I Dreamed a Dream

As a child, Christmas Eve used to be full of excitement, trying to fall asleep so the morning would come faster and trying to not hear mom and dad pattering past my bedroom to fill up the stockings or put the finishing touches on the bike or move the presents they’d stashed in their room out under the tree. This year, I glanced down at the right hand corner of the computer screen in the ER, “12:03,” and turned to the intern next to me who I barely knew, “Merry Christmas.” Most everyone else they schedule to work on Christmas is Jewish, so they didn’t care so much about the holiday, other than it meant that many patients come in because the holiday prevents them from going to their normal doctors.

One of the senior attendings tells me only the really sick or very lonely or crazy people come in on Christmas. I take to typing, “Happy Holidays,” at the end of the discharge summaries I write for the patients to take home. Of course some of them get admitted, which means that I have to convince my colleagues that the admission is valid—that the patient really does need to come in to the hospital. It’s tough to be a medicine resident in the emergency department world. The ED is the source of new admissions, some of which are very painful to deal with as inpatients.

I worked Christmas Eve, 7pm to 5am, but really didn’t leave until closer to 6:30 am, drove home in the dark, sat alone on the edge of my bed and opened the presents from my grandparents that I’d been saving, took a shower, put on my PJs as the sun rose, took klonapin and passed out. Bob awoke me several times around 10:30 by banging on my window wanting me to come have Christmas breakfast with him, Jane, Joseph, and Doug. He finally stopped when I stumbled out of bed, pulled an ear plug out and pushed back my black out eye cover and opened the door to tell him Merry Christmas and I’m sleeping and I work again at 7pm. I felt hung over. Christmas this year was a far cry from those I remember as a child.

Despite the sleep disturbances, I do find immense comfort in this place I live—in the people in it. Phillip and I had talked about his surfing career and my doctor career as he tanned by the pool. Jane and I spent Christmas Eve day riding our bikes along the beach (in the sand and through the seaweed even!). I feel lucky to have crossed paths with these people who live in the nine studios around mine. I felt less isolated when I drove home Christmas morning and, though everyone’s lights were out, the Christmas lights we’d put up together were on; and some of my neighbors become friends were there, sleeping, or struggling with their own distances from their families or their dreams on Christmas morning. I wasn’t alone really, neither in space nor time nor sentiment. Because of that I didn’t cry until I woke up much later, and even then not for long before I remembered the joys of this life, and at “the root of the root and the bud of the bud,” how lucky and how loved I am. I woke up around 4pm, in time to watch the end of “Memoirs of a Geisha” with Jane, return to my place upstairs, cry a little over the stew I ate alone in my quiet kitchen and throw some scrubs back on as Joseph wandered in to say Merry Christmas and call me a humbug before I returned to work.

The first patient I signed up to see was an obese 24 year old woman with three young children whom she’d left with her sister while she lived at an alcohol rehab shelter; she returned to the ED for the third time that month with abdominal pain. She continued to have unprotected sex, but her last pelvic exam cultures from two days ago didn’t show anything growing, her abdominal CT didn’t show appendicitis or diverticulitis and her pregnancy test was negative. She may have irritable bowel syndrome, but she’ll see a primary care doctor to help her with that. She can get one after the holidays. Her family history of lupus stung me; it always shocks me a little back into remembering. I don’t think she noticed.

The new patients who need someone to see them pop up on the computer board in blue and what to my wondering eyes should appear, but Mr. Robinson, and triage notes of an another seizure! Again he’d broken his colostomy bag and I knew before I signed up for him that he would be covered in feces and probably drunk. I signed up; it would be easier than having someone new see him and I felt bad for the guy. He had most of his gut removed because of C. difficile colitis, which is somewhat similar to gangrene of your intestines, so now he had his bowel connecting to the outside of his body and supposed to drain into an attached colostomy bag, which he kept losing (this time he told me someone took it—I can only imagine that a used colostomy bag is quite a hot commodity on the streets). Plus he and I had a strange sort of understanding which would come in handy as the night progressed.

He had a new satchel since the last time I’d seen him two days prior, one that looked like it had been sewn by a charity organization, with Christmas tree fabric and a festive handle. I imagine it was given out to some of the homeless in town. He also had a new yellow scarf that looked like part of the same donation gift. At least it didn’t have poop on it. When I asked him about his new possessions, he was nonchalant and seemed not to care much about his new possessions nor the fact that I’d noticed them. But later in the night, when he refused to go to x-ray I went to talk to him about it and discovered that he was afraid if they took him to radiology that someone would steal his stuff.

His life is hard. He served in the military, hated it, and threatened to kill himself unless they let him out. His wrists are covered in scars from where he cut himself to prove his point. He was discharged, apparently without benefits. And now he’s homeless and unable or unwilling care well for his colostomy bag. I understand why he needed the surgery, but it still seems like a bad long-term picture for him, especially coupled with his alcoholism and seizures. It bugged me as I thought about him throughout the night, so I called surgery on-call. As soon as I mentioned his name they got defensive, “Oh no! We’re not admitting him. There’s no surgical issue.”

“I know, I know.” I had to calm them down so I could ask what I really wanted to know, “I just want to know if his colostomy is reversible.” I knew patients had had reversals of ostomies once their acute infection was over. Their bowel movements were never the same, but at least it would come out the right hole. “Oh,” the surgery intern calmed down when she realized I actually had a valid question about patient care and needed help answering it, “Sure, he can probably be reversed eventually, but it will be at least four months and we will have to keep him in decent shape until then.” He had some hope. That made me feel better for him. He gave me the same probing skeptical look he always did when I told him the news, but I think it was like our discussion about his new Christmas bag: he’d remember and think about it later.

I told him he was being admitted (to the medicine service instead of surgery) and he quizzed me on which room would be his. “I don’t know; the charge nurse and the transport people will know when they take you upstairs.”

“A lot of help you are!” He yelled at me.

I looked at him and said, “I am a lot of help, actually. I’m trying to figure out what is best for you. And there’s no reason to yell.”

“I don’t have to do what you tell me to do,” he yelled again.

“That’s true. It’s always your choice. We make recommendations on what we think is in your best interest. There’s no reason to yell and be disrespectful.”

He calmed down and apologized, “I’m sorry, Doc. I’m hard of hearing so I talk loud. I’m sorry,” his voice softened considerably and he stared piercingly at me again.

“What’s with the look?” I asked.

“What look?”

“You’re looking at me like you have something more you’d like to say.”

He paused, “Why is your hair light and your eyebrows dark?” I knew he saw more than he let on. Somewhere in him, buried in some tortured past was a man who noticed things. He’d told me on his last visit that his ex-wife had blond hair and green eyes.

