion?) And they go home feeling good about themselves. It’s like expensive shoe stores in Berkeley or similar telling you some minuscule percentage of the shoes you buy goes toward breast cancer research, or something. So you feel good about going shopping – there’s your good deed for the day. (at least that’s raising something for something. maybe. maybe.) At any rate.

I work in an HIV clinic in the states, now. This is a poor town (where I am currently). These patients do not have much income, and they get assistance from the Ryan White foundation (and federal) for ARVs and such. There are social workers in the clinic, case managers, a psychiatrist, nurses who do home visits…And the patients look good. They look damn good, in fact. For 90%, you’d never know. They may have presented with AIDS, even, cachectic from tuberculosis or PCP or something in the hospital. Then they got into a care, on a good regimen, and they got better.And damn, they look good. They come to the HIV clinic, get refills, basically, and take care of their hypertension, diabetes, hypercholesterolemia, insomnia, depression, chronic back pain, headaches, sore throats, etc, etc, etc….

We give them graphs of their viral loads and CD4 counts. This is pretty amazing to see, too. They look good.

In Cameroon, I did see some who looked good. And I saw a lot who didn’t. And I saw a lot of babies die. (Another day. Another day). World AIDS Day? It’s pretty incredible what’s happened here. I won’t say it’s not. It’s absolutely incredible what the transformation has been, from GRID to the 1993 HIV/AIDS definitions from the CDC, ACT-UP, AIDS memorials (movements that did, I think, do something), the literature of HIV of that era (Mark Doty. Thom Gunn. Etc…), Angels in American, And the Band Played on, Rent, even... We’ve come a long, long, long way. So it’s easy to forget sometimes. Even fellows doing infectious disease/HIV don’t often see the kinds of opportunistic infections I’ve seen (wow, lucky me). We should celebrate the progress. We should disseminate the progress by figuring out ways that make sense to do that for other countries. And we should show the rest of the world – the southern world, the developing world, whatever – how well people can do with ARVs (HAART), and how well life can go on. This is the reality. “Poor” and “AIDS” and “Africa” have lost all meaning in connection to each other.

Far away, on the forgotten continent, who remembers Africa as more than a pop cause?

~j

And I leave you with a photo of my health club in Cameroon, performing a skit they wrote for World AIDS Day. December 1, 2006. (friends of mine). Below.

I feel bad. Guilty, 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.” 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 think a lot about “for better or for worse” these days. In medicine, you see a lot of “worse” and “worse”, and I see a lot of partners who are there for both. For anything. Siblings, children, grandchildren, nieces, nephews, friends. I guess these would be the ‘chicken soup’ or whatever stories (are they even still publishing those?) But it’s true – rushing around, where so many things are difficult and sad – it’s something to stop and think about. Or try to remember to stop and think about. With the sickest patients, it’s their loved ones that I know. The ICU patients, the altered mental status patients, dementia, kids…whatever. I’ve spoken with a lot of family members. In anesthesia, wheeling people into surgery, you leave Loved Ones at the corner. (They call it the ‘kissing corner.’ Really). And you see them into the waiting room, point it out, say go get coffee or whatever, we’ll be ____ hours, and don’t worry, we’ll take really good care of X. Your X. I’ve seen the wide eyes when we push through the doors again, X is barely waking up from surgery, likely has an oxygen mask over her face, and we’re rushing into the PACU. It doesn’t mean anything’s wrong. It’s normal, and it means the surgery’s over, and if people don’t look like they’re freaking out (The doctors), everything is probably fine. It’s a vulnerable position to see someone in. And in the OR, they’re alone.

There’s the couple who came in with the wife’s entire medical history typed out – each had their own version – with a list of questions. She suddenly went blind, no one has any idea why, no one has any idea if it’s part of something more progressive – probably. So they’re searching. And with each doctor, they get more frustrated at not having answers. But the other point, to me, is that it’s always both, it’s really about their health, and the patient is – almost – both. Making sure you do speak to both.

There was the man whose wife died of ALS (Lou Gehrig’s disease). She lived with it for twelve years, far longer than the average prognosis. At the end she was, as they are, completely paralyzed, ventilator-dependent, and could not speak or do anything independently. He ran marathons with her – there were photos of the special chair he ran with. For ALS research. There were vacations…. everything you can imagine that is so hard to imagine in those circumstances. So when she died, he wanted to donate all of her special equipment (hundreds of thousands of dollars, I think), some of which he had designed or modified, to other patients. He drove across the country with this. He’s still working with ALS.

And there’s the patient who had a second stroke on top of her first one and was almost comatose. Before the second one, she and her husband had been living with their daughter, just while she was doing rehab. He kept trying to convince us – again, again, again – that she was fine, that they could go back to their own home. They’d been together over 60 years. All he wanted was to take her home. And then there was the second stroke, and she wasn’t talking but I saw him every day, the daughter, the granddaughters. He left to get food sometimes, when his daughter was around. Otherwise.

There is love in medicine. And it’s the patients who don’t seem to have that support who are the hardest, for me. Almost doesn’t matter what the diagnosis is. When you can’t send a patient home because there’s no one to help, there, or the people there will not help… it’s hard. And it does change the medical plan. It’s been gratifying to me to realize how much this is taken into account. Teams don’t – or try not to, anyway – discharge patients without knowing where they’re going, and how. (and yes, then they pawn the patient off onto a social worker. but that’s why everyone is expert at different things).

But medicine has to be a little bit about love. It has to be about healing. When we’re in surgery waiting for pathology to call back – cancer or not cancer – everyone is holding their breaths, a little bit. Everyone wants to know what is finally said. And yes, people get jaded when they are overworked and overtired and it’s overwhelming to care individually about every single person in a day that you’re caring for, and if you’re in the hospital, some of them will die. I’ve heard people comment about the annoying paperwork of death certificates, rolling up the sheets (like we do with everything else) and sticking them into a pocket. Everyone’s job has lots of paperwork and bureaucracy. In this job, the papers can say things like “full code/do not resuscitate/ do not intubate.” A progress note can describe a scene of death, at what time, what exactly happened, who was there. And it can also describe a birth – clinically, the first moments of someone’s life, and not just that but exactly what happened before. And who was there. And what happened. It’s a little bit of personal history before the lungs are even shocked into expanding and the fetal vessel connections close, and, and….

This is our bureaucracy. This is our paperwork. Birth, death, prescriptions, and “orders.” And “progress notes.” And more “orders.” To me, it’s a heady thing to decide how much pain medication to give someone – what drug, how much of it, how often can they take it, and how many (the decisions are often left up to me, with the attending shrugging “sure!”. Then the attending signs the prescription I’ve pre-written). I write admission notes and orders, and yes, everything I do gets co-signed, but not every resident is going to re-read every line. I wrote out the medications and dosages. It seems like a small thing, maybe. But from my scrawled handwriting, faxed to the nurse’s station, to the patient’s chart, to the pharmacy… I’ve decided something, I might have changed it, I might have screwed it up. I decide a lot of things for patients, now, and as long as it’s a “fine” idea, it generally gets signed. There are a lot of choices, a lot of not-right/not-wrongs, and it can be unnerving. For another patient, her subspecialty doctor decided to proceed to surgery for her rather than medical management – based partly on my exam. My exam which had not been verified, up to that point, but done and recorded by me. I was terrified of this responsibility until we went to the other specialist who confirmed my exact findings. I wasn’t wrong. But I could have been. Easily. (and residents are, too. and attending are. this happens). There are so few things directly in my control, currently, that each thing that is can be terrifying. Shattering. What if I’m wrong. I’m in no life-or-death position, yet. Yet. It’s really not very far away.

