The Great Beyond

Maps

2010-04-19T20:21:00.000-07:00

The other night I dreamt I was seven months pregnant. All sorts of things were going through my slumbering head. Who was the father? Did I care really? Mostly I was worried that I had had NO prenatal care at seven months gestation and I was trying desperately to get in touch with one of my three Ob/Gyns (in real life I only have two), but it was Friday and no one could call me back and something seemed wrong. I can't remember now what. Just before I woke up, I remembered that I had been on coumadin (or warfarin--the rat poison I actually do take to keep the clots in my brain from growing) during the entire pregnancy. And that it is a teratogen, which means that it causes severe damage to fetuses--in the case of coumadin, usually bony deformities.

I awoke feeling anxious and strangely happy to at least be pregnant. I reached down to my abdomen but there was no swell of a seven month pregnancy. Just the disguised 6-pack from those sit-ups I've started doing again.

That dream lingered all day. I was in neurology clinic and a woman brought her five-week old and her husband. The baby was their third.

It was not the first such dream I'd had. I had a dream a few months ago that I'd given birth to a litter--literally five babies and that I hadn't expected that many and that my family kept trying to put them in the back of the pick-up truck to help get them home and I was unmarried and had no partner and beside myself trying to tell them that we at least needed to get car seats to strap in the back of the truck for the babies.

Another was about being pregnant also--two months that time.

A father to these nighttime deliveries never surfaces.

These next few weeks I'm on Ob/Gyn. Today was my first clinic back in reproductive-endocrinology-infertility clinic since med school when I rotated through one. This time I'm older, though. "You can't cure birthdays," my attending jokes. Very funny. "The female residents who rotate through here always get freaked out and get their FSH checked." How did he know? Anything above 12 three days before your menstrual cycles and your chances of conception are 3% per cycle, and half of those will have birth defects. Or something like that. I told him I didn't want to know anyway.

I lament this my age-related fertility and the coumadin and lupus and singleness occasionally. Today to my friend Karen, whom I have known since kindergarten, who has a husband and an adorable little boy of her own. She says sometime she wishes her life were different, too. Rarely, but sometimes.

Yes, we all have different challenges and goals and paths we take and have taken.

Now that I finally have my life somewhat back with a regular schedule, no more overnight calls unless I moonlight, a job contract signed, nebulous thoughts of training for a triathlon again (flat on the bike this morning and walked home barefoot), a puppy, new music to explore, time for more travel, I have thoughts of a family of my own more often.

I find myself wanting to say to the universe, "Hello Life! I barely recognized you. Oh how I have missed you. Welcome back."

The last patient of the day in infertility clinic was 35 years old. She was the only one there with her husband that day--some of the others having spouses overseas and there to try to get pregnant with their frozen sperm. The attending briefed me on the situation before we entered the room, "She has breast cancer. She's had her surgery and is ready to undergo chemotherapy. She's here to have her eggs harvested since she's not sure what will be possible after the chemo." I find out also that her tumor is estrogen receptor positive--or was--they'd told her they got it all out.

There is a question of whether or not to fertilize the oocytes (eggs) before preservation. There exists more successful experience with freezing them this way, but it raises the question of creating a form of life when the mother may not survive to grow them into reality. The couple doesn't hesitate to choose to freeze fertilized eggs instead of the unfertilized eggs. They seem confident that she will come through it well. Despite this her eyes start to well up a little when she asserted, "I want these embryos." Military families don't cry often in public in my experience. I watched her concerned husband and thought I could see fear in his eyes--fear of losing his wife, fear of no child in their future, fear of having to change his expectations. Fears--or perhaps those were some of my own fears shadowed onto him. I won't know.

On the way home from clinic, feeling distant and thinking dark uterine thoughts, I glanced up in time to see a bookstore to which my aunt and uncle had given me a gift card for Christmas. I like books. "Maybe this will undo my mini-funk." I pulled in and got out of the car by a tai bo studio with a homeless person rifling through bags on the back step and a barefooted man with boxing gloves blowing his nose in the bushes in front. I pretended I didn't see either.

The bookstore was new to me--and enormous as it wound its way back through the converted movie theater with the beautifully painted ceiling. I meandered by the gift cards--Mother's Day approaches, but mom likes the cards I make from my pictures best anyway. She needs a new address book since her ancient avocado green one continues to disintegrate but it makes more sense to just enter things into her new Droid for her. Easter stuffed bunnies are on sale and Sophie loves the one I got her last week--loves to destroy it that is. The kids' section is at the back and I move in that direction, recognizing authors and titles along the way, pausing at the pet section and noticing a title, "In Dogs we Trust." Really? I move on. The kids section has beautiful books from my youth. "Where the Wild Things Are." "The Giving Tree." But nothing that catches my eye now.

I decide to leave and walk slowly back toward the door, looking left I see maps. I like maps. They take you places. They provide guidance but don't insist that you end up anywhere in particular.

I like maps. So I turn left. The maps are accompanied by travel books; the Eyewitness DK books are my favorite. I look at the familiar format and see the ones I've carried with me overseas to their namesakes: "Italy," "London," "Spain," "Barcelona," "New Zealand," "Thailand," and the ones I've purchased but not yet delivered: "Greece," "Turkey." And so many more. None of the European or Asian destinations feel right this time around. I go to the other side of the bookshelf and see South American titles. "Peru" catches my eye. I want it. I remember the Mayan ruins we visited during my high school years when my parents were together and our family friend who was the only doctor I really knew was still alive and our families traveled together to the beautiful Yucatan peninsula. He died suddenly when I was in college. His only daughter is getting married this weekend.

I barely look at the "Peru" book in the store. It feels right. I'll devour it with dreams over the next weeks or months. Maybe I'll go. Maybe I won't. Either way, it will be fun to know I might--and that I can. Being without child does have its advantages.

Maps have all sorts of paths--and all sorts of destinations.