“I don’t know,” I answered him about my eyebrows, “they’ve always been that way.”

“I like it.”

“Me too. They’re going to come get you for x-ray soon. We’ll close the door so no one takes your stuff.”

“Okay, Doc,” his voice had lost the hunted animal edge for the time being, “Could you please turn out the light when you go? The brightness gives me a headache.”

I walked out and switched the light off on my way. They took him upstairs soon after the x-ray.

A 22 year old man with diabetes got arrested for possession on Christmas night; his blood sugar was much too high when they checked it in prison, so the cops brought him to me. His personal guard hovered at his bedside all night asking when he could take him back to jail. When we’d finally given him enough fluid and insulin, I saw him walk back out in handcuffs and his jaunty brown fedora-type hat. It was a rough Christmas for him, too. The hospital where I work has the “jail contract” so if anyone gets sick in or on their way to jail, they come to us, with chains around their ankles and wrists and waist and cops always at their bedside.

In the wee hours of Christmas morning, I sewed up the eyebrow of a tough-looking convict who’d had a seizure in jail and hit his face on the cement floor as he fell while seizing. He needed a head CT so I waited until they’d taken him for that and he fretted over the little numbing needles I told him I would use. He wanted to be completely sedated for the suturing. He ended up having bones in his face fractured and a small head bleed. His cop escort asked me if his wounds were more consistent with a fist fight than a seizure. It’s possible, but with unwitnessed events we can’t know for sure.

Another of my patients slept on a gurney in the hallway most of the night while we evaluated her weakness and high blood sugars and dementia. She spoke no English and her caregiver had left her there hours before, saying she’d return soon. My patient used to be the nanny for the twenty-four year old girl who now cared for her. They didn’t know I spoke Spanish when they said, “La doctora? Muy joven.” Very young.

“Tengo veinte-nueve anos.” I told them I am 29. The young woman told me she is 24 and had a young son so she took time off from school to raise him. She seemed envious of my ability to dedicate time to a career instead of a family. The envy was conversely mutual. People often ask me how much school it takes to be a doctor. The factual answer is four years of med school after college and then residency length varies depending on specialty. The real answer is: your whole life. One of my residents in medical school told me that once you become a doctor, it’s not something you can separate out from the rest of your life. I think you can sometimes. I think you have to. Otherwise you go crazy yourself.

“I dreamed a dream my life would be, so different from this hell I’m living.” I’m reading “Le Mes”, Fantine has just left her beautiful daughter Cosette with the mean inn-keeper’s wife because her cad of a boyfriend deserted her and she has to work to support herself and her daughter. I dreamed I’d have my own child now, a someone with whom to celebrate Christmas, some time, no pill boxes or “past medical history” of my own. But just because it’s different, doesn’t make it bad. Hard sometimes—and lonely—but not a “hell I’m living.” As I told Joseph when I left for Spain, this life gives me space to take such adventures. It was a different Christmas; perhaps working in the Emergency Department is the best way to help—in the true spirit of the season.

The New Colossus

Not like the brazen giant of Greek fame,
With conquering limbs astride from land to land;
Here at our sea-washed, sunset gates shall stand
A mighty woman with a torch, whose flame
Is the imprisoned lightning, and her name
Mother of Exiles. From her beacon-hand
Glows world-wide welcome; her mild eyes command
The air-bridged harbor that twin cities frame.
"Keep, ancient lands, your storied pomp!" cries she
With silent lips. "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!"

Emma Lazarus, 1883

Err Freshener

“Do you have cats or dogs?” my Emergency Department attending asks. “Neither, “ I say, “I have plants” His question is somewhat rhetorical and in response to my mumbling that in addition to the chest x-ray and urinalysis I have ordered a meal tray for my homeless patient with a cough and polyuria who had her car (which she’d been living in) stolen five days earlier. He stares ahead when I say I have plants. I understand the lesson he’s trying to convey. “If you feed them, they keep coming back.”

I just don’t agree with it. The hospital has plenty of food. One less cold turkey sandwich on white bread without mayonnaise is no great feast, and does no one any good in the refrigerator where it will get thrown out if not eaten soon. And she has cried to me minutes before, “Please help me!” She pleads with me between face-reddening coughs. She needs more than the medical help I can provide. And the homeless shelter downtown is full by 7pm. My church’s shelter has closed the night before. And it’s almost Christmas Eve. I don’t know what I can do.

So I drag my feet with her medical work up, despite the senior ED resident breathing down my neck about “dispo” of patients (ie where they end up, admit v. discharge) and what is the hold up. I get to her last in my to do list. I let her sleep a little longer in the busy, but warm, hallway bed because all the other rooms are full. Maybe it isn’t a great use of medial space. The hospital cannot accept elective ambulance transfers because the ED is too full right now. There are times in the night when we don’t even have a bed held for an ambulance emergency. A 400 pound woman in respiratory failure has just been intubated and the waiting room is full.

We get most of the homeless patients at the university hospital--all the ones the cops find on the streets and think need medical care. Like last night, the police called the paramedics for the first patient I saw. A 60 something year old veteran without an honorable discharge but with a very bad attitude covered in his own feces which had leaked from his colostomy because his last bag broke when he fell after two seizures the day before. He didn’t even want to come in this time, though he’d been there the day before, drinking vodka in the waiting room. And he was there the day before that, insulting the female senior resident by saying, “Huh, they’ll make anyone a doctor these days.”

He smelled awful. The whole hallway smelled of feces. The residents in the “doc box” discussed at one point if burning incense or bringing in air fresheners might be acceptable. I thought after seeing him what a long-term disservice it had been to give him a colostomy without any means to take care of it. Of course, social workers had seen him many times, and he didn’t want help finding a place to stay. He wanted to stay on the streets in front of the Jiffy-Lube where he was proud to tell me he was the only one who had an agreement with the owner to allow him to stay there at night as long as he was gone before they opened and as long as he didn’t go to the bathroom in the parking lot. “Easy enough,” he said to me with a matter-of-fact shrug. He conversed with me because of the MD after my name. He glared at the RN when she tried to help him, then commented to me when she left the room that he liked her but she just got on his nerves. “Do your job. It’s your job to help me!” he berated her as I tried to set some ground rules about courtesy which I don’t think he heard.

I thought of the psychiatry recommendations regarding my narcissistic antisocial personality disorder patient at the VA: Don’t bargain with him. Don’t accept rudeness unless he is in imminent danger. Don’t engage him in banter. ED nurses catch a lot of flack sometimes. Most of the time their patience amazes me--especially with all of the literal shit they have to deal with.