*

Another patient hugged me today.

I’m not exactly sure why. I told her nothing was abnormal with her on my exam – which sometimes, under the circumstances of having annoying/uncomfortable symptoms – I would think would be frustrating to hear. Apparently, she had been worried about “something wrong”, however, even though she hadn’t said it. And so she hugged me.This was in urgent care – we hadn’t talked for more than 10 minutes, my whole exam was five, then 2? 3? discussing results and giving her a prescription. And she hugged me.

Another patient today, when he started discussing serious depression (this is not in psych clinic) said “wow, I’ve never talked about this with anyone before…”I get that a lot.And it sure as heck is ego-boosting.

Is it true? Who knows. Yes, probably. But it’s the white coat, the concerned look, leaning forward, attentive body posture, language (is it true? Yes……is it true every minute? …no). I am listening, caring, I am making notes. I’m also conscious of what I’m doing, though it is becoming fairly ingrained. (And I have an agenda, and questions I want to make sure I get to, I have a time frame, and I do have to redirect and interrupt). It’s not anything anyone can’t do. The mistake people make sometimes is forgetting all the human skills they already have, had before medical school. The best, most rewarding, most meaningful things I have managed to do, have, for the most part, drawn upon things I’ve had for years.And maybe I’m more comfortable now than I was pre-med school in discussing difficult topics.

I’ve got the… license to do it (technically speaking, 1/3 medical license). I have gone through all these years and still am going through them in order to be…trusted? Trustworthy? Organic chemistry certainly didn’t make me that way.

I am engaged in each encounter. I try to be. But there’s also the walking briskly down the halls, always, around people in the hospital, looking busy-and-important. And trying to read my watch while a patient goes on and on and on because I’m going to be late for rounds and I still have to write down the vitals and the labs and do my assessment and plan and I have to present and I’m already supposed to be on the 9th floor and I keep interrupting anyway but…

*

In a hospital (this isn’t true of all of them) with widespread, good, easy-to-access wi-fi and cell service, I walk down the hall reading and answering email (thank you, ipod touch, and medical school that requires PDAs in the third year, and younger sister with a job and a penchant for buying the latest gadgets and sending the older ones to me…). I know where I’m going and I don’t need to look. I can do this at the same time, and I’m not wasting time. I’ve walked down the hall writing progress notes, before. It saves time. Today, between 7 am and 4:30 pm, I found 5 minutes in which I could – between dropping off orders on the second floor and running back to meet my resident in the ER – sit for 5 minutes and have cereal left in the resident lounge. (This is a sometimes-but-not-always-necessary occurrence. As is the 4.5 hours of sleep – some things are self-inflicted, as I sit writing this rather than reviewing current guidelines for opportunistic infection prophylaxis, adrenocortical insufficiency and leukocytosis, or TIMI scores. Or differentials of syncope and alcoholism and dehydration. Or bullous pemphigoid. Or altered mental status.)But I digress. AGAIN.

Here is an interesting exercise. “What is your name?” Correct answer. “How old are you?” Correct answer. “What is the date?” Confused mutterings, similar to “what is the day?” and “where are you?” This is where, in psych, we start in with choices. (Psych or neuro. same diff). “Okay. Are you in a store? A hotel? A hospital? your house?” Still no answer. I think maybe next time I’ll make it more interesting and add zoo or something…. heck, I have a friend whose grandmother had Alzheimer’s and lived in a delusional world that consisted of a perpetual cruise ship. Not bad, as far as delusions go).Yet – the patient knew – “What city are we in?” “What state?” and “Who is the president?”

The things we retain.

~j

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

In brief. Before we take off on 30 days and nights of literary abandon (NaNoWriMo.org , thanks for that phrasing and the Office of Letters and Light reference), something on the importance of writing. Writing is important. (and..done). In science, I fight the stereotype that it's not. That literature's not serious. That pursuits of the arts arenot (as) important. That "easier" physics is "physics for poets." The easy, blow-off majors. Can't be serious if it requires fewer credits (college) and doesn't include hours drudging in chemistry labs among fumes and uncomfortable metals stools.

Writers change the world, too. Writers dictate what we know about the world, everything that we cannot directly ascertain for ourselves (which is most things). Speechwriters, copy writers, editors, blog writers, journalists (obviously) - influence. Everything. I was influenced in no-small-way to work with the Obama campaign, to go to Chicago, after reading Dreams from My Father. In medicine, every single thing we do with a patient, we talk about, must be documented. Is written down.

But that's "non-fiction", if such a thing, complete objectivity, exists.

(even in medicine - it's fascinating, reading through a patient's record, to see how the past medical history/family history/social history "changes." As in, that particular writer asked different/more questions, didn't ask/wasn't paying attention, or the patient said something completely different. )

Sumerians, Hammurabi, hieroglyphs, Rosetta stone.

But fiction changes the world, too. It's how we learn about different cultures, different ideas, different times - stories, personal ones, are what make things poignant. Make them stick. In getting into a character's head, you start to understand - something - else. It changes the reader and it changes the writer. And poetry? Poems are listening, seeing, paying attention in a different kind of way, and trying to connect with a human experience. Reading and writing. The ether, the Jungian collective consciousness. To write more about poetry, I really need to reread Plato.But I digress.

Whatever it is you write, fiction/not, 50,000 words/not, handwritten, typed, online, in a letter, in an email. it's important, it's November, so - write.:)

~j

(of corporate America)

(and peer-reviewed medical journals)

Stop. Advertising. Anti-Psychotics.

...and every other drug.

More soon.

~j

In a discussion of DSM IV axes of psychiatry, Dr. A, the department chair, asked us what we thought the most common psychiatric diagnoses amongst physicians were. We came pretty close to guessing. His top 3? Obsessive-compulsive disorder. Masochism. Narcissism.

The first is probably self-explanatory. The second…in brief… is related to the extremely delayed gratification process we willingly go into. I’m not sure any other career (tell me) is like this, in the time between deciding what you want to do, the years and pre-reqs until you can actually start school, school, training, and practicing on your own. And the hours, oh, the hours…Between my starting pre-med classes and finishing residency, at least 14 years will have elapsed.(it is possible to do a bit more quickly. But not by a lot, actually. Shortest duration would be approximately… 9).

The third. This may seem interesting in juxtaposition with masochism, but I think it goes along with a martyr complex. Do we talk about the hours we work? How hard it is? How much debt from school? The pay in residency, which works out to close to minimum wage, calculated per hour? (assuming 4 weeks vacation, 80 hours per week (and it’s really closer to 100), not taking out taxes, hourly is about $11: 4 years of college, 4 years of graduate education, and an MD). (I just said it). Do we complain about pre-med classes, in particular organic chemistry, and the weeding-out process that does make things brutal, demoralizing, and…just…mean at times? (Professor for my second semester orgo lab course – “congratulations! You’ve made it this far, we don’t have to weed you out anymore. We’ll stop deflating grades.”). To get into medical school, we take an 8 hours- straight – test. It’s not that it’s hard. It’s about endurance. So much of this is about endurance, sacrifice (because of the god/martyr complex. Because you’re going to be, to do something “good” in the world). Do martyrs complain?Maybe.