Every time a bell rings, an Angel gets his wings

2010-03-24T00:52:00.000-07:00

It has been two years today since Pop died in his sleep at home. Mom called me as I strolled along the New York streets. Numb. Instantly numb. I lost the messages he'd left when I switched phone providers last month. I didn't think about it until afterwards. They were already gone by then. Him saying, "Hi, hon! I just got your little message. I never know when it is okay to call. I know you're busy. I'll talk to you soon. I love you. Bye, bye for now." Or excited that last time they released him from the hospital, "I just wanted to let you know they're going to let me go today. Becky's going to come get me. They think around noon I'll be ready to go." He was so happy to go home. Or calling about the package he'd sent me with my snorkeling flippers and a "little note." Or even that last conversation from New York when he was sick and I told him I wished I were there to take care of him, and he said he wished I was, too. I regret that. It does no good now, I know, but I'm sad about me here in Michigan at 4am. I'm probably just tired. I miss him almost everyday still. I've taken to wearing my grandmother's wedding rings, one from Max and one from Pop. They tinkle when I move my hand sometimes. I know he already has his wings, though, many times over.

Anne Morrow Lindbergh

2010-03-24T00:33:00.000-07:00

For sleep, one needs endless depths of blackness to sink into; daylight is too shallow, it will not cover one.

North or South

2010-03-21T11:39:00.000-07:00

As I hosed the cobwebs from the rafter and the leaky hose dripped water down my arm, shirt, jeans and sandals, I felt remarkably comfortable. Solid. Stable. Warm. And at home. The rafter I hosed was in the barn where I’d spent the two decades of my childhood. The saddle rack where I cleaned my saddle for Pony Club Events dripped where I’d rinsed off the chicken poop from the top. The barn swing I remembered catching between my legs on leaps from the hay was tied over to the side. The bails like the ones we spent those sweltering nights collecting from the field rested out front where we’d pulled them out of the way of the water. The cobwebs may well have been the same as the ones that were there when I was a kid. I don’t remember the barn ever getting this thorough of a cleaning.

So despite my physical drenched state, I felt dry, warm, at home. Colin and Becky worked out in the sun emptying a porcelain bathtub long ago turned horse trough. We’d spent part of the sunny morning fixing fence. I’d brushed the horses with Katie. We completed solid, physical, tangible task.

The field shines a lovely light fresh green this time of year. The plum trees bloom in the lawn. The red oak that once was as tall as my mom towers over the arena fence. The old tractors sit in the remarkably clean path to the barn (a testament to Becky’s industry) in the sun where my dad left them with plans for restoration years ago--as it turned out not the only aborted restoration on the property.

Bear, the black lab my mom got when I was in medical school, sat on my feet and smiled backward up into my face when I scratched his ears. I thought of Sophie, my new puppy--a Yorkie-Shitzu cross--who weighs less than the cats on the farm. Despite my denials to the recent relentless teasing, she is a “So Cal” dog. I knew it. And I knew that parts of me had adapted to the Southern California life I, too, used to mock when I lived up north and begrudged the water “they” took and thought of them as prissy whining traffic-jam loving foreigners. There was something distant about that part of me, even as I sunk into it.

I thought, as I moved further back in the now dripping barn, of where I wanted to go next. I love San Diego. I love the ocean. I now even love my residency and appreciate the training I have been blessed enough to receive. I have friends down there. I have work contacts. I am known in the medical community. There is a job I have chased that will eventually become a reality--a job like one I always said I wanted. One treating the underinsured. It will take time to turn it into the job I envision, but the potential lies within.

I love it here, too. Spring is a beautiful time in Northern California. The seasons keep you focused and centered. I don’t miss the rain when I live here like I do down south. The closeness to the growth of so much of our world’s resources feels fundamental, actual, and real. The people are different, too. They are hardy and supportive--the kind of people who will stand beside a friend until the end, or stop along the side of the road to help strangers. They look familiar to me. At the spaghetti feed in Vina tonight, I recognized the now man who gave me bread. I went to school with him from the time I was a very small girl. I recognized another now woman who I knew from somewhere. I sat next to my brother and his wife whose family we’d spent every Fourth of July since I could remember. The mediocre food tasted better because I knew the proceeds went to the poor school where we ate.

I don’t know where I’m visiting anymore. I know where I find my past--wrapped up in this big old farm house with my brothers’ heights marked on the door frame, or that dusty saddle in the tack room, or the small jumper with my name embroidered on it I found in the shed. I know where to find my present, in the hospitals and clinics and beaches and bikes and patients of the warm sunny south just north of Mexico. I don’t know where I’m visiting. I don’t know where I’ll be a year from now. I don’t know where I want to be.

At every juncture like this, I have envisioned a partner to help guide my decision. I guess I should stop thinking like that. I’m perfectly capable of making these decisions on my own, despite how much I fret about them and tangle my worries into the plethora of crocheted hats I’ve been producing lately.

I supposed I’m waiting for an epiphany. I guess I should look a little harder.

I still have my Bhudda bracelet from Thailand around my wrist. Bryce’s fell off and Becky’s broke, both in the last month. Mine remains strong because I don’t wear on it much. I don’t work as physically hard a Becky nor do I take it off when I need to pitch like Bryce. I just read and do yoga and run (recently again at last!) and go to the office or clinic where the work is in my head and my callous-less hands. That’s the practical explanation at least.

It’s also, I think, because I still need it. This tattered piece of string around my wrist is a symbol of a blessing from a monk in a language we didn’t understand. The best we could gather is that it is for good luck. Fortune. Maybe for epiphanies?

Yesterday, I yelled at my Bhudda bracelet about the things I wanted it most to find for me. I’ll give it time. I’ll even help it out if I can.

When I moved so often during my lifetime of education, I learned to take my home with me--inside of me. It became physically lighter and lighter to carry around as I shed items that no longer mattered. My home is with me. My home is me. I just need to figure out a new place for my home to live.

Seasoning the Wok

2009-10-07T23:42:00.000-07:00

I returned from Thailand seven days ago. It seems longer than that and already like another world away (perhaps the nineteen air hours it took to get there contributed to that). It was another world in many way, though. Warm and humid and sandy and tasty and sensual. Massages to be touched. Cooking class creations to taste and smell. Elephant skin and warm coral filled water to feel. Tonal language with unfamiliar rhythms to hear. Blue salt water lagoons, green rice patties, pink dragon fruit to see. Sensual paradise.