Another of my patients had soiled himself today, also. He was embarrassed about it, but still insistent about getting his pain medications before he got cleaned up. He’s another patient well-known to the ED staff. He has spina bifida so he can’t walk and has imperfect bowel and bladder control. He has chronic wounds on his foot and his rear end. As I pulled the sodden bandages off of his feet, the smell of anerobic bacteria momentarily overrode the smell of feces. Everything smelled bad. “Maloderous” is the politically correct medical term.

I remembered Dr. Vaiyerman as I looked at his wounds and remembered how he’d smelled the culture swabs or bandages to help him characterize the infection. I followed his example when the nurse at the VA paged me, as I’d asked, in time to see the dressing on my antisocial personality disorder patient’s sacral wound deep enough to reveal the bottom of his spine. The patient tried to make me feel bad for keeping the nurse waiting because I’d shown up later than planned as I was admitting another patient at the time. The nurse was gracious and said it was fine, but my patient still glared at me as he rolled over for the dressing change. I had already learned I could not please him; he called me a rookie and often wanted to speak only to the attending. Anyway, I probed his wounds to try to find any new area of drainage to culture so we could choose the correct antibiotic. And, thinking of Dr. Vaiyerman, I gingerly smelled the dressings the nurse had removed. “Anaerobes,” I though. Maloderous. The nurse later stopped me in the hall to tell me that he’d never seen anyone do that and that he thought it was an important part of taking care of patients—using all your senses—“So I just wanted to compliment you,” he said.

In the ED, I smell urine often, too. Less diagnostically specific. My overweight homeless patient the other night had become incontinent prior to arrival and we didn’t have any extra clothes large enough to give him. When we discharged him, he had to put the pants back on. Most of the time the homeless patients don’t wear underwear; he didn’t have any either.

The drunk patient I took care of Thursday night smelled of alcohol and sand; he too is homeless and usually stays at the beach where Jane and I had gone to the wonderful farmer’s market the night before. I catch myself looking into the faces of the homeless people now, to see if I recognize them, to see if they I can see a past in their eyes. An explanation for their predicament. I ordered one of the awful turkey sandwiches for this drunk patient. He ate half of it and told me he threw it up in the bathroom. I don’t know if he did or not. The nurses and attendings didn’t believe it. The advantage of telling me this is that it would delay his discharge back to the streets if he was still vomiting. “He’s lying to you,” the nurse insisted. He probably was since later I saw him walking around easily looking for a bathroom or the door to go out and smoke. Then I discharged him. But no one knows for sure. I’d rather give them the benefit of the doubt. What does it hurt?

My attending tonight thought the homeless woman was lying about having her car stolen, too. “Convenient,” he scoffed under his breath when I told him the story. I just went on with her medical history and pretended I didn’t hear him. Thing is, he’s very medically careful with some of the patients. I actually think he admits more than he should to err on the side of caution, or to clear out the ED, or to avoid law suits, or to ensure thorough patient care. I don’t know. It’s so hard to know true motivations—of anyone. It’s hard to truly know anyone, let alone drunkards and teachers and strangers.

It’s hard to know how to help, too, particularly when you’re still close to the bottom rung of the medical hierarchy. I reluctantly canceled my homeless patient’s meal tray, with a glance at the evaluation paper he had for me beneath his computer keyboard. Looking back now, part of me wishes I hadn’t done that; wishes I had taken more of a stand; wishes I’d done more than make sure she at least got some of the emergency crackers and juice from the nurses. Or maybe it’s better I didn’t draw attention to my tray-ordering practice by objecting too loudly; next time I can just order the meal more discretely, because if I’m going to err, I choose to err on the side of kindness.


Merry Christmas Eve!

Befores and Afters

“Tell your heart that the fear of suffering is worse than the suffering itself (130).” I have just finished “The Alchemist.” The fear of the unknown is worse than the unknown itself. The words of Thich Nhat Hanh come back to me again, “Hold your fear like a baby, examine it, hold it close, know it, recognize it, love it. Then let it go.” When I know my fear I see that it is not really fear at all, but a part of the knowledge. And knowing is loving. “Darling, let me know you.”[1] “We forgive ourselves, and each other; we beginning again in love.”

“When you want something, all the universe conspires in helping you to achieve it.”[2] Thoughts float back to me and my life feels divided into befores and afters. I struggle still with the integration of my existence. Do I see this disease as a test? As a lesson or a challenge to overcome? Do I see this as a burden? Less and less as a burden as my health returns and I commit to life as I never could have if I had not felt death. “Usually the threat of death makes people a lot more aware of their lives.”[3]

And when I cease to see it as a disease, but merely as a part of the continuum of health and life, I see it as part of the whole. As everything is one part of the same. “To see a world in a grain of sand/Heaven in a wildflower/Hold Infinity in the palm of your hand/And eternity in an hour.”[4]

Words fall into me from junior high poetry collections where I accompanied that poem with a colored pencil picture of the earth surrounded by a yellow cuboidal grain of sand. Words come from lectures, from songs, from poems, from books. They conspire to integrate themselves into the present. Into my now and out of the befores and afters.

The before the diagnosis of lupus words prepared me for the during, and even more for the after. The after which was already then. And which is always now. I remember the deconstructionist lectures in college, how I struggled with the concepts but once grasped how they seemed so simple. So obviously clear that I learned that I already saw the world through them, as through cleansed "doors of perceptions.”[5]

I feel that way now in part with “The Alchemist.” I found myself predicting the words on the next page, as Coehlo relayed his message in the language of the world. I knew how it would end before it began because it is part of the stories of our existence. It is a hero’s quest, like King Arthur, like Harry Potter, like Jesus Christ. A tale of searching for self and finding it in the very place where you have begun—finding the after in the before, and finding both in the now. “We will arrive where we started and know the place for the first time.”[6] Over and over we will. “I carry your heart (I carry it in my heart).”[7]

Over and over I am reminded to do this, like the omens. “It is always only ever now,” I heard it complementary medicine when I thought my world was ending with a love that was never truly mine anyway. Words calling me back to center of myself. Sometimes they fall without meaning and later the same words rush back in moments of intense suffering and need, having waited for the longing and the mind reaching for wholeness in the eternity they convey. I see also that there is a profundity beyond all words, beyond all the books conspiring together. I see that the most infinitely wise words are never committed to paper because there comes a time when the confines of letters and footnotes and covers of books become limiting: the letting go of the words becomes the lesson. When the hoarding of thoughts and the desire to imbue them unto others becomes less important than the fact that thoughts exist, realizing that others must find their own words—their own Personal Legend. And that when words reach that level of knowing, they no longer need to be written, only known, understood, loved.