But this goes along with narcissism. It’s a very elite club. We believe we’re “special.” And, as Dr. A said, we’ve grown up being told we’re special. You’ve got to be high achieving for awhile to get into med school, later. Not smarter. More competitive? Harder working? Maybe. Goal-oriented? Yes. And getting in – well. Families like to brag about that. There’s an awe, a halo, a cachet about the profession. We’re “special.” Orientation week, we were already in the alumni association (true). We had a white coat ceremony – a whole ceremony, with parents/etc, to have our advisors put the *&^%#$$ (my current feelings about them) white coats on us as we walked solemnly across a stage. And then we repeated, solemnly, the Oath of Lasagna (formerly…Hippocratic. This is the updated one. And yes, it’s really the oath of Lasagna). You get a new name when you finish medical school. My preceptors, many of them, will walk into a room and say “My name is Dr….” (Somehow, I prefer “I’m Dr….”. Yes, you are that. But saying it’s your name? As if you were born with this, this indelible…? Maybe the verb “to be” seems more permanent than “name.” Maybe it’s just me). PhDs don’t get called doctor as often. My patients often call me doctor, even though I do tell them I’m not one. Nurses will call me doctor, and I tell them too. (Some get annoyed, sometimes, asking me a question, calling something to me, “Doctor!” when I’m sitting down, back to them, reading a chart. I don’t turn around. Talking to me? Must be someone else. “Doctor’ isn’t my name anymore than Ntangen was. It’s not their fault. They don’t always know my name. And calling out “medical student” might sound odd. But I’m not in the habit of responding, anymore than I would respond to someone else’s appellation).

Our entire lives, we have been told we’re special. We’re “special.” And then we enter a profession in which we are allowed to defy societal norms of behavior, every day. I walk into a room and tell someone to take off their clothes. Do they? Yes. Do they let me touch them? Yes. Granted, it is with a therapeutic purpose, and that’s why they came to see me in the first place. Particularly in exams where they can’t see my hands, I tell them “You’re going to feel my hands now.” Or “I’m going to start by examining your neck.” Or your eyes. I ask questions that, if I asked to any other strangers, I would get yelled at, hit, or thrown out of the establishment (potentially). At the very least, people would probably walk away. While examining…say, a person’s abdomen, if I see a scar (particularly if the patient told me she had never had surgery – this happens more often than you might imagine. People forget. A lot), I ask “what’s this?” “What happened?” And they don’t get to ask me questions back – though sometimes – very benign ones. And they don’t get to touch me.

We think we’re special. I was thinking about medicine in relation to massage, the other day. Supposedly, doctors have “healing hands.” (some surgeons insure their hands. I’m pretty sure this is true). Overall, in the grand scheme of things, yes – things doctors might find with their hands could lead to serious findings, could lead to healing. But our “healing hands” often cause pain. During the exam, discomfort, at the very least. If I find something that hurts, I’m going to press on it at least twice. I need to check. And then, again – “does it hurt more when I press down, or when I let go?” After a visit to the orthopedic surgeon, my hands ache – a lot – for at least a day, if not more. Does this hurt. “Tell me, if at any time, this hurts.” And I write it down.

We have the power to inflict pain. “Things that are good for you.” Injections. Drawing blood. Procedures. I like procedures. I like having practical skills. So, do I enjoy lancing the abscess, doing the incision and drainage (I&D)? Yes, I do. Did I enjoy doing my first paracentesis the other day? (after ultrasound, I used lidocaine to numb the skin of the patient’s abdomen and then stuck in a large bore needle to draw off fluid from his ascites, 2/2 liver cirrhosis. At least 5 L of fluid. Getting the fluid out helps him breathe better, be able to walk without stopping to catch his breath every few feet, being able to sleep at night without waking up, gasping. He knows this. I know this. But when I put the needle in… victory! For me. Pain – for him.

One of the patients I I&D’ed asked me if it was the worst abscess I had ever seen. Well, it wasn’t, not remotely, and I told her I’d seen worse. Did she want to hear that, or did she want to hear that she was “special”, too? I hastily reassured her about her pain – I know it’s very painful. Can’t intimate that this is, should be easy for her. I learned suturing on foam, then pigs’ feet, then patients in surgery. Now, I do it on patients who are awake. We tell them, the lidocaine, the numbing medicine injections, hurts more than the procedure itself. Is it true? I don’t know.

Surgeons, actually, don’t inflict pain. It’s much easier to forget that the space you’re cutting into, that layer that takes a little pressure from the scalpel to slice neatly through and start spreading open layers, separating beautifully….Is human.It’s draped. The surgical field is draped in blue, there’s a hole, and that’s where you cut. The hole might actually be sticky plastic wrap, which helps keep the skin in place and keeps the area a little neater. Slice through the plastic. Into the skin. You can’t see the patient’s head – anesthesia gets that, on the other side of the curtain. It’s not sterile on that side. But to anesthesia it looks like a head with tubes sticking out of it, maybe, eyes taped shut. Things beeping. Lots of machines with things beeping. And vacuums and containers and things flowing out of tubes, and the smell of the cautery…maybe not everyone wants all their senses engaged with this one.

I will always be grateful for the first surgery I observed. This was in Mvangan (Cameroon). I won’t say “scrubbed in on”, though in American parlance, I did. I walked in, wearing sandals. December 30th, 2005, must have been. It was the same day I left village for the first time after moving there, going up to Ebolowa to celebrate New Year’s with other volunteers and some of our Cameroonian friends. Doc knew I was interested in surgery, so he’d invited me in – I was hesitant, the first time. He was scrubbed, and he was the only one in scrubs – no, maybe Eco was too (first assist). The room was hot, humid, in the perennially 85-950 rainforest with 90% humidity. Approximately. No screen on the window. No power – but this was daylight. We did have sterile drapes. No general anesthesia, without electrodes or intubation or any other way to monitor. It was ketamine and..something else…that I wish I remembered. Description for another day.The patient, 30 or 40 something year old man, had been in a moto accident. His bowels, perforated. Had to be fixed. They had trouble putting him under – everyone was saying he must use drugs, he must, he must – they couldn’t do it. He wasn’t lucid, but he wasn’t completely out, either.And so for the entire operation he was moaning. Moaning as he was cut into. Moaning as he was eviscerated, bowels piled on his abdomen as Doc searched for the defect. And then he started kicking. Knee into Doc’s stomach. I reached over and grabbed his leg, held it down, whicle the surgery was finished. No one in that room could ignore that this patient was alive, that what they were doing, this violation of bodily integrity and autonomy in the purpose of – to put it succinctly, playing god – was to someone with a beating heart. Whose lungs were function on their own – proof, the moaning. Proof, the kicking. ABCs? Check, check, check. He was alive.And he lived.

When you’re operating – open, laparotomy – on someone who is moaning, you know you’re inflicting pain, you know the pain will be even greater when they wake up, and you have to concentrate even more (I imagine) on the task at hand. With a patient fully sedated, you can focus. Hands. Anatomy. Moving things carefully.

I do remember that day. First worried about what my own viscera would do when faced with…viscera, outside of another person’s body. But then, you do what you need to do. I wasn’t quietly in a corner, holding a towel over my hands if I hadn’t scrubbed. Trying not to fall over , standing for so many hours, as I kept shifting my weight. I was there, I was active, I was doing something basic to help. Keep the patient from kicking the doctor whose hands and knives are inside him. Can’t get sick when you’re concentrating. And not a single thing about me was sterile. My hands to his foot. That, too, is necessary.

~j

One year ago, a friend challenged me to join her in National Novel Writing Month (NaNoWriMo) – which occurs every November. (www.nanowrimo.org). It started in SF ___, and the point is to write 50,000 words in November. We were, then, in our second year of medical school.I’m mostly a poet (a year ago, I might have said “only”), and, a year ago, I’d never written any hold-together-able short story – that is, beginning, semblance of middle/end – longer than 2000 words. If that. But rather than turn down a challenge….