And now I'm seasoning a wok I bought. Or trying. They made the cooking look so easy in the class in the warm kitchen under the papaya tree with the garden out back. Ingredients chosen expertly by the team from the fresh outdoor market, portions divided up, sauces mixed for us. All we had to do was chop and heat basically. Even though heating did involve purposeful flames at one point. I'm in between oil seasonings now. The wok is cooling. I have no idea if I'm doing this right. The instructions in black and white don't have the color of the smoking oil coated pan included. Even the internet pictures aren't helping much.

I'm thinking that our cooking instructor's guarantee for perfect Thai food is sounding better and better: "Go to the night bazaar," pausing while she stirs her perfectly cut and beautiful vegetables, "Buy a big suitcase." I'm wondering if there are secret ingredients to take back--something that will magically transform me into San Diego's best Thai amateur cook. I stop stirring and look up. "And take me back with you! No visa required!" A smile crosses her face as she cocks her head to the side, daring us kindly to laugh as she looks up and I hurry to start stirring again.

"Four secrets to good Thai stir fry: 1) Thin wok, 2) High heat, 3) Fresh ingredients, 4) Small quantity," her words echo in my head as I'm back in my own country and dreading work the next day with an anxiety that has become ever more familiar but no less uncomfortable. The woman at the Great News cooking store which is layered with aisles and aisles of shiny pots and pans, tiny overpriced mortars like the big one I carried back with me from Thailand, and coconut spoons with stickers and manufacturer information on them tells me about woks as I think about the difference between this clean well-stocked orderly store and the chaotic market with pots and pans hanging, knives out to examine, and coconut spoons made from tying the actual husk of the coconut to a stick. No price tags, no labels. Nothing shiny. Questionably clean. And the puppies with price tags on their head yipping nearby and the smell of fried and seasoned insects and ever present sticky rice on the hot wet breeze.

The woman in the sterile cooking store tells me about their fancy woks made of some sort of conducting material that heats everything evenly but if you put it put them on high heat the expensive surfacing could bubble or crack. I remember the four tenants of good stir fry and the woks we used in class--simple thin, dented steel affairs with a wooden handle which we held with three fingers as we tipped the oil closer to the gas flames just before we threw in the vegetables that went up in brief flames in an instant.

I choose the thinnest wok, which still is shiny and comes with rubber long handle and a shorter one across which will preclude a repetition of the flaming stir fry even if we did have a gas stove. She tells me I have to season it and that she will give me a hand out. It doesn't sound so hard.

I start to smell the stir fry as I place it and the wok brush (also well-labeled but at least wooden) in with my trunk full of food and large quantities of Costco purchases in the cloth bags I reuse. A far cry again from the bustling crowded market full of fresh produce, more eggplants and mushrooms than I knew existed, fragrant spices and roots, and fish swimming in their version of a feed lot. Costco is big and crowded but the high ceilings with artificial light don't recall the high grey blue sky over the jumble of canopies and make-shift roofs. Our instructor tells us about the eggs (which they leave out) and rice (which is in different grades and prices) and eggplants (which are small and green) and roots (ginza, a relative of ginger) and encourages us to take picture of her as she is "so bootiful!" People in Costco rarely make eye contact.

Granted, it is vacation, and therefore an immediate distance from the reality which pays for the fantasy, but still, I choose to take it for such in this moment, perhaps because that is what I need.

The entire time in Thailand, my head did not hurt, my joints did not ache, my ankles which were swollen from the plane ride over recovered effortlessly. I remembered my pills in the mornings but not every night. Otherwise, I didn't think about the lupus. It was irrelevant.

I did think about it again back in the States. I wondered, as I have before, if I would be alive if I'd lived 100 years ago, or even if I lived now in Thailand where I doubt MRVs are as readily available. If I had never taken the hormones which I think precipitated the clotting (to which I seemed to already have a strong disposition) would they have been avoided? Or would pregnancy hormones have mimicked the same and sent me into fits of brain clots without which the MRV and heparin drip I likely would have stroked and died, perhaps with a baby inside of me. I won't know. I can only guess. I know I'm here now and I still wonder. And learn how to season a wok (I'm about to start round #4).

The knots in my neck and back melted away under the expert comfortable rhythm of the beach-side aloe or oil massages. They tiny women would point to have us lay on our stomachs and start with the back, warming and rubbing up and down, untying the damp bathing suit top to make it a smooth plane for hand on back to touch, extending out to the upper arms briefly. They'd finish there with a sideways loose karate-type chop which livened up the muscles and then would move to the legs, covering the butt with a small towel and leaning into the muscles that gradually released under the stabilizing but non-expectant pressure of her weight. The legs were next. She'd sit at the end of the bed near my feet and closest to the flat warm ocean and bend one up, then the other. My calves were tight and painful on the first day at the beach. By the last they were loose and pliable under her strong sure hands. Rubbing my feet was one of my favorite parts. Sometimes she'd hold pressure in one place on the sole of my foot and I'd feel the tension release from my neck or face or chest. Just float away. Even when she released the foot, the freedom from that small piece of anxiety stayed away.

She karate chopped the legs, retied the back of my bathing suit and asked me to turn over, squirting the cooled aloe on my slightly sunburned belly with a momentary shock and I twitched and smiled and she smiled warmly back, chattering in Thai to the other women awaiting customers. She'd put one hand on each of my hips and apply her weight, holding steadily, releasing the tension there out into nothingness where it could no longer hurt anyone. She rubbed the front of my legs again and cupped her hand around my warmed and loosened calves rubbing repeatedly toward my feet. My arms got more attention on this side as she rubbed the muscles of my forearms and stretched my hands and snapped in a slip off the end of my fingers. My middle finger almost always cracked gratefully. Sometimes she'd rub aloe gently on my face. With concluding chops, she'd ask me to sit up and rubbed my back and neck (the corporeal resting spot for the deepest of my worries). Knots were left sometimes when she'd finish, but it was okay. They would leave in their own time; I felt sure. Maybe with the next touch, or the next banana pancake, or the next dive into the warm waters, or the realization of a long warm day ahead without expectations or responsibility, with people taking care of me and directing me and making decisions for me.

This, too, has passed.