[1] Lecture, Hanh
[2] “The Alchemist” Paulo Coelo, page 40
[3] “The Alchemist” Paulo Coelho, page 142
[4] Auguries of Innocence, William Blake
[5] The Mairrage of Heaven and Hell, William Blake
[6] Little Gidding, T. S. Eliot
[7] I carry your heart e. e. cummings

Excerpts from "Little Gidding"

If you came this way,
Taking the route you would be likely to take
From the place you would be likely to come from,
If you came this way in may time, you would find the hedges
White again, in May, with voluptuary sweetness.
It would be the same at the end of the journey,
If you came at night like a broken king,
If you came by day not knowing what you came for,
It would be the same, when you leave the rough road
And turn behind the pig-sty to the dull facade
And the tombstone. And what you thought you came for
Is only a shell, a husk of meaning
From which the purpose breaks only when it is fulfilled
If at all. Either you had no purpose
Or the purpose is beyond the end you figured
And is altered in fulfilment. There are other places
Which also are the world's end, some at the sea jaws,
Or over a dark lake, in a desert or a city—
But this is the nearest, in place and time,
Now and in England.

If you came this way,
Taking any route, starting from anywhere,
At any time or at any season,
It would always be the same: you would have to put off
Sense and notion. You are not here to verify,
Instruct yourself, or inform curiosity
Or carry report. You are here to kneel
Where prayer has been valid. And prayer is more
Than an order of words, the conscious occupation
Of the praying mind, or the sound of the voice praying.
And what the dead had no speech for, when living,
They can tell you, being dead: the communication
Of the dead is tongued with fire beyond the language of the living.
Here, the intersection of the timeless moment
Is England and nowhere. Never and always.


In concord at this intersection time
Of meeting nowhere, no before and after,
We trod the pavement in a dead patrol.
I said: 'The wonder that I feel is easy,
Yet ease is cause of wonder. Therefore speak:
I may not comprehend, may not remember.
'And he: 'I am not eager to rehearse
My thoughts and theory which you have forgotten.
These things have served their purpose: let them be.
So with your own, and pray they be forgiven
By others, as I pray you to forgive
Both bad and good. Last season's fruit is eaten
And the fullfed beast shall kick the empty pail.
For last year's words belong to last year's language
And next year's words await another voice.
But, as the passage now presents no hindrance
To the spirit unappeased and peregrine
Between two worlds become much like each other,
So I find words I never thought to speak
In streets I never thought I should revisit
When I left my body on a distant shore.


What we call the beginning is often the end
And to make and end is to make a beginning.
The end is where we start from. And every phrase
And sentence that is right (where every word is at home,
Taking its place to support the others,
The word neither diffident nor ostentatious,
An easy commerce of the old and the new,
The common word exact without vulgarity,
The formal word precise but not pedantic,
The complete consort dancing together)
Every phrase and every sentence is an end and a beginning,
Every poem an epitaph. And any action
Is a step to the block, to the fire, down the sea's throat
Or to an illegible stone: and that is where we start.
We die with the dying:
See, they depart, and we go with them.
We are born with the dead:
See, they return, and bring us with them.
The moment of the rose and the moment of the yew-tree
Are of equal duration. A people without history
Is not redeemed from time, for history is a pattern
Of timeless moments. So, while the light fails
On a winter's afternoon, in a secluded chapel
History is now and England.

With the drawing of this Love and the voice of this
Calling

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
Through the unknown, unremembered gate
When the last of earth left to discover
Is that which was the beginning;
At the source of the longest river
The voice of the hidden waterfall
And the children in the apple-tree
Not known, because not looked for
But heard, half-heard, in the stillness
Between two waves of the sea.
Quick now, here, now, always—
A condition of complete simplicity
(Costing not less than everything)
And all shall be well and
All manner of thing shall be well
When the tongues of flame are in-folded
Into the crowned knot of fire
And the fire and the rose are one.

T.S. Eliot 1942

Excerpt from "The Marriage of Heaven and Hell"

The ancient tradition that the world will be consumed in fire at the end of six thousand years is true, as I have heard from Hell.

For the cherub with his flaming sword is hereby commanded to leave his guard at tree of life;" and when he does, the whole creation will be consumed and appear infinite and holy, whereas it now appears finite & corrupt.

This will come to pass by an improvement of sensual enjoyment.

But first the notion that man has a body distinct from his soul is to be expunged; this I shall do by printing in the infernal method, by corrosives, which in Hell are salutary and medicinal, melting apparent surfaces away, and displaying the infinite which was hid.

If the doors of perception were cleansed every thing would appear to man as it is, infinite.

For man has closed himself up, till he sees all things thro' narrow chinks of his cavern.


William Blake 1790-1793

http://en.wikipedia.org/wiki/The_Marriage_of_Heaven_and_Hell

Carpooling with God

On Thursday night, I walked out of the VA into the dark and uncharacteristically cold night with visions of more than sugar plums dancing in my head. The end of my four weeks as the ID consult resident and intern at the VA was ending; I felt sadness realizing I would not be back there the next day. I wouldn’t walk around the halls and recognize half the patients’ names on the small plates by the door. Some of whom I’d admitted last November on my first intern month there. One in particular, a cantankerous one-legged bearded man, just kept living despite all physiologic and pharmacokinetic odds. The patient who had broken his hip and celebrated his 49th wedding anniversary with us was in rehab there. My patient who had danced with death from a GI bleed the week before had made it back out of the ICU. As I rounded with the ID team on his roommate, I gave his wife a hug. She and I had shared tears and talk about her decisions to decide not to try resuscitate him if his heart stopped again (he’d already coded twice, had a heart attack and pneumonia, after he broke his hip when he fell at an eye appointment a month and a half earlier). He kept going against all odds, too. She told me she didn’t know how to live without him. He used to play the piano and dance with her in their living room. When she looked at him, I know she saw the man who’d held her close, instead of the confused shadow who waved at people the rest of us couldn’t see.

I felt particularly sad to be ending my time with my attending. Dr. Vayairman is a long pause in the search for a word to describe him. A white haired intimidatingly kind man with a confident giggle, he has cared for patients and taught students and medical residents for the past 35 years. As he taught me over the past three weeks, I found myself scribbling notes on scraps of paper in attempts to hold onto his wisdom. The notes I have from him in my head, however, outweigh the words on paper, however. If I were dying soon, I would want him to be the one to tell me.

When I started as the ID consult resident four weeks before, I recognized him vaguely from my VA time last year. He always has something to ask or add at noon conferences. He maintains his curiosity and enthusiasm about medicine and the advances the field has made in his time as a physician. He combines his vast experience with a freshness that keeps him intrigued and awe-inspiringly real.