Before November 1, I was terrified. I had no idea what I was going to write. Could I modify it and try for 100 poems? Write something non-fiction about Peace Corps? Try to write some short stories? How could I write a 50,000 word (that’s about 200 pages) story when I had no plot in mind, nothing, nothing, nothing….

Then it was November 1, and, while sitting in a café, (s/p a Book Festival – perhaps that helped with inspiration, too) – a voice started telling me a story. And I wrote it down. I didn’t even know (her) name for a few days, not until she went to work and someone called her by it. And I didn’t know exactly how things were going to turn out in the story (I still don’t) until about 2/3 into November. I didn’t figure out her motivation (ie, she didn’t reveal it) until about that time, or later.

And it was an incredible and thrilling adventure. Every night, sitting down to write (tried for an hour a night…sometimes made it… and more hours in the end) was like sitting down to read a book, because until I started typing, I had no idea what was going to happen. Somehow, somehow, I got to 51,000 on November 30. I’m around 60,000 now on that one, with more to go – and a lot of cutting and editing to do.

And my friend and I both won – ie, we got the 50,000. Together. (or in tandem). It was an amazing month. It’s like being part of that collective unconscious (…Jungian) into which we were all tapping, everyone writing, all having this experience. It doesn’t really matter what you write – that matters to you, and the transformation matter. It will happen. It’s not about being “good”, technically or in whatever other aspect.

Writing is a way to discover things, explore new ideas, employ and exercise the mind and imagination. And when you let yourself go, with abandon, without self-consciousness, there will be new thoughts, new connections, new solutions that you could not have pieced together otherwise. The beautiful thing is – when you’re going for word count – you’re certainly not editing, because that takes away words! That can happen later. Just write, write, write. And don’t self-edit, limit, or stifle.

It’s how I see African dance, in a way. To do it – to really do it – you have to let go of everything. Everything. There is no counting, there is no self-determining of beats or numbers or rhythms. The drums determine. And by following the drums, you become part of the music, you are reacting to it and you are in it, you are integral and integrated, and you can’t think about how you look or what you’re doing or how you’re doing because something else is driving you. And that, precisely, is when it becomes right, exquisite, and everyone is doing it slightly differently but it’s all beautiful and all works together as part of the whole. As such, writing does not have to involve conscious thinking. It comes.

You don’t have to do NaNoWriMo in the haphazard way I did. Some people are capable of planning or prefer it that way. Or you don’t have to plan at all.You can start pondering now. Or wait until Nov 1, waking up….whenever… and do it then. Or a few days later.

You don’t have to write fiction. One friend just said she might try it with letters. Write ideas. Whatever. And even if it isn’t 50,000, for November, it could be a goal to try to write something every day (which I’d only once before even had the discipline to do. As someone who tries to be a writer….)

Both my friend and I, now in our third year of medical school, are going to try again. We might not finish this time, but….that doesn’t matter as much as the process. I did this because of her, last year, and so this year I really want to recruit more people. Anyone. Everyone. And yes, everyone can write.

Just write.

~j

Somehow the neurologic exam is the most intimate.

You can lie on psychiatry exams. (And maybe experienced psychiatrists can always tell. And sometimes I know, even, based on demeanor, hedging to questions, changing flavors of answers, and the previous records I am privy to. And yet I’m always surprised and amazed at how many answer my so personal, so intimate questions. Would I, in half a curtained room, to a stranger in a white coat who drags a heavy chair over to the side of my bed while I’m dressed in a hospital gown and looking slightly helpless and mostly naked underneath? When this person has woken me up because one of my other doctors thought I needed to talk to a psychiatrist, and she isn’t even a doctor? (not that most realize that. I never tell them I am. But people assume…either I’m a doctor, or I’m a nurse, they think, or, occasionally when doing psych, a social worker) And later, when she comes back with five people, all crowded around the bed in half a room divided by a curtain and not sitting down but leaning over me? (I hate that part of psych rounds). No. No. I don’t think so). Both neuro and psych are examining your brain. With neuro, I'm examining parts you don't know about, and you might not know that any of them have problems. Or you might. With psych, at least some things you are aware of. Mostly. I'm looking into your brain. With psych, I ask questions that give you some idea what I'm asking about, what I'm wondering about, what I might be thinking. With neuro, you generally have no idea what I'm looking for.

Somehow the neurologic exam seems more intimate, to me. We’re both actively involved, in this one.

I’ve started to care more about appearance than I did before. This applies more to ‘professional’ life than other, but still. I’ve been lucky and spoiled and allowed to continue for awhile without “growing up” – that is, having any sort of traditional-ish job in an office with colleagues and clothes. And clients. Labs don’t give you that. (And I loved that. You come in when you want – after all, you’re designing your own experiments – and you get your work done in a time frame that works for you. Some people in my lab did their 12 hours cell checks at 8 am and 8-10 pm; mine were closer to 10,11 am and midnight… or on later days…2 or 3 am. And clothes are…whatever…and covered if you don’t want caustic chemical stains on them. My blue tie-dyed lab coat sufficed when needed. And when your PIs aren’t there, you have music on. Nothing and no one is looking at you closely; instead, you’re (if me, again) peering into a microscope at 100,000 x magnification or something to look at fluorescing mitochondria. I scrutinize them. I scrutinize everything. Nothing does that to me) Five years of independent researching, writing, and consulting don’t give you that. Teaching MCAT doesn’t really give you that. And Peace Corps – I may have been second in command of a health district, but – chacos it was.

Things are different now. And patients think I’m young – certainly, I am younger than most of them. I’ve had a handful – maybe ten? Fifteen? patients who were both a) not pediatric cases and 2) younger than me.

Things about this job include: people stare at me all day. In fact, I tell them to. At close range. A lot. “Look at my nose.” (it’s a central point for them to focus on while I examine their pupils and extraocular movements. Part of the cranial nerve exam). I get pretty up close and personal. For the ophthalmologic exam, for even the ear exam, the side of my hand is resting on the patient’s cheek. But I’m the one doing the touching, they’re not. I always have a hand on the shoulder when I listen to lungs. Reassuring? Maybe. When I do the abdominal exam, I’m not looking at my hands but at the patient’s face. This is how we judge pain. Subjective. Objective. It matters, a lot, when the patient describes 9/10, 10/10. We will address that, we will try to control that. But in terms of figuring out the disease process, you know by watching the face as you press and press harder. Patients are stoic. It still shows, the eyes, the corners of the mouth. If they almost jump off the table. You know if it’s involuntary. And you know how worried you should be. But this doesn’t seem most intimate. Even GU (genito-urinary tract) exams don’t seem as intimate – not to the practitioner, at least, maybe most to the patient. It’s all clinical. Again, assessing facial expressions for “TTP” – tenderness to palpation. Pain is what a patient tells you. Tenderness is what you see and feel. Again, if something is very TTP, or feels concerning and is not TTP (this is actually a worse sign, in general), I’m going to repeat it. At least once. I have to be sure. And this “healing touch”, these “healing hands” do inflict “pain” (we call it discomfort. You never, or almost never, tell a patient a procedure is going to be “painful.” It might be a “little comfortable.” Mm-hmm. Experience is starting to not feel like a hypocrite or a minimalizer while saying that. Realizing, though, that it’s more to put patients at east and less anxious rather than trivializing the “discomfort” or denying that we do, indeed, cause pain. With purpose, with long-term purpose. But it is and can be pain. Depending on the person).

The neuro exam includes presuming yourself as the normal point. I, the examiner, become the standard.