2009-07-22T19:55:00.000-07:00

I finished my last day as a Children's Wards Senior today. Last day with my own little team, teaching, rounding learning, orchestrating, helping, guiding, talking, listening, healing. Ward months there are rough months, long days and longer call nights with the admit pager like a constant time-bomb on the pocket of my white coat next to the ridiculousness of my other TWO pagers on the outside of my pocket about which people comment at least three times per night, "Got enough pagers?" I always offer to give them one or all three, but never had any takers. Admit pages would flood in and I'd triage and delegate and strategize and examine and consult on sick surgery patients and review orders long after I'd sent the med students home or to bed and the rest to finish dictating. Or sometimes not and we'd wander around the hospital. I'd give them my ventilator talk, or my Peds in Pictures talk, sometimes a little Neurofibromatosis, or show them the x-rays of the patient I saw with rickets or with dermatomyofibrosis or go over line placement, or just how to read a chest x-ray.

Being a senior, once you get beyond the terror, is really a bit of a high, especially at the beginning of the academic year with all new med students and interns and acting interns and this year even with new co-seniors. I'd try to balance the admissions by work-load and learning-potential between the interns and med students. I'd have the students read and give weekly presentations so they would learn about disease, we'd all learn from them, and the attendings would learn who they were.

It is a small funny world at the Children's Hospital. Loren told me the other day that I saved a patient's life. Perhaps I did. I was the one there; it was what any one of us would do. It was what I try to teach my students and interns to do. To learn what is sick and serious and to distinguish that from the other children who can wait until you save this one takes practice. It always takes practice, but you get better. I saw them get better this month. I felt myself be better at my role, more comfortable in it and more confident, and more humble, more supporting. I felt proud of them and the growth they'd shown over the month. I looked at my med students this month and remembered that five years ago this month was my own first ward month on pediatrics with two med-peds seniors, Dan and Dave, on my team and Jim as mine and Szilvie's intern. I thought my seniors were geniuses. I still don't think I'm as smart as they are, but things have completed a cycle. My acting intern (fourth year med student) from this month is going into med-peds.

I remember my first patient as a third year student. Osteogenesis Imperfecta. I read all about it. I knew the kinds, I knew his kind, I knew very little about the arc of his care or disease, but I did what I could. I got better. Another patient that month had AIDS. He was very sick, but they let him be my patient anyway. I looked up his nutritional needs and his antiretrovirals. He drew a picture one day and handed it to the team on rounds. One of the seniors took it at first but my patient corrected him, saying it was for me, his "doctor." He's dead now, from complications of his disease. I learned that during my fourth year in my Medicine and Literature class. I still have that drawing somewhere. I remember my first ER patient with tracheomalecia. I remember the LPs we did on the children with febrile seizures.

Now I supervised my interns doing lumbar punctures; they both did perfectly. The med students learned to re-assure parents with a thorough physical exam. We all learned how to do better cardiac and neuro exams. They learned how to befriend and not terrify the small children, and how to treat the teenagers with respect and firm boundaries simultaneously. They learned to be excited about the patients and the healing and the learning and teaching we could share.

I can't believe, not that it is over, that it actually is. I started my first month as an intern there three years ago yesterday. Lost in the pink corridors with the round, triangle, or bowl shaped lights, sleeping in the daytime social work office turned call room by night (sleeping very rarely still), slow and worried and lost and nervous. I'm a bit sad, actually. Nostalgic. Dr. Bradley says that means I was good at what I did; that that is a good sign. I'll take that.

Residency is a long, long, grueling training path and yet it is also a precious time of camaraderie and learning that cannot be duplicated. I'll miss the time and the team and the trial by long sleepless nights. I'll miss the dull lull of energy and personal temperature disregulation at 4am (that only a little). I'll miss the emergency chocolate pudding and grahm cracker snack at 3 am because I missed the cafeteria closing. I'll miss my interns and med students. I'll miss chaos of the morning pass offs at the end of the call which precede the drive home and the comatose sleep. I'll miss the daily teaching and noon conferences and morning report and EBM. All of the things that seemed so time-consuming and arduous when I started now seem like old friends.

I don't know if that's good or bad, that it sounds like I have just written my wedding vows to a job I have been dating constantly for three years when we are doomed to separation in another year. I guess I've only ever been good at serial monogamy anyway.

Out of this World

2009-06-17T23:22:00.000-07:00

I'm on MOD-2 for 13 shifts, and in the middle of my fourth shift--they run from 8pm to 8am--and reminded of a bumper sticker I saw last year which I am modifying for this rotation: "Worst. Rotation. Ever."

But, that is not the entire reason I'm writing now (from work in the hour and a half before I start admitting from the ER). The reason I'm writing now is because the supposed "lupus cerebritis" (but really psychotic) new admit needed a lumbar puncture and I was helping Charlene (my intern from the ICU last month) while her supervising resident admitted another patient with her other intern. Seemed normal enough. To start.

Charlene tried the lumbar puncture a couple times, as I'm standing there all gowned up in our sterile blue garb. Of course I had to find an extra head cover because the patient wanted the one in the sterile kit (first clue of impending crazy?). She asked me if I could try next. I sterilly move the table out of the way, the bed was high up in the air so I didn't have to bend over as much; I re-evaluate the landmarks and re-direct the needle to try to slide it in between the vertebrae to get the cerebral spinal fluid. I hit bone and redirect again.

During this time, I reassure the patient that she is doing well. She is courteous and says, "thank you." Then the tenor of her conversation changed, "I have to go. We're going to be late for the party. It's 11pm and we need to go. You need to finish this procedure." I'm trying to concentrate on getting the fluid, and reassure her and ask her to stay still and remind her she has a needle in her back. And then she says, "I'm leaving. I'm going to go." In the split second while I try to decide if she's serious, she sits up and begins grabbing her personal items. I pull the needle out of her back just in the nick of time. Blood starts streaming down her back where it had been jostled by her movement. Fortunately, she wears only the blue bouffant cap, an untied hospital gown, and Depends (which catch the dripping blood), so her clothes are spared.