Of course, that first week, when I presented patients to him in ID clinic, I felt completely inadequate. Despite trying to gather the latest culture results and antibiotic history and hospital course, I didn’t have the answers to all the questions he asked—a combination of the patient’s macro health situation as well as the details of the last drug resistant microbe that infected the diabetic foot that the patient hadn’t felt in years. I knew that because he asked them, they must be important. I started to take notes in my head of what to look for next time. I needed to not get so caught up in the details that I lost track of the patient situation. Yet, I needed to know the details in order to affect the big outcome. This was an art he had perfected, and I was just beginning to learn.

A weeks or so later, when I was fortunate enough to have him as my ward attending, I watched him tell one of our patients he had perhaps a month, but not six, to live once we’d seen the metastatic lung cancer had spread to his brain. The way he told him made it seem to fit into the progression of life—made death a part of the journey—and somehow perhaps not the end.

The medical students were terrified of him. They literally sweated under his persistent questions when they would give “five-minute presentations.” He set high expectations on the first day of the rotation when he told us he expected full physical exams, which he modeled himself throughout the month with grace and skill, once picking up a stroke patient that even the neurologist had missed, always smelling the wounds to help decide if we need anaerobe antibiotic coverage also. He wanted concise, organized, relevant patient presentations. He wanted information and attempts at decisions. He wanted us to try to be like him. And this seemed an unachievable goal, especially to the two medical students who struggled under the weight of just beginning the grueling schedule and studying for exams.

On rounds with him, he displayed how to take the patient history into account when asking questions, to not discount details of travel or social situation, to look at the whole body, to listen for heart murmurs carefully, to watch the toes attentively when we tested for Babinski reflexes, to find skin changes named after orange peels, to pay attending to the relevant but not forget everything else. He showed us how to be gracefully perfect, and it seemed impossible.

Whereas other teams took the radiologist’s or the micro lab techs’ reports in the computers at face value, our team went to x-ray rounds everyday to see the films and discuss them with the radiology team in their dark rooms. We spent time at the teaching microscope in the microbiology lab looking at the gram positive cocci or the gram negative rods staining more darkly at both ends that might be Klebsiella. Of course, Dr. Vayairman is the head of infectious diseases there, and the chief of the micro lab, so it is part of his business to know all of the inner workings of the micro lab and the microbes that grow smeared across the agar plates or make clear circles around the drug saturated discs to reveal their resistant adaptations. He brought science back to clinical medicine for me. He took away the disconnect I felt when I got lost in frustrations about the impossibilities of trying to fix everything. He showed me how he tried his best to fix what he could, kindly and thoroughly and realistically.

With my patient who had died that month, he told us from the first day we saw him as a team that he wouldn’t make it long. His liver was too sick. As all of the consult services gave us different recommendations about what to try next, he let them try, but I could tell he knew most of our efforts were likely futile. He stopped us from pouring blood products into him in what he knew was a loosing battle. As I talked to my patient’s brother more and more frequently, trying to convey the severity of the situation, I wish that I had Dr. Vayairman’s confidence to say that I knew he wouldn’t make it. If had could have said that, I think his brother would have let us make his last days more comfortable, instead of a prolongation of the struggle. I could have given him morphine sooner than I did. Even given that, I fret over the decision I made with the consult service to do a trial of clamping his chest tube despite the infection there.

It is one of those decisions I think of now and cringe with guilt, wondering if it was wrong, if it made any difference in the overall picture. And when Dr. Vayairman said quietly to me that it shouldn’t have been done the next morning as we rode down to x-ray rounds in the elevator, the guilt and doubt rose up again. He would later put that in my evaluation, also. I needed to learn from it. I have. I just wish I could shake the feelings of mistakes and not expect myself to be perfect. In the end, I know it didn’t change the clinical course. My patient’s brother granted permission for an autopsy when I called him again the day after his brother had died. The pathologist called cause of death end stage liver disease, as we all expected. And yet, I worry. I get so tired of trying to be perfect. Perfectly right and perfectly caring and perfectly alone.

Dr. Share, my own wonderful primary care doctor, tells me I need to not expect so much of myself when saw her as I was falling apart with another lupus flare. Dr. Vayairman takes me aside a couple times during our time together to look into my eyes and ask how I’m doing. He means with my own illness—the lupus that makes call nights so hard and makes me tired and makes the blood clots in my head. He has told me at the beginning of the month that perhaps I shouldn’t do this demanding combined residency. Perhaps something with better hours would be better for me, he says: pathology or radiology. I tell him I would miss the patients. By the end of our ward time, he has submitted the online evaluation I see five days after he wrote it. At the end he has written, “I predict she will be an outstanding physician. She was coping with her own problems but never let that interfere with her care for her responsibilities to ward her patients.”

Coming from him, a man I respect so very much, this is huge. Even before I saw what he’d written I had run I into one of the chief residents in the hall. She calls him a genius, too, as does my own program director. We all talk of him with awe and respect and envy. In x-ray rounds one day, an x-ray of a man from the chief resident’s team was displayed and he comments in his infinite wisdom that only two things make that pattern on the chest x-ray: an upper lobe very round density. One of them is cryptococcus, a fairly rare entitiy. They send the serologies based on his passing comment and discharge the patient to home, only to find out that Dr. Vayairman has been right and they have to track the patient down to make sure the infection has not invaded his spinal fluid. “Your attending knows everything,” the chief resident says. She is doing her own first month of ward attending, and struggling with the responsibility and the transition of authority and involvement. She wants to be like him, too. When she has time, she tells me, she likes to round with the teams and she always chooses Dr. Vayairman’s team when he is on wards.

I tell her how much I have enjoyed working with him and how much I have learned from him. Before he fills out my on-line evaluation, he has given me feedback in person, as attendings are supposed to at the end of working with the house staff. “You are a good house officer,” he has told me. “Your physical exams are thorough and you are compulsive. My suggestion is: don’t be afraid to ask questions. You are here to learn. You are not supposed to know everything yet; that will come with time. We are here to teach you. You will be a good doctor.”

When I tell her he has said this, she’s shocked. “That’s huge,” she says a few times, “He usually thinks the house staff are all idiots. That’s huge coming from him.” I feel shyly and profoundly proud. I wonder if he still thinks I should be a pathologist.

I think that he sees me struggle with myself and he doesn’t want me to struggle the way that I sometimes now have to in order to make it through this training and these changes in my life. I think part of him wants to shield me and take care of me. And part of him wants to let me grow, even though he knows, in his clinical and personal experiences, that life has become much more of a challenge for me. His response to me reminds me of what my dad has told me when I hurt so much from having my heart broken: he wants to protect me from ever hurting, all the while knowing he cannot.