I test visual fields to confrontation of my visual fields. (assuming my peripheral vision is normal). Strength to my strength (how far can your muscles resist my pushing on them?)Everything is about how I see, how I touch, how I hear, occasionally how I smell (transitive verb. Fruity breath means ketoacidosis. etc…), and, used to be, how physicians tasted things (diabetes mellitus? it means sweet urine).

I am the neurologic normal.

Supposedly.In neurology, there are five basic senses (in the test of sensation. The cranial nerve exam is slightly different). Light touch/vibration/proprioception are the large nerve fibers. Pain/temperature are the small ones.

Light touch. (my fingers, or gauze, touching you delicately down your face, arms, legs. I’m sliding, lightly. Do you feel this? Is it the same on both sides? Different?)Vibration (I strike the tuning fork on my elbow, place the end on your arm. or leg. or face. Same questions).Proprioception (joint position in space). (Close your eyes. Relax your fingers/toes. I’m going to pick one up, hold it carefully by the joint, and move it up and down. Which way is your finger pointing? And now? And now?) This sense can be lost. People can lose their knowledge of their bodies in space, when they don’t have visual cues. Pain. (I prick you. Do you feel this? What does it feel like? (…”you’re poking me with a needle. Ow.”)…yes, yes I am. I usually make a joke about me torturing them, or something light along those lines).Temperature. (Back to the tuning fork. It’s cold, it’s always cold, that’s why you can use it for this).

There are strange questions like: “close your eyes. am I touching you?”

People often don’t realize what they’ve lost, unless it’s completely numb, unless it’s tingling or hot or in pain. Recently, I had a pt who didn’t realize he’d lost pain and temperature in part of his body until he couldn’t feel them on my exam.

Romberg: stand up, arms out in front of you, palms up. I’ll stand behind you. Now close your eyes. (And I will push on the you. Front. Back – this I don’t say. This is a secret). Do they stumble? No? Good. Otherwise? Well, the plan is I’ll catch them…

Even reflexes become intimate. It’s not just the hammer-on-knee that everyone thinks of. We check five normal – biceps, triceps, brachioradialis, patellar (there’s the knee one), and Achilles tendon. Problems with those, we check the pathologic ones (ie, if you have them at all, you have a neurologic disease). But it’s not hammer to tendon. We grade reflexes on how “big” they are of a response. On both sides. On all people we touch. How do you know you’re always hitting with the same amount of force? Easy. I hit my fingers. I place my two fingers on the tendon of the muscle I want to check, and I hit my fingers. Reflex happens. And I can judge whether I’m hitting myself about the same every time. My fingers.(there are a few more normal reflexes that we don’t…generally check… sig. cremasteric. anal wink. abdominal…)Sometimes I will hit your forehead with a hammer. Sometimes I will hit your chin. (Still over my fingers. Still).

and I’m sorry about the foot scratch. Really, I am. And I know I’m dragging a sharp metal object over the bottom of your foot, and if you jerk away or there’s not a clear response of what I’m looking for, I’m going to do it again. And again. And again. I am sorry…truly. But it’s really damned important. (…true. and, when I have an abnormal/positive finding, I’m going to check it. Again. And maybe again to make sure it’s really there and I’m not seeing things…)

Also with the neuro exam, more than with any of the others (or is this the only one?) I demonstrate a lot of things. I demonstrate almost everything. Hold your arms like this. Push against me. It’s active. The patient isn’t passive while I look-feel (percuss. palpate. light touch. deeper touch) – listen. Open your eyes. Open your mouth. Saca la lengua. Turn your head. Touch your nose. Now touch my finger. Again. Again. (and in the confusion, the ones who will touch my nose…No, no, start over…). My hand on my thigh, turning over rapidly, rapidly, rapidly. Now copy me. Your hand on your thigh. Good. Now the other one.(I’m taking notes. Unless everything is completely normal, I’m taking notes.

Walk across the room and I’ll look at you intensely. Now walk back. Good.Walk heel-toe. (looks like sobriety test). Walk on your toes. Walk on your heels. I’m watching. And yes, I demonstrate. Heel. Toe. In front of the other.The woman – monolingual Hmong, I think, her daughter was translating. Two people copying me. She laughed. Giggling, during the exam. She’s right. It can feel silly. I respond: I know it main seem strange, but it’s all part of the exam, I promise…

How does it feel when I touch your face.

Close your eyes. Tight! Tight! Now don’t let me open them. My hand against your cheek. Push your tongue into your cheek, against my hand. Good. Other side!

Smile at me – and I’m not going to smile back – I’m just going to look, intently, at your face.

~ j

From the hospital, United States, today.

She reached her hand for mine, gentle clasp, and shook it. Simplest human contact.I almost cried.

Over a month ago – 6 weeks – she couldn’t have done that. She could barely hold anything. Barely speak intelligibly. And we didn’t know if it was ever going to get better. Today, she was dressed in her own clothes, not a hospital gown anymore (strange what a hospital gown does to a person. More on that later). Six weeks ago she didn’t want to live.Yesterday I was laughing with her and her friend about how she owes him money, has to get back to work and overtime, fast, to make it up.And today she shook my hand.

And I almost cried.

Beaming, dazed, I – again, it’s not marked! – opened the stairwell that sets off an alarm. Ohwell. Wandered around to find the staff exit (you’d think I would know, by now, what was where). It didn’t matter. I have been so sad about this patient, so desolate, and over the past few weeks, I have spent so much time beaming. And laughing. Laughing with her.

Today I almost cried.

From Mvangan, Cameroun, today.

And today I almost cried.I don’t cry enough, I think, maybe I’m numb to this sort of thing.Email from good friend in Cameroun: Alice la commercante est morte suite d’un incendie dans sa boutique au marché. Megan était malade mais ça va un peu. Régine ne cesse de penser à toi.

« Alice, the one with the boutique, died from a fire to her boutique at the marché. »“Megan (friend’s niece) was sick, but she’s a little better.”“Régine (another friend) thinks of you all the time.”

And this is how the news goes.I have been so, so incredibly lucky. I am so incredibly lucky – born here, basically things are going to be okay. (with my circumstances of birth/family/etc). But there…not even that matters. None of my close friends have died since I left (that I know of). Friends of friends. Young friends of friends. Babies. And no, no – that’s not true – I think I had heard that the boutique owners near my house, the ones where I went in the mornings sometimes for breakfast or just to pick up something quick from the ‘corner store’ – died. One or both. When I was back a year ago in Mvangan.

Alice, the one with the boutique, died.

“MON AMIE!” She exclaimed every time I walked by. My friend. Every time. I walked past her old boutique at least once a day. At least. Alice was anglophone, but mostly she spoke pidgin and not anglophone English, so we communicated best in French. Some Bulu (hers was much better than mine, of course). I bought things from her – kerosene (I stayed faithful with that) and various others. I realized after a few tries that her bags of pasta were so old they had weevils in them, which I wouldn’t see in the dim light of the kerosene lamp or flashlight when I was cooking. They floated to the top, and after the first, disgusted viewing (very, very early in my service), I would skim them out, no bother. Kerosene, candles, other. She ended up buying the boutique that had better hardware (nails, basically, rope, locks). I would get those from her when she moved to the marché. I didn’t see her as much then. There wasn’t much I went to those boutiques to buy, except on days I did manage to get up early enough to go (ie before 6 am. Funny, now it sounds pretty relaxing… ). Occasionally tomatoes from the girls there during the week, and I’d look at kabbas or babouches (the only ‘window shopping’ available in Mvangan, on those wooden stalls.

I do miss living there.