When she grabs her stuff, she also grabs Charlene's white coat and pulls out Charlene's phone, books and papers from that night's work out of the pockets. "Ma'am, that is my coat," Charlene is calmly reminding her as the patient yanks it back toward herself, "No it isn't! It's mine. I bought it." The nurses threaten to call security and try to reason with her (though she's entirely unreasonable). She's out of bed now and Charlene tries to pull her coat from her and they struggle back and forth in the 6-bed hospital room. Then the patient takes a swing at her, gouging Charlene's hand with her finger nails, and Charlene lets go of the coat.

She storms out of the room muttering nonsense as her 72 year old mother gets out of the way (she's been through this before and sometimes has to lock herself in her car when her 40 year old daughter gets out of hand at home). With blood dripping down her back making a red stain on her white Depends, she makes a bee-line for the elevator. "Someone has to stop her," her mother says defeatedly as we stand there and watch her go, afraid to get into an altercation with her.

Security comes up the other set of elevators after she's already taken the main elevators down, "What's going on?" they ask a little late. We explain. "Is she on a hold?" This means has psych or the ED placed a "psych hold" on her meaning that we can hold her against her will for the protection of herself or others. She is not on a hold. Yet. We page psych and the ER to see who can place one on her fastest and send security after her.

Then we wait.

We wait.

Where is she?

Her mom is concerned, but calm. Charlene wants her coat back. We bandage up her wounds. I'm still a little stunned and ask Charlene how badly her team wanted this LP. Not bad enough to try again. We order haldol to have on hold for when (if?) she is returned.

She is. Three security guards escort her down the hall (now in a wheelchair), still clutching her personal belongings and Charlene's white coat. They tell us they found her at the outpatient clinic a block away and mention that she had blood dripping down her back. They also come up to Charlene and tell her the patient had her badge also, in a somewhat accusatory tone.

The patient has calmed down, apologizing even, but making no sense, "How do they get her into the galactaca when it is all round without windows?" And when we asked her if we could put a bandage on her back, she said, "No, I'm just going to let it bleed for a while." And then when she's all tucked back into bed, she asks, "What does combative mean?"

Charlene's got it under control for now. I return upstairs to relate the saga to the rest of the on-call team and Mark, the night float intern, and continue coveting a root beer float until the cafeteria opens at 11:30 pm. Mark says I should have taken pictures during the coat tug-of-war. He's even willing to reenact it with Charlene. But we settle for a computer stick figure picture for the time being.

O O
{ X ]
/\ /\

1123

2009-05-30T01:05:00.000-07:00

The next day he was still alive, but barely. Barely. They'd moved him up to the 11th floor and something told me right away that he would be in the room I'd been in two years prior.

He was. I learned that his housekeeper and her daughter had come to see him that night after I'd left. She held his and and said his name, disbelievingly.

I went to see him upstairs. He was no longer responsive at all. He breathed a scant 8 times her minute with his mouth gaping open and his body arching back with each painfully deep breath. He's alone in the room. The view is the same as I stared at for days and day. The pictures are the same. No flowers for him, where I had several bunches. They've taken the night stand out, also. He has no need for it.

His bag of personal items in on the chair next to the bed. His wallet is there. I look at his drivers' license picture and he looks sad in it. Healthier, but still sad. He has the card with the mortuary on it. He's made all the arrangements and written on the back the phone number "to call in case of my death." It made me feel a little more at peace that he'd done that, for some reason. He wanted his housekeeper to have his valuables. He had a few rings and bracelets that he must have been wearing when he was brought in originally. His clothes were old, but clean and neat.

He felt warm when I held his hand again.

I went back downstairs to the rest of our sick patients. We rounded on them and saved him for last. By the time, the intern, fellow, and I got there, I looked at him from the door. No more of the gasping breaths. No more breaths. "He's gone," I said.

We walked in. I took his hand. He was still warm. Charlene pronounced his time of death. Tears rolled down my cheeks and she asked if I was okay, "It's just sad." Just sad.

Not Forgotten

2009-05-20T18:24:00.001-07:00

He's probably dying right now. He was breathing in the teens--comfortably for the first time in days and the morphine drip had been turned up to 10. They said he was unresponsive but when I went in to hold his hand and say his name and tell him to relax and everything was okay, he opened his eyes. I stood with him for a while, watching out the window, thinking how sad it is to die alone. They only person he had was his housekeeper and he didn't want us to call her. When Julie, the nurse, tried anyway, no one answered. He was breathing with a face mask now. He'd been grumpy since I'd admitted him a week before. At first he had a head bleed from taking too much coumadin (or at least his INR was too high at 9.8) and had bled into an unusual spot in his head that neurology thought might be a metastases from an undiscovered cancer. I went in to visit him even after I'd transferred him to the neurology service. Once day I went in and he was sitting at the side of his bed with his head bent down over his bedside table. I said hello and asked him how he was feeling. He told me to wait a minute. I thought he had questions for his medical team so I told him I was only visiting now and the neurologists were his doctors. "Just wait a minute. We can talk." I felt bad. He'd only wanted company, which is what I wanted to be, but I didn't understand. He didn't really have much to say. I stood there and held his hand for a minute before he shooed me off, "Okay, you can go now. I'm going to meditate."

Ali surprised me with a visit on that first night when I admitted him with the head bleed. He was sitting outside the room after I visited Mr. M. and he'd curtly dismissed me, telling me he wanted to sleep. Mr. M. was grumpy. He wanted to be left alone, "I'm fine!" He softened up a little. He'd been having trouble breathing for at least a month, he told me, but today he had weakness on his face that was new--"heaviness actually." He came in because he was worried he'd had a stroke. When the head bleed showed up on the CT and his INR came back at 9.8, likely from taking too much coumadin, a grilled him about his diet and his activities. He didn't shop. He didn't eat well. That last month he could barely walk around his apartment without getting short of breath. He'd been to the coumadin clinic 1 month before and always on time for the past three years and his INR has always been in the right range--until now.

It wasn't until a couple nights later when Ali and I started talking some how about how many older people who are lonely commit suicide by either taking too many pills or exacerbating their medical conditions on purpose that I wondered if Mr. M. had done that. He insisted to me that he'd taken the right amount, recited his doses to me correctly and everything, "Five on weekday and seven mg on Sundays." He looked irritated and disheartened when I told him I thought it was the medicine that had done this to him. He seemed shocked.