After Dr. Vayairman and I have finished our time together on wards, I switch back to a week of infectious disease consult service and am pleased beyond all reasonable glee to find that he will be attending there for the week I’m there also. I feel bashful around him. Like now that he has seen me, all I can do now is disappoint him. Again, I expect too much of myself. When he asks questions to which I don’t know the answer, I feel like I have failed and when I do know the answer I feel victory. Everything is blown out of all reasonable proportions. I calm myself down by just focusing on the patients—always my safety and my home. Even if I don’t know all of the workings of their disease, at least I can know what is important to them—at least I can assess their priorities and their fears and tell him about those things, because when you try to affect people’s lives, that’s how you do it, not by curing their illness, but by helping them integrate their struggles and health into the life they want.

I see a 40 year old man on a positive blood culture result auto consult, but it becomes much more interesting than that as I investigate his history and meet him. He is a full time student, studying sociology. He has been sick for almost a month with pneumonia and now with presumed pericarditis. He began to feel fatigued when he played soccer with his wife of one year soon after the fires burned through the hills north of town. I notice in his labs that he has a fairly profound eosinophilia. These are the white blood cells that usually respond to parasitic infection, I remember from med school microbiology classes. Before I have time to investigate further, it is time to present to Dr. Vayairman. I get out the ginger-chocolate biscotti and pumpkin cookies I have made and brought to share.

I tell him what I know of the man and point out the elevated eosinophils. He clarifies the clinical course with his piercing interest; he makes me be more precise with the dates and times of events and the trend of his elevated white cells. “What could cause that?” he starts to quiz me. “Parasites,” I start to feel inadequate again, “Strongoloydies.” I mention the only one I can remember, though knowing most of them affect the gut. They do have lung phases when they crawl around inside the body to reproduce. “What else?” I blank again. “Ameba?” he says. I don’t know. “No,” he answers himself. “Giardia? No.” My Midwest med school training comes back and I remember the lung infection endemic to the Ohio valley, “Histo?” I say tentatively. “Close.” Then I have it, “Coccy.” Relief comes along with the knowledge I will never now forget.

And then we start to work together to integrate it into the man’s clinical situation. I know he has not traveled much lately, but I have not asked if he has construction near his home. He is African American. Dr. Vayairman, who studies coccy epidemiology and behavior in his mice lab, tells us that the disease is more complicated in blacks and Filipinos, though no one is sure of the exact genetic basis of why. He pauses at one point while teaching us about the disease to take a bite of the biscotti, “Nice cookie,” he looks at me briefly, “Thank you” and then resumes his teaching, barely missing a beat. I take notes about the disease on my scraps of paper and scribble the compliment about the biscotti down in my head, again with disproportionate pride. When we look at our patient’s x-rays and chest CT, we see the pneumonia in the lingula (the lung lobe right next to the heart). “That is probably how he got the pericarditis,” says Dr. Vayairman. “Only two thin layers of tissue separate the lung and the pericardium there.”

From getting to know my patient earlier, I predict he may have gone down to the computer terminals to get in touch with his professors about the classes he is worried about missing. He’s not in his room when we first visit, and I go to find him at the computers and ask him to meet us up in his room. When we get there after reviewing his radiographs, the phlebotomist has a needle in the back of his hand to draw blood cultures. I cringe, knowing from my own experience of 24 blood draws in my ten days as a patient on a heparin drip that that is a painful spot to draw blood. Dr. Vayairman knows this too, of course, and comments to the phlebotomist about it with some quiet disapproval as we watch the young man grimace in pain.

When my antecubital veins were raw and inflamed from the sticks I got every six hours, the phlebotomist started to pick up my hand to look for vessels there. I pulled back and told her to keep looking at the inside of my elbow. Most patients think they have to accept what is done to them. It is always a choice.

Dr. Vayairman asks the patient more about his exposure to construction sites and finds that he has not been around many recently. He explains that we think he has “valley fever.” This will change his treatment from the normal pneumonia antibiotics that the team has chosen to fluconazole, an antifungal medication, that the patient may be on for an extended period of time, given the severity of his disease. We would recommend checking his serologies to confirm that this is what he has, but the clinical picture fits well enough, that Dr. Vayairman would start him on treatment before we knew for sure. I knew he had probably saved the man perhaps months of lingering illness and ongoing investigation into the real cause of his disease. How fortunate for him to have had a positive blood culture (which is likely an insignificant contaminant) and therefore had his hospital course intersect with Dr. Vayairman.

We rounded on one more of my patients—the cantankerous one I’d admitted a year before—who now had a severe cellulitis on his one remaining leg. Dr. Vayairman had been afraid the night before that it was progressing to necrotizing faciitis, a very severe infection that could take his life quickly. The night float intern had to get surgery to see him right away and get a stat CT of the leg to look for gas in the tissue. As we saw him the second day, the leg was still red, but better. The patient felt well enough to again mention the poor quality and quantity of the hospital food. Dr. Vayairman smiled at his return to his regular self and put his hand softly on my arm as I stood to his right, interrupting the complaints to say with a smile, “Well, she makes really good pumpkin cookies,” as we moved out beside the bed. “I’ll bring you one if there are any left,” I told the patient.

We had to hurry to infectious disease conference next. It is held at the university hospital campus a few miles and potentially a lot of traffic away. Brett, the infectious diseases fellow was stressed because he kept getting late requests for more consults that would likely keep him there late the next few nights. I knew I’d have to come back after conference to finish up my work for that day, which would likely make me late to the big medicine holiday party that night.

Dr. Vayairman asked if I needed a ride over to the other campus. I got immediately nervous again. My respect for him mingled with awe and intimidation and the persistent low-level fear that anything I would do now might disappoint him. “Are you coming back here afterwards?” Even as I asked hit, I knew it was a stupid question because why would he offer me a ride if he weren’t. He knew my car was at the VA. But I didn’t get the look that he usually gave when someone asks him a dumb question. I accepted his offer, feelings strangely like it was some sort of first date with someone I’d had a crush on for a year and never expected to take any notice of me.

I fiddled around anxiously, waiting for him to get his keys and wondering if the fellow would ride with us or if the offer was just good for me. Apparently just me. He changed from his white coat into his leather jacket in a medically comforting act that reminded me vaguely of Mr. Rogers. We walked together to the special staff parking lot and he picked up one of the local publications and offering me one as well, saying his wife was often in it because of her involvement in the local political scene. He explained to me about one of the journalists who kept up with all of the on-goings in the city scandals. We got to his car—an unexpected little two-seater Miata. He told me that his wife had bought the car when she’d given up on their three children ever getting married and having grandkids. Now they had three grandkids and his wife drove the sedan and he got to drive the Miata, which he said he loves to accelerate until something makes him stop. A side of him I hadn’t seen, but somehow wasn’t completely surprised to discover. We talked about his kids and how he suspected his daughter was, but would never admit, she was jealous of his son’s wives. And how his oldest son didn’t forgive his younger son for being born until he was a senior in high school. The three of them got along now. He got to see them often and for the holidays.