Alice died. Alice had a goiter – no iodized salt, probably. Maybe hypothyroid, maybe not. Alice with the three little kids running around – third born when I was there, but I hadn’t even known she was pregnant – kabbas, larger woman. Alice taught me to make beignets. There. I must have bought those from her, in the mornings I would brave crossing the mud. I sat in her kitchen. After awhile, I would just stop, having nothing to buy, feeling slightly guilty that I did so much of my shopping at other boutiques, now. But I would sit with her. Mon amie.

Mon amie taught me to wrap pagne. I walked by one day, early on, with pagne around my waist tucked in the way any Westerner might imagine. Somewhat like a towel.

It’s wrong.

It doesn’t stay.

(I also realized soon after that…who the hell wears pagne into town? no. At home, sure. Au quartier, sure. Then again, I could get away with just about anything. But in general, you don’t wear that into town. I learned. Ce ne se fait pas).

So she taught me. She called me (yelled me) over – I may have been a bit annoyed, I was probably on a mission to get somewhere with as much of a goal as I could have managed – "MON AMIE!" – Alice pulled me into her shop and started taking my clothes off.

The pagne, I mean.

(oh….Cameroun). I hadn’t been in Mvangan very long, maybe a month. So it was strange, a bit, and I had no idea what the *&$# she was doing… but, okay. (and no, it’s not so strange).“Non, comme ca!” I don’t remember what she said. She redid it for me, showing me.And that is how they do it – so miraculously, it doesn’t come off. I can walk, dance, carry water on my head without it slipping. Without safety pins, without anything else holding it up (the elegant, subtle, confident brilliance of African women).

So chastised, I walked the rest of the way into town (she was half-way). I know how to wear it now.She probably fixed clothes for me a few other times. Mon amie. Never Ntangen. Never la blanche. Or la whaat. Whiteman! No. But not my name, either – and she did know that. She had her own name for me (and no, it's not what she called everyone).Always. Mon amie. Always.

Alice, mon amie, slept in her shop. Most people do that. I’m not sure if she had a new room behind the marché one – her old one was much bigger, lots of space to walk around. The marché one was more of a counter crowded with many, many items. I bought locks there. The mugs I coveted for months – then bought, matched set. Probably cost me about 1000 F CFA ($2). Maybe more. Gods, the comparisons to life here. Online shopping. Amazon storing my credit card number. Mon amie slept in her shop. Her mother was there, not when I first met her but later. Her older mother – we didn’t have a language in common. I would alternately ask things in English, French, Bulu, my broken pidgin – probably asking where Alice was, or that’s what she was telling me. Her mother did more of the cooking. I learned with them.I should have sat more.I should have been more.

I wonder if I have any photos of her. Probably not – the dailies, I didn’t. Alice. Ma’a Monique. Pa’a – still forget my Fulani boutiquier’s name. I learned it eventually. We spoke a lot, though. Pa’a Jerome. Ma’a…Dorothee, I think. Names are slipping. And yet – and yet – when I was there, last summer, things came to me that I didn’t think I remembered. Bulu. People’s names. So many people I remembered, that I can’t recall now. As if the memories are stored in a particular place. I got in a taxi in Limbé, and until I got in I had no idea where I was going. I knew exactly where, but couldn’t think of the name of the town. I started to describe it, and a few words in I remembered the name. It was there. It was I needed it. That is enough.

Mon amie died. Megan was sick and got better – she’s three now, maybe. Sick doesn’t always get better, there. I know she’s in good hands. Régine thinks of me.Régine’s sister died, TB. Other....? Probably. Maybe. She was coming back from Gabon – seemed that was always the story, or so often. Gabon as a source. Not that Cameroun didn’t have its own sources. But travel, travel of any kind…

I took photos of her dead sister in the morning – that’s tradition, before the burial. Morning after she died. I got up, went to take pictures, and bought avocadoes in the marché. Must have been Wednesday, then. The photos are on Régine’s wall. One of the strongest women I have ever known or will ever know.Régine thinks of me often.Mon amie died.Megan was sick and now is a little better.Mon amie died.Régine is there – and in health – that’s what he means, he would say so otherwise. Régine has been sick and almost not gotten better, before. Malaria. Yellow fever. Etc.No news of her soeur (another sister) in the Camerounian sense, or of her soeur’s daughter, who was named for me. Her môn-a-minga . Little girl. My mbombo. Namesake.

And the friend who emailed me has email now, has a job, and has a facebook page. He has skype too. All of this at the government office where he works, and internet cafés. He has all of this (and may be reading. Mbamba mos, N! Akiba.)Some people are doing well.Alice, the one with the boutique, died.And some people are doing well.

As in the hospital. Some people are dying, have died. And some are doing well. Some will go home, some even better than when they came in.

There are things doctors try to do, maybe, that work, maybe.

In Cameroun – things happen as they happen. People are fatalistic – don’t often think or plan past tomorrow, which or what will happen dieu voulant (god willing). A Zambe.A Zambe wôm.

Because you don’t know. Shops burn down – might have been burned.Children die. Crops die. Not enough food or water.Some people – so few people – get lucky, get jobs or opportunities to go to school, the 10% (maybe) of the examinees who get by on merit (the rest on corruption).Probably less than 10%, most of the time.(Things that stop being shocking, surprising after awhile. They shouldn’t).

Alice, the boutique owner. Mon amie, always smiling and with the voice carrying out to me, she heard/saw me somehow from the inside of the shop and would come out to greet me. I don’t yell or project as well – but I would do the same thing to her. MON AMIE!

Mon amie.

And some people are doing well.

~j

I was having a discussion with some physicians the other day about Dante. (rather, they were discussing, and I was somewhat on the fringes of the fire, I, the student trying to dry the clothes she was wearing as she’d forgotten to bring extra pants on the trip to swim in a mountain river…) But as often-enough happens, there was a trigger point for me in the conversation and I jumped in.

I do believe that essentially everyone is more learned than I am (the people with whom I generally surround myself, at any rate. I like to be around people I can learn from. Then again, everyone can school someone else on something).

I’m a dilettante, professionally (perhaps euphemistically aspiring to be a renaissance woman…). Even title-above-and-description-wise. Could be a better physician(in training), could be a better writer, but – can’t pick one – and therefore can aspire to be kinda good or okay, maybe, at both. And I’m in general wholly impressed and overwhelmed by the general culture and knowledge of the physicians I know and have the privilege of spending time with (though these are, also, those who have chosen to remain in academic medicine and spend a good deal of their time teaching).

However. This particular group started discussing Paradise Lost and then The Inferno. One started going on and on about how Dante was so ahead of his time in writing about/describing heaven and hell in that way, etc, that that was the big thing about the work, and I’m thinking (and soon saying) ahh…no. Two things. Writing in Italian. And politics. Big, big politics. Just as political as Machiavelli, in some ways, but a prettier and much more interesting and complex story. (no need to expound. again, amongst people (I’m sure) who know this better than I do.

so...sometimes I know things.

Everyone’s a poet. Poetry is natural, poetry is breathing, it’s a way of being quiet and looking at the world. People translate that – or feel impelled to translate, transcend that into another form. Or they don’t, and it’s still poetry – the moment is, still, poetry. Anything exquisite. Anything that makes you catch your breath, or stop, or see or listen or feel in a slightly different, slightly new or nuanced way.

But people are afraid of poetry, think it’s esoteric, complex, overly intellectual, overly analyzed, and – frankly – pointless, perhaps a historical footnote. “I don’t understand poetry,” they say. I hate that. I hate that it seems – or makes itself seem – so inaccessible. There are so many different ways to read. If you read something and you like it, that’s good enough. If you see a painting, hear music, and you like it, that’s good enough. That’s appreciating. There are other ways and more and more things to delve into and appreciate and fall in love in other ways… but it shouldn’t be inaccessible. Art should be – is – for everyone. Enjoyment, expression. It’s all about communicating and translating, bringing across experience, which is not unique to the artist, at all. At all. (There are what, two stories in human experience? In literature? If that?) To me, anyway, art is something about a collective unconscious, to get slightly Jungian.