When I first saw him in the ER he didn't even want to talk to me because so many people had already asked him a million questions. I told him I'd wait and we could see him upstairs. The neurosurgeons wanted "neuro checks" every hour all night. Wake up, open your eyes, have a bright light shone in both of them, move your hands and feet. Go back to sleep and repeat every hour. (I remembered my neuro checks every four hours when I was a patient and even that was horrible. Every single hour. There's no way he slept much those first few days he was there.) I asked him if he felt depressed. He did. He lived alone and had no family. Had been married once, but wasn't now and didn't seem to want to talk about it so I dropped the subject. Had no children.

He did fine in the ICU and I transferred him out the next day. I almost sent him to the medicine team, but on second thought I figured it should be neurology to watch over him since his head bleed and his new kepra dosing was his main concern. Though he had so many medical problems that I knew they couldn't handle well that I hesitated. His COPD was "end stage" with an FEV1 of 1.47. His heart failure on his new echocardiogram had progressed to "severe diastolic disease." His atrial fibrillation was uncontrolled since we'd stopped his medicine for it because of his new low blood pressure. His coronary artery disease had necessitated a coronary artery bypass graft a few years before. His legs were almost black from decreased blood flow related to his peripheral vascular disease. His chronic kidney disease had acute kidney injury stacked on top of it since he hadn't been eating or drinking well and since his volume status was a fine balancing act with his heart barely able to pump any more.

On the neurology service, they started him on an antidepressant and got a medicine consult to follow him (unfortunately not one of our most stellar attendings was on consults at that time). They didn't restart his home medications and they gave him more fluid than his heart could handle so a lot of in ended up in his lungs, making it harder and harder for him to breath. He may also have been aspirating some of his food and developed pneumonia in the interim.

He transferred off our service after about 12 hours and out of the ICU the next morning. I had the next day off but was worried about him so followed along as much as I could on the computer from home. After a couple days I didn't hear about him until one of the traveling nurses who worked in the ICU also came to find me since neither the neuro intern nor attending had paged her back for three hours, during which time she'd called a rapid response o him because he was working terribly hard to breath and his PO2 on his blood gas was 45 and he was in afib and tachycardic and hypotensive. She came to find me just as I was having anesthesia intubate another patient in the other step-d0wn unit, "Can you come see Mr. M.? I can't get in touch with his team." He looked terrible when I got there. I ordered a few things and then asked him if he remembered me and how he was feeling. He remembered me, and though his breathing was very labored he said he felt fine, in very short sentences.

I paged the neuro intern again, signing it "ICU resident" and he called back at last. When I told him how sick his patient was he said he'd be there in 10 minutes--and he'd called from an outside line though he was supposed to be in house. My worry for Mr. M. mixed with my irritation about the lack of recognition about how sick and fragile he was. I told him what to do and cleared a bed for Mr. M. in the ICU again (the same bed he'd had before--the one with an ocean view where you could see downtown and the airplanes fly in and out). But the neuro intern didn't say anything about moving him. I called him shortly after and got a little more stern, saying that he at least needed to let his attending know how sick he is and strongly suggesting that he be trasnferred to at least a medicine team and probably back to the ICU (me). "Oh. Okay. Yeah. Thanks. Sure. I'll call him." I'm sure they do a much better job with all the stuff above the neck than I do, but at the very least he needed to know when to ask for help. And though I very rarely make a fuss, I fussed at him quite a bit about needing to respond to pages and recognize when his patients get much worse.

Soon after I got a page saying his attending "would be happy to transfer him to wherever I thought most appropriate." Good thing since I'd all but finished the transfer orders already.

That whole night, I tried not to intubate him. His COPD was so bad I thought he'd never get off the ventilator if I put him on it. He didn't want the BiPAP mask (though he agreed to it by the next morning) so we fiddled around with face masks and nonrebreathers and oximeters and the like. I diuresed all the extra fluid I could off of him with a bumex drip and diuril. I controlled his out of control heart rate with a continuous infusion of a diltiazem, a rate controlling medication. His blood gas didn't get better, but it didn't get worse either. The fellow that night gave him a 50/50 chance of being intubated by morning. We made it through the night, though.

When I went to say bye to him that morning, I told him I had the next day off but would be back on Wednesday (today) and that I wanted to see him without a tube down his throat.

He was already telling the nurses every morning, "I'm going to die today." Of course yesterday he said it more non-chalantly. Today he was more serious.

One of the interns was going to round on him this morning, but I told him I wanted to instead. He looked no better, but also no worse. He still worked hard to breath and that couldn't last forever. We decided to put an arterial line in him on rounds and by the time we got around to doing it, the results were terrible, pH had gone from 7.37 to 7.19. Not good. And while he'd been more of his cantankerous self the day before and even this morning, he was no longer saying he felt fine. "How's your breathing, Raymond?" "Not so good," he gasped.

Neal, the intern, talked to him about wanted a tube to help him breath. He shook his head, "no," no longer able to talk much for lack of breath. "Do you understand that you might die without one?" He nodded. "Open your eyes, Raymond! I need to make sure you understand this." And he repeated the same questions in different phrases. The answers were the same. My eyes welled up as suddenly I flashed into his acidotic mind and wondered how it would feel to have someone ask you if you understood that you probably would die--very soon. And die without anyone except people you'd met seven days ago. Like your life had been a blip on a screen that was about to go out and no one would even remember you. No one, except perhaps your cleaning lady and her daughter, would even know that you were gone. And who knows if they would care.

The day before he'd met with social work and had been very anxious about being able to pay his rent by June 1st or he would lose his apartment. He also worried that if he died his cleaning lady, Rosarita, had only three days to clean out what she wanted from his apartment where he's lived alone for 15 years, before everything else went to the Salvation Army. He'd fretted about it since before he transferred back to the ICU. On the day when the nurse came to tell me he was breathing so badly, she told me he'd made her look in his wallet and get the card for a mortuary that he carried there. And get the card for his house-keeper to tell her to make sure to clean out his apartment within three days of his death.