I remembered his granddaughter’s name and what she’d been doing from the first time I’d been in his office four weeks before when he’d called his wife to try to discover the name of a good restaurant he thought I should try for Thanksgiving. He had a new message from his granddaughter that he listened to then played out loud for me with a contented smile. Emily rambled sweetly on about wondering when he would be home and telling him about the gingerbread house she’d made with his wife that afternoon. I asked about her and the gingerbread house as we drove to the conference and his smile reappeared.

He remembered about Bryce playing baseball in New York; and I wasn’t even sure when I’d talked with him about that. Somehow the topic of my parents divorce came up. He asked how long they’d been married and we talked a bit about that as well. I felt safer away from medical topics, since with them I had every chance of saying something stupid and I would rather avoid the look he gave about those comments.

The conference was fascinating, too. A very sick patient with what appeared to be a disease that was based on the body making antibodies to a tumor which then attacked the brain. A difficult clinical diagnosis to make, but one that, once made, could potentially have a good outcome for the patient.

I waited for him and again offered to ride back with the fellow if he didn’t need to head all the way back to the VA. “No, I’m going back,” he reassured me, then asked with infinitesimal insecurity perhaps, “Unless you want to ride with Brett?” Did I make him nervous, too, in some strange complicated yet perhaps infinitely simple way? No, I would rather ride with him. Besides I’d left my stethoscope in his car.
We talked more on the way back, some about the science and medicine. He remained fascinated by the human body in all its complexities. I did too, commenting that I was awed that it worked as often as it did, knowing all the things that could go wrong. We talked about Bryce’s friends whose phenomenal beach house I’d visited the night before. I found out that he knew the man who had designed it. And his son had warmed the bench with Bryce’s friend’s father on their high school basketball team. I asked if he planned on going to the party tonight, “No, I used to go until I realized that all the house staff just waited until the attendings left to let loose.” I nodded remembering the drunken debauchery the year before as the group of socially stunted and overworked young doctors tried to relax and interact in some semblance of social comfort. I told him about the renal attending who had stayed late and danced a wild jig with one of the third year residents. He grinned and giggled in surprise and amusement.

When we got back to the hospital, I went into the resident room to finish my work and he returned to his corner office. I felt giddy—like I’d just carpooled with God. I wanted to tell him how much I’d enjoyed working with him over the past month, how much I respected him and how much I had learned from him and how much I appreciated his concern and understanding and what a wonderful clinician and person I thought he was and how I would always remember him and draw strength from his example. I didn’t know how to even start, though. I want to believe that he knows. He stayed for only a couple minutes to grab a few of his things before walking by our door and saying goodnight.

I finished my work and walked out into the cold dark night, hurrying to get home and get cleaned up and changed into my blue satin formal to meet my mom and brother who were my dates for the party that night. It would be the first time I’d seen them since my dad had dropped my brother off two nights before and my mom introduced her boyfriend to Bryce and handed my dad the divorce lawyer’s bill all at once. My dad was sobbing when I talked to him about it. And I was furious with my mom and realized how much I’d missed my little brother in the six months it had been since I’d seen him. That night, I finally had finally cracked about the divorce. I drank too much and felt guilty about hurting Bernie’s feelings and being mad at my mom and bringing it all up and crying with my brother as we sat on my bed and mom watched us hurt and started crying herself.

But I thought, in those dark moments as I walked away from the VA, mostly about the patients I would miss seeing the next day. I thought about missing working with Dr. Vayairman. I felt grateful for the time I’d been able to learn from him—and not only about medicine. I thought about life changing and how we all had challenges and stories and struggles. I wanted time to explore more than the edges of the thoughts that glanced off my consciousness. But I also wanted time to live and learn and do.

I tried to suppress the sadness that comes with a transition away from the time I’d spent at the VA and focus on looking forward to seeing everyone that night and the new rotation I would start in the emergency department the next day. I could take it with me, after all, all that I’d learned and thought and done. All of that was now mine, and portable. If I could minimize the guilt and learn from the mistakes and ask questions and not expect myself to know everything or be able to fix everything; if I could forgive myself a little more, maybe I could get centered again, for a while, on this ever-shifting balance beam of life.

Discharge to Home

Sunday night was my first 30 hour shift in a while. And the first one when I got no sleep at all in an even longer while. Usually I can rest for a couple hours, but not that night. One of my patients died--little red-bearded bald Irish man with a very big sweet personality and a very sick liver. He hadn't woken up in four days. He had been staring off to his left with glassy dolls eyes for two. The med student who has been following him stood at his bedside and held his hand. I had told her he was dying and she didn't want him to be alone when it happened. She left at 8:30 pm. His body struggled to breath erratically for another hour and then it began to breath in whispers. I'd given him morphine earlier because his heart was beating fast, telling me the only way he could that he was in pain. The nurses called me before 11pm to tell me his pulse was in the 20s. I had nothing left to offer him. I had not been able to fix him when he was awake and talking to us. He needed a new liver, but had still been drinking so couldn't get on the transplant list. And then he kept getting sicker. Just earlier that day he'd had a partially collapsed lung which we re-expanded. We could fix the little things, but the over all body was too broken.


He would be my med student's first patient who died. She took it hard when she realized what was happening, "I've never seen anyone actively die before." She'd spent quite a bit of time with him when he was alert and talking. He was a nice man. We all liked him. Toward the end I talked to his brother in Seattle daily, encouraging him to change his brother to "comfort care" so we would stop trying to fix every minor thing and fix the big thing and make him comfortable as he moved away from this world. But I was reluctant to say that death was inevitable. "Very likely," I said. "Short of a miracle," I tried to convey to him. But I do not presume to know for sure what will happen. In my heart I believed he was dying. My clinical and guttural knowledge had wanted to stop trying to save him days sooner when he still had the ability to talk to us and tell us what he wanted. But even then he'd said he wanted to keep trying, "Might as well try," he'd say. He was a fighter.


At 10:52 pm that night he could not fight anymore. "The patient has expired," the nurse said to me on the phone. "Okay," I say and collect myself for a moment before going to pronounce him dead. When I get to his room, the curtains are drawn between him and his roommate--a patient I took care of days before when he stroked and no one believed it until it was too late. My dead patient's hands already felt cold. The nurses had put patches over both of his eyes--they didn't like the unblinking blue eyes that stared even when he still had breath barely in him. But now, he wasn't breathing. His heart wasn't beating. When I removed the eye patches and touched his cornea with a tissue he didn't offer to blink or move. He saw no more here. He had wanted to make it back to his home in Mexico--to his friends. Even as he'd asked me days ago, I felt that he never would. I didn't want to take away his hope, though. Sometimes hope for life wins against all medical odds.