I took a class called “Art for the People.” And bridging science and art, as I did and still try to do, flailing-ly, I see people have the same-same fears and feelings of inadequacy vis-à-vis science and art. Science makes itself out to be intimidating. Medicine speaks an entirely different language – not just in medical terminology. Medicine turns English, commonplace words upside down.“How is the patient mentating?” (thinking. are we judging? yes. cognition. alertness and orientation. but also judging… the patient’s relationship to the world, as if we know how to govern that).“Please ambulate the patient.” (‘order’ to nurses. help/make sure the patient gets up and walks).“Is the patient’s sensorium intact?” (ie. hearing voices/seeing things? feeling things that “aren’t there?”)Medicine auscultates heart, lungs, carotids, abdomen, rather than listen.Rather than sortof sad, someone is probably dysthymic, and if they’re just feeling normal, they’re euthymic.Patients “complain of.” (did you know that’s what you were doing when you went to see a doctor for a particular reason?)Patients “deny” symptoms (did you know that’s what you were doing when you said you didn’t have whatever the doctor asked you about?)There is too much to digress upon here.

Poetry used to be communication transmitted across towns, countries (by modern definitions), across time. The poets were idolized. (in some countries, they still are. In France, streets are named for poets, philosophers, composers. In the US…presidents…some generals, maybe…)Plato banned poets from the Republic because they were too influential, and because they made mirages, in some sense. Turned things upside down. Forms are supposed to be pure, organic. Words are powerful.Words can destroy.It’s a dangerous thing, to wield a pen. It could get you exiled, incarcerated, killed.Still does.

That is poetry. That is writing. That is being a writer.A good friend once told me that all you need to do to be a writer is to write. It’s a heady thing, to call yourself a writer.To be a writer, you just have to write.

I’m intimidated in the same way by writing poetry that rhymes and by drawing or painting in color. I feel like, with both, you have to do it really, really well – really skillfully, artfully, delicately, and deliberately – or it comes off as heavy-handed and trite. And overbearing.So I almost never write things that rhyme.And I prefer to draw in charcoal.By the same token, I love writing, and I love drawing in black and shades of grey (I supposed I don’t actually draw “in” white, except for the pieces that are pages shaded full of charcoal then erased to create shapes and shadows.

For poetry. Rafael Campo, a personal hero who I am honored to call mentor (and, as he said once, future colleague), often writes formal sonnets. Many of his poems – entire books – are composed of formal sonnets (the Shakespearean, not (or sometimes?) Petrarchan kind – ie, 3 stanzas of four lines each plus an ending couplet, ABAB CDCD EFEF GG. Iambic pentameter. End-rhymed. You’d think something like that would be pretty damn obvious. And yet I didn’t notice for awhile. I’m slow, perhaps. I don’t notice things. All true. But it wasn’t until a second, third, reading, and perhaps reading the poem aloud, that I realized the lines rhymed.

I was floored.

Knocked over, stunned, gasped. Floored.(this is what poetry does to me).

It takes a subtle, delicate, absolutely %$*&#*& brilliant writer to pen lines that ‘happen’ to rhyme, where the words are completely organic and belong there, each in their own right. You would never question any of them, or see them there only to serve a purpose. It’s completely fluid.

And, in my mind, next to impossible to do. (for mere mortals like myself). Formal poetry has a place both in history and in vivid, living memory and practice. There are those who say, probably, that contemporary poetry is too…anything…not rigorous in the same way it used to be. Or something. Forms are a fantastic exercise to use (and for those who are absolute masters, a natural vehicle in which to write). As an exercise, I wrote a sestina (if you want to talk about ridiculously complicated forms… suffice it to say, 6 stanzas of 6 lines each plus an ending tercet. There are six words, through the poem, that end lines. That’s it. And the alternate in a particular pattern through the stanzas. And they rhyme. My six words were: alive, body, line, words, hypochondria, worry. These are sometimes slightly altered – “live” for “alive”, “align/realign” for line, “wary” for worry, once. But still. Imagine a poem in which “hypochondria” appears 7 times….)

But you can’t do this if you can’t do it well. I say. And writing something that “happens” to rhyme is unbelievably difficult. You can’t choose a word because it’s close enough/approximate enough to what you mean, and rhymes with the word you want it to. They both have to be exactly, absolutely right. Standing alone. And then they have to rhyme.

Art is similar for me. I can stand/sit/stare at paintings for time that doesn’t seem to pass. There isn’t thought. There’s something…visceral, zen, implicit. Indescribable. Each large city with which I am familiar has a few paintings like this for me. And when I’m there, I have to visit. It’s like going to see friends. You don’t * not* see some people when you’re in a certain place.

Dear gods, I digress. In writing and in live conversation.

Drawing. Art. Mine. Anything I do in color feels garish. I have to really mean it. It can’t be incidental, it has to be exactly right, or it feels out of place and like artifice. Pencil. Charcoal. Black ink wash. I hesitate to use color. I hesitate to use rhyme.

When flute players first learn to do vibrato (really a ‘coming of age’ moment for that instrument)…we want to use it all the time (or, I did). Showing off? Yes. Does it sound good? No. Vibrato is, in my mind, one of the most unique and beautiful things about the flute. It is an instrument that feels organic – not quite the hollow bamboo of yore (though some still are) – but – in essence – the music is from a column of air pulled up from my body, directed across and into this hollow cylinder by the force and delicate shaping of my lips, and I, in the same way, control the octave and the tone itself. Nothing fancy. No reeds. Nothing. You can play a range of beautiful notes on a headjoint, without any keys or fancy trappings.And the separations in the air, the notes, are merely small, deliberate interruptions of the air by my tongue. Breathing marks phrases. This, too, is visceral.

But back to vibrato. It’s a decorative element, it’s a way to add emphasis, to add color or mood or shading. And at first – WE FIGURED IT OUT!!! – it’s all the time, and the flute section melodies (cause we always have the melodies) sound wobbly, slightly off key, and annoying as hell as the wobbles are all happening at different frequencies from the vibrating throats of the young arrogant flautists*….Until we learn.Delicate. Deliberate. Only when it means something. And then, dear gods, it can be stunning.

* okay there * may * have been a similar phenomenon when I learned to do the back-of-throat clicks in Cameroon. There are just some things you do have to respond to that way, though. And that here I keep trying to (still!) because, really, why say “uh-huh” or “I hear you” or nod or make non-specific murmurs of assent when you can do this. Which took a lot of assiduous practice to figure out the mechanics thereof.

I did learn to use vibrato sparingly. Somehow, that hasn’t been true yet of rhyme or of color. If it is the same thing.

Patient today. “Are you going to be my regular doctor?”“Yes, for now.”“What does that mean?”“Well…I’m not here forever (why do I hesitate to say – only for a few more months?). There are other people who will be here longer than me, that you’ll see later.”“Will they be like you?”Step back. “…what do you mean?”“Will they have your personality?”“Ahh…well they’re all very good doctors…”The patient’s friend looks at me. “She likes you. She hates most doctors.”