It was as if his life would just blow away with the ocean breeze, as if he'd rustled around with the leaves for a few days and then...gone. Nothing left. Things he'd known and recognized and used daily given away. Maybe items he's saved or treasured left without stories or context or care, with no one to remember or know.

I wondered what he thought as he drifted off into that morphine-induced haze as I held his hand and stroked his hair and tried to imagine what his life might have been like, or what he'd wanted it to be like. If he'd had regrets. If he'd pictured his end differently. If there was someone he'd love who he wished were there instead of me. He still opened his eyes when I called his name, "Raymond," the muscles above his eyes flickered and his eyelids rolled slowly up and his eyes moved to focus on me briefly, "It's me. Everything is okay. You're doing great. Just relax now." That morning he'd told us he was fine and that he needed a shave and a haircut. It was hard to understand him through the mask and he'd had to repeat the "shave" part a few times and got irritated.

I looked at his salt and pepper stubble under the oxygen mask and wished we could shave him while he still had any connection with this world. Julie rubbed his face with a warm washcloth over his eye lids and his forehead and his hair and his dry lips sucking in numbered breaths. The scar across his chest reminded me of his CABG a few years before and I wondered who had helped him recover from that. Or who had gotten him to his coumadin appointments or to his doctor's appointment with one of my co-residents. I remembered Pop had had a CABG too, and I'd come home to take care of him. My hands were colder than Raymond's, but I knew they wouldn't be for long. I squeezed his hand and rubbed his shoulder and looked at the liquid drip into his veins. His arterial line was oozing and when I moved my hand away there was a puddle of serous fluid in his palm. I was surprised each time I returned and his hands felt so warm.

His heart rate had slowed way down, despite us turning off both rate-controlling medications. His blood pressure was low again. His O2 sat was 92%. I watched his heart monitor flutter around 66-62-60-58-59-58-57. When you don't get enough oxygen and your most recent blood gas shows that your pH is 7.10, your heart doesn't work well. Your body is tired.

I remember now what I said at Pop's service, that he was tired and it was time.

And maybe it is time. I fretted and went back and forth with his intubation with the attending earlier, knowing that I could convince him to get the tube in in throat and that on the ventilator I could fix his blood gas. But I couldn't fix his lung disease, or his heart disease, or his kidney disease, or his loneliness. The most I could do was prolong this inevitable thing that may have taken him even as I have been writing. And he may do to a nursing home or a "rehab" facility which the fellow, who did moonlighting there, said was "a fate worse than death." I knew Raymond was tired, too, and that he felt tired, and sad, and frustrated and alone. I supposed he was ready, "Do you understand that you might die?" Neal yelled at him as we tend to do with those who are very sick. He nodded.

I fought back tears as I held his hand and looked out his window, thinking of my med student's patient who had died a couple years before at the VA and her asking me if I'd been there when he died. I hadn't. The nurses called when he was almost gone, but I didn't want to see the end and he'd been in a coma all day.

All I could do now for Raymond was bear witness to his candle flickering out. I could make him comfotable so his last breaths weren't agonal. I went to the bathroom and came back to say goodbye to him, "Just relax," his eyes flickered again and I placed my other hand over his heart feeling it beat, still warm, in his scared chest, "Everything is okay. I'll see you soon. You're doing great." I squeezed his hand and asked Julie, who was now doing her charting in his room instead of outside where the nurses usually sat to keep his respiratory rate below 30--to keep him comfortable. She said she'd thought he would go faster once we'd started the morphine drip, but she wanted to not let him die alone.

As I waited to talk to her before I left, they moved his 84 year old neighbor out in a body bag. He'd come in the night before after being found on the floor of his apartment covered in flies and feces when the management came in to see if the fire alarm was still working--so dehydrated his tongue was retracted back into his throat. His leg was dead with dry gangrene and by the morning when I came in his arm, too, was cold and pulseless. And while he'd been report-ably able to nod appropriately in the ER, he was no longer waking up at all even though we'd turned off the sedation hours before. I cringe to think that his last days were spent alone on the floor of his apartment like that. I cringe and I cry. I'd tried to find any family or friends of his that morning, but he'd only listed the security guard at the place where he had lived five years ago, a man who remembered him but had only had casual small conversations with him and knew of no family or friends. Every year after that when he'd renewed his lease, his apartment manager had said he'd left that line on the form blank. "No family or emergency contacts listed." Not a single soul to call or care or even know that he's gone. No one to claim the body. No one to know.

Perhaps they have both touched people in their lives who will remember them. Perhaps Raymond was grouchy always and drove people away. Perhaps the other patient, who his landlady called, "a sweet man," did not remember those last horrible days, but some good day. Maybe a day he spent in the woods or at the beach with someone he once loved. Or maybe a day spent alone but with that unreasonable happiness that has no explanation except that it is. Maybe Raymond is glad he is not dying alone. Maybe he's glad to be going. And maybe he's going somewhere more hopeful where he can breath easily and his heart can beat strong again and he can walk on feet that done constantly ache. My fellow said she doesn't know how people can do this job without some sort of belief in a higher power and some place after.

I don't always know what I believe, but as I placed my hand over his heart and said goodbye, I said to myself, "May God bless you and keep you." May he indeed. In a way that mankind has not blessed or kept you. And in a way you have not been able, perhaps to bless and keep yourself.

When Raymond came in that first night, grouchy as ever, I'd asked him what he liked to do and if he had any friends. "No, I don't talk to people much. I'm a thinker. I like to think. I like plays and opera. I'm deep. I never finished more than eighth grade, but I like real conversation. I don't watch that trashy TV. I read books." I pictured him then in his apartment, alone, thinking about ideas he didn't or couldn't express. I wondered how he'd watched opera or if he really had or just wanted to. "I'm deep!" he'd insisted to me, as if he still has something to prove.

But he had no more time to prove anything. Or maybe he did. Maybe that it really was his time to die, and those cards he carried around in his wallet and his worry about his house-keeper cleaning out his apartment said that he was ready. Maybe he proved again to me that sometimes it is okay to go. Maybe even that it is okay to go alone, if that's what you want. Maybe that this grief of his solitude that we have imposed on him is akin to the pity he disdained. Yet, still I believe that holding his hand and a wet washcloth on his face and a stroke of his hair felt good, and felt like someone on this earth cared enough to make it okay for him to go on to the next.