His brother told me he wanted to be cremated, but he didn't know where he wanted the ashes spread, or if he did. His family granted permission for an autopsy, feeling that their brother would have wanted to help contribute to medical knowledge; he'd have wanted to help. From what I'd known of him, I thought he would have wanted that, too. They did the autopsy today. I'll hear the results tomorrow.


When a patient dies, I do death note and a discharge summary where I answer prompted questions like: "discharge diet" and "discharge activities" and "discharge location." In this case, what was I to answer? Diet: whatever he wants, ambrosia and honey perhaps. Activities: the canned answer is "as tolerated." I suppose that could apply here, but I chose to type in "not applicable." Whatever activities he would not undertake would not be tolerated by this body, perhaps with the next he would drink less and take care of his liver. Or perhaps he lived briefly (he was only 58) and brightly and hard and happily. The quality of time, for him perhaps, trumped quantity. I wonder if he thought that at the end. I'll never know.


In answer to the question discharge location, I usually get to answer, "discharge to home." I suppose that could apply to him as well, the final discharge--to home.


And hours and hours later, I would discharge myself to my much more earthly and tangible home. All I wanted was food and shower and bed. I was so tired. So very very tired. And yet. I ate. I showered. I'd ran out of energy to find my PJs so just climbed into bed (benefit of living alone, I suppose). Then I hear Jane outside my door discussing if she thinks I'm home and awake. It's only 8pm by that time. I hear her and get out of bed to say hello without thinking. I could have laid there and been asleep in about ten seconds but I wanted to connect with live people. I wanted to say hello to my friend. I didn't want work to drain the life energy from me so I would not have time to do things that are important to me. It nearly does. Everyday it tries.


Somewhere in my subconscious, however, the words that the Reverend had reiterated in that Sunday's service about Bhuddism must have echoed. He ended the sermon with them:


"Life and Death is a grave matter
time passes quickly away, and opportunity is lost
each of us should strive to awaken
take heed, do not squander this precious life."


At 5:30 Monday morning, after I'd been up all night, covering every single medicine patient in the hospital, a man in his a t-shirt and tighty whities with a cane had cornered me in my workroom and demanded my name because he'd told me to come fix a bed and I'd passed on the request instead of doing it myself right away. I'd heard him down the hall as he hunted around for "the nurse in white." When he asked the nurses (who wear festively colored scrubs) where she (I) was they said they don't wear white. The hallway where I work is deserted that time of the morning. And he stood ominously in the doorway when he found me and waited as I finished up the current crisis and phone call. "I want your name!" he barked at me. I tried to surmise why he was so upset but he was cryptic about it. I explained that I'd passed on the message about the bed and that someone had planned to come fix it for him. I hadn't come to tell him because I didn't know his name or which room was his. He was silenced for a moment, but stuck to his guns, "I want your name!" I wrote it down on one of the index cards we use to write down daily labs and "to do" lists and test results and patient histories so we can keep track of caring for our patients. I added the "MD" to the end of my name. I haven't heard any repercussion from the incident since.


In retrospect, I should have documented it immediately. Who I talked with, etc. But in those sleepless moments, I felt too hurt and abused to act logically. I took it too personally. I was upset that I'd been up all night (and the prior day--and as it turned out the day to come) taking care of patients who now take out their frustrations on me. I thought this way because I was frustrated too. Frustrated that I'd been up all night. Frustrated that I could not "save" my patient. Frustrated that the rules had been bent yet again that night so that my last admit had been hours after our team was supposed to stop taking new admits. Frustrated that my resident had been yelled at about something that she felt she'd done right. And frustrated that soon I would be a resident; and I really don't like to be yelled at.


I recollected myself while doing a little of the more mindless, but required, paperwork. I reminded myself I was tired, not to take things personally. His anger was not about me. I thought of some of my happy thoughts. I remembered my WWII vet patient who had broken his leg and who had celebrated his 49th wedding anniversary in the hospital where his friends brought a cake with a picture of him and his wife on it for all to share (that day I let it slide about his diabetes). His wife brought us all hats she'd hand-crochetted. I picked out a brown and black and cream fuzzy one to go with the scarf I got in Spain. And there was another happy thought: Spain. Even when I'd talked to the brother of my patient who had died, through his grief he'd thanked me and the rest of his brother's doctors. "You all did a great job. We appreciate you so much." And I felt better remembering these things. Incidents like patients yelling at me used to upset me for days; I think getting the upset down to hours is progress--progress I'll have to accelerate when I'm a resident myself. Either get over it faster, or spend more time crying. In reality, I think I'll end up doing a combination of both.


So, exhausted after my long long day, I still found myself not squandering this precious life, but instead out with my neighbors in hastily thrown on clothes, putting up all of our collective Christmas lights until I simply could not remain vertical any longer. On my way home, Jane had sent me a text excited for me to see their project. She had been ambitious and put up a feel lights around her apartment. Jane's were in a perfect Martha Stewart style shaped into Christmas trees all in white. As we put up more lights, every one's part seemed to reflect some bit of their personality. Judy's were random and ended abruptly. Bob didn't want any up by his place. Everyone helped put mine up in a green Christmas tree shape next to my framed kitchen window.


I laughed uncontrollably with them because it felt good; and I was too tired to remember how to stop. Judy kept saying how "glad this made her heart" to have all of us out and decorating for the season. She hugged everyone many times. And she kept finding more lights in her apartment and coming out with them and directing Joseph (the tallest) where to hang them. Sean produced a couple strings of lights also and wrapped them around the little tree by his door (his aunt died unexpectedly the other night and he rushed home to see me so I could fix it--I couldn't fix that either). As he put up the lights, he started to smile a little again, too. I drug the ones I'd had around my inside window outside and contributed to the lighting effort. Doug even came out of his door to which Randy had donated lights with bulbs the size of fists that made you feel like you could walk into the twilight zone coming out of it. He smiled and planned a disjointed string along the corner of the red termite-eaten fence at the edge of the property. Randy fiddled with the 15 automatic settings of his perfectly turned blinking lights next to the Santa and Rudolph lighted figures in his window. It was quite a show. Quite a show.

And Hanukkah starts today--the Festival of Lights. We got our lights up just in time. And I made it to bed way past time, but well worth it. And tonight, I must do the same. Discharge thoughts to dreamland. Discharge to home. Good night...