Masquerading in a short white coat. Trying to get people to call me by first name. Never introducing myself as doctor. And yet – and yet. Everything I say, can say, can think or figure out to do in medicine feels pretty black-and-white, simple. I don’t have the nuanced colors yet. And if I try to use them, I’m generally – wrong. Anything fancy, any shortcuts. There’s a hell of a lot of color in the body. New language to learn. It’s easier for me, sometimes, with patients because I don’t have enough of the language or the knowledge, I am a lot closer to their level of understanding. My physical exam – black, white, subtle shadings of grey that are emerging. “Within normal limits” or not. (and even that…) “murmur” or not (aka ‘I didn’t auscultate one). Or “I think there’s something there…but I’m not sure what it is.”Easy to start to feel fancy and knowledgeable and…real… when you’re (sortof) dressing the part, all the right toys are arranged in your pockets, the sign on the exam room door has your name written, the MAs call you doctor, the patients call you doctor (though they see your attending coming in to ‘visit’ and talk, probably exam them as well, every time..). Somehow, somewhere, there will be the time and the will to learn, to remember that none of this is “real” and it has to be made real, really earned – if I can find both.

~j

I think I wrote about both of these before.The patient, not-so-slowly degenerating over a year to the point of losing function, losing vision, and starting to lose speech, who wanted to kill herself because she could no longer do anything he cared about. Who couldn’t do it because she can’t take the pills, by herself.She’s getting better.This almost never happens (at this level).She’s getting better.I go in, not often enough, but a few times a week. And, gods, she’s glad to see me. That in itself is miraculous. The doctor-patient relationship. Being someone to someone, but in a very different way than every other relationship in my life.

(addendum to the other, the patient with the wires in her heart. She survived. She went home. And if she has brain damage, after all that, it seems minimal. These are. Miracles. And by miracles I mean unlikely events that turn out well)

The only doctor I’ve ever really liked or felt like I had a relationship with, at all, was my orthopedic surgeon. Ironic, as they’re renowned for not having charisma, warmth, all the things we call ‘bedside manner’ (there has GOT to be another name for it. I’ll ponder that). But I saw him every week for months, then every two weeks, then every month, then every time (once? occasionally twice) per year that I was back from college. Then once, twice after Peace Corps. I think. I haven’t seen him in two years; perhaps I should stop by and say hello.

Orthopedic surgeon. By stereotype, jock-ish types who like to break things. And run a lot. And be really mean to residents. And be crazy in med school and only study in order to have stratospheric USMLE scores that have no correlation with either future promise in medicine/actually application of knowledge/ ability to be a good physician.

Orthopedic surgeon. He saw….forty patients per day? Perhaps. But the five minutes he was in the room meant something, and he was connecting for that time. You didn’t count it. It wasn’t short. It was real, he was there, and he was there. That’s what matters.

Dr L didn’t fix me. He tried. Twice. Things are put back together, then other tendons were moved around and remade, and then… well he told me before the second surgery that for some people it didn’t work even after three. That they were still in pain. (why he told me this directly prior to surgery, I’m not sure). And two didn’t fix it, but as there’s no guarantee that three would – there’s no point in reopening the thin white line that I think gives my wrist character.

He didn’t fix me.But I read the records. I was seventeen, and in my medical records it mentions that I was filling out college applications and that’s when I had noticed how difficult it was to write anymore. It mentions that, a little later, I delayed surgery because of Academic Decathlon, and I didn’t want to schedule it until I knew if we were going to Nationals, or not. (not. but only by a few points). It doesn’t mock that. It states it. This is what was real in my life. The things that matter to me are written down.They were not only listening but remembering.

In medicine, left is right and right is left. Things are organized according to the patient. That is our perspective in space. Looking at a person, their left faces my right. Same with x-rays. Looking at a CT or MRI, we look from the feet up. Seeing into a person from the ground to the sky. So, sometimes, now (and I was never very good at this) – I get it wrong with myself. I become my mirror-image patient and I’m confused. Directions are not according to me, anymore, or to my body in space. In the neuro exam, we test for the integrity of nerve fibers that judge position in space. Proprioception. Where is your body? Where are you….and yet we, ourselves, no longer see ourselves – at least in the encounters – as our own point in space.

(as a sidenote, I once examined a patient who had lost his joint position sense. It’s fascinating and strange, almost unbelievable. We test by having the patient close his eyes and moves a finger or toe, at the joint, up and down. “Is it up or down?” we say. Sometimes we’re tricky and keep it neutral. This patient didn’t know. He didn’t know where his body was, when he couldn’t see it anymore.

I try to remember this. I don’t always write it, but I remember. It’s a great PR trick (I’d imagine) to remember clients’ families, their names, favorite hobbies, important things in their lives, etc. Schmoozing points. So maybe it isn’t all that different. Do I want them to like me? Of course. I want them to trust me, and I want to earn that – whatever that means. Be respectful of it. The shrewder docs who were in private practice (and love to tell me how much money I’m hypothetically losing, sometimes, by taking too long and not billing enough) say it’s because patients are much less likely to sue a doctor they like who made a mistake than one they were indifferent towards. Fine.

So why does it matter, then, that I remember the salient details and ask about them? Yes, I care. It also helps me remember the patient, file them in my head as a person and not just a disease attached to a face/name. But why, other than the insecure need/want to be loved, like, appreciated, or the normal-human aspect of that, does it matter if they like me?*

* there's also the patient who told me her son calls me "the pretty doctor" (as opposed to her other, ugly doctors? ha....the real doctors....i never say i'm a doctor, but it's confusing, apparently, because to them i function as one. or, they think i'm a nurse)

Then there was the ophthalmologist. Dr R. I saw him a few times a week at first, then every week, every two, and a few months apart. It was an infection that (somewhat dramatic, but serious, as well) could have left me blind in one eye. Granted, this is without treatment/ or with much-delayed treatment, and being a person who is informed about health, has access to medical care, and has a job and life situation flexible enough so that I could see a doctor… I could do it immediately. And “immediate” meant the day after I woke up and couldn’t really see out of one eye. Not itchy, not painful, but everything blurred and just difficult to…see…at all. It took a month for normal vision to come back. At any rate, in those frequent visits, I lost my sense of squeamishness about eyes, and I started to connect with the doctor I saw as saving my vision. I remember him, still. He wore glasses. He thought contacts were part of the problem (for everyone), in general, and recommended (as did the US govt) that contacts shouldn’t be worn in Peace Corps. Little details. But he appeared in a poem, later that year*. He never saw the inside of my hand, manipulating and moving the delicate wires, like Dr L. He put green fluoroscein drops in my eyes, looking at arrays splayed through an opthalmoscope (spider webs, I picture, little fingerings). Bright green tears from the extra liquid. You can see into the brain through the eyes. (We learned that, last year. I’m amazed by medicine where you can see internal organs. )At any rate.

* come to think of it, so did Dr L. Not by name, but a very vivid image of him in the OR as I drifted into a dreamless, timeless sleep.

Hands. Eyes. There isn’t much that’s more personal about how we see the world. Perhaps an otolaryngologist, if I lost my voice. A neurologist, if I couldn’t think anymore because of a mass lesion, an infection, something else blurring my vision, changing my sense of touch, of senses, of…everything. Perhaps a psychiatrist for the same reason.

Hands and eyes are easy symbols.

But it is everything. And there I return to what I do love about medicine, what makes me stay in the every 2-3 week episode of wanting to drop out and do something more, more, that isn’t micromanaging and expands my mind and my world rather than contracting it.

It isn’t the disease, it’s the person and how the disease process affects the person. How they feel it. (everything’s subjective). What else it means to them. How it affects daily life. How it affects their vision of themselves. (…and here, the grammatical structure breaks down).

To wit. “Written on the Body”, Jeanette Winterson. “Illness as Metaphor,” Susan Sontag. The canon.

There are things that vibrate in this world. To finding that….

~j