All he'd wanted to eat on his meal tray the day before was the vanilla pudding. Julie said he'd scarfed it down. Today we got him more vanilla pudding. It was all he wanted to eat. That and a milkshake. Two puddings and an Ensure (the closest we could find) sat unfinished on his bedside table.

You see, Raymond, you are not forgotten. Now at least someone will remember that you liked vanilla pudding. And that you liked opera. And that you meditated. And that you liked to think. And that you were tired and ready to move on. I may not know your whole life, except what I imagine, but these things I know. You are not forgotten. Even as I picture you barking, "Forget me! Leave me alone. That's what I want."

Is it?

Expiring

2009-05-08T21:13:00.000-07:00

"Doctor, I do have one more question: Can I kiss her?" He asked the intern as I stood off to the side. Neither of us had ever met this strong and kind-appearing man in jeans and a brown plaid shirt. We'd only spoken with him on the phone several times that night. Each time with worse news. Matt, a bright and kind intern, had called him to consent for an arterial line when her blood pressure was dropping into the realm of other worlds. He'd spoken with him about his wife's state. He'd done everything he could with the two small peripheral intravenous catheters that he could. He'd called me when she needed intravenous medications to keep her blood circulating. Medications that usually have to run through a more invasive central venous line--medications you only can use in the ICU.

I'd met her two days before. But she'd died two months before I'd met her I later discovered as I read through her records. Six months before she'd gone in for surgery to replace both of her knee joints due to severe arthritis. One became infected and they tried antibiotics. A lot of antibiotics. Some of which she was, as it now seemed, deathly allergic to. She got a rare condition in which the top layers of skin separate from those beneath. She had "toxic epidermal necrolysis" over 90% of her body.

Your skin is your largest and possibly most important organ in your body. It keeps in what needs to be in and it keeps out what needs to stay out. They'd taught us that in medical school. And the woman I met two days before proved it to be true.

In the time since she'd developed TENS, she had undergone multiple rounds of bacteria in her blood and low blood pressure and months of ICU care and central venous catheters to deliver more antibiotics and blood pressure medications. Then her kidneys failed from one of her episodes of low blood flow and she stopped making urine and needed a larger central catheter to be on dialysis. These catheters got infected along with her blood. The bacteria that she started growing in her body became resistant to all but the strongest and newest antibiotics that we have. Then on February 2nd, she'd died.

She went into cardiopulmonary arrest, or as we say, she "coded," necessitating extreme measures to resuscitate her. And the resuscitation worked in the sense that her heart restarted and her brain kept the centers that told her body to breath. But the rest of her brain was gone, having suffered massive strokes as a result of the intervention. It was like the little babies I'd see who don't get enough air to their brain when they're born. Sometimes they live for years, but they only know to breath reflexively.

Her skin was the color of a severe sunburn. And it sloughed off wherever tape or catheters were attached, and even in several places where nothing was attached. Her hair had almost completely fallen out; what was left was in greasy curly wisps across her scalp. She was swollen from what I imagine were high doses of steroids to keep her body from attacking its skin and from the large quantities of fluid we'd given her to keep her alive those last few days. She smelled of infection and we put on the yellow "contact precaution" gowns when we went into her room, not wanted to transmit her infections to ourselves or our other weakened patients.

That night when we were losing her blood pressure, I called her husband and told him we would need to start medications to keep her blood pressure going. It was the first time I'd spoken with him but I knew from the chart that he'd had several conversations over the last months about his wife's state of health and her impending death. The next days he'd planned on moving her to a hospice facility so she could die comfortably.

To preserve her live that night what I really needed was a large central line--one for pressors and dialysis. It would be difficult to get on her and it would be painful. He didn't want to keep trying to perpetuate what remained of her life, however. I supposed that I could try peripheral pressors, which don't take long to burn through veins and cause longer-term complications which I knew would not be an issue with her. She was out of "long term" on this earth.

I offered that to him, only wanting her to make it five more hours to 8 am when she could go to hospice and die comfortably. I suspected, though, that she would not make it that long. And I knew she wouldn't unless I gave her those medications.

It had taken him months to come to terms with the fact that she was going to die and finally, he was ready to let her go. But I didn't think I could keep her alive much longer. He'd only recently changed her "code status" to exclude compressions and shocks (she'd had a tracheostomy tube placed months before). But he said we could still use code medications, which are temporizing at best without the other interventions.

So I started a pressor peripherally; and it worked for a while, but then we were using as much of it as we could and her blood pressure was still falling. She started to die at 6 am and I went for the "chemical code," which ended up feeling futile as we stood around her in our yellow mourning dresses and injected epinephrine into her small peripheral lines which made her blood pressure temporarily jump to 210/150 and then trickle back down to 70/30 and keep falling. I asked the nurses to call her husband as soon as we'd started and fifteen minutes into the code I called him myself from the room. We'd talked several times by then and I knew he lived far away and had just gotten out of the shower and was planning on being there at 8:30. We weren't going to last that long. He said it would take him 45 minutes to get there, "depending on traffic," he told me in a steady voice. I begged him to please drive carefully, unable to truly imagine what he'd gone through those last several months.

I started another intravenous infusion to keep her blood pressure in the alive range until he got there and the nurses needed to give her boluses of epinephrine even with that. They paged me when he arrived.

By the time I got down to her bedside, Matt was already there explaining things to him and asking him to put on the yellow gown. He did a god job--calm and sensitive and thorough. He'll be a fine doctor. I stayed back, not wanting to complicate matters more with one more face. And, not wanting to see the pain in his stoic eyes any closer than I already had.

He asked Matt if he could kiss her and Matt said yes.

In the room, he spoke softly to her, telling her he'd tried everything he could to keep her alive, but now it was time to go. Now she could go. He kissed her red swollen mouth as her eyes roved purposely around the room. I don't know what she felt those last moments, if anything. He asked us to turn off the pressors and start a morphine infusion to ease her pain and calm her labored breathing. He stayed at her bedside, whispering to her for the next few hours in took for her heart to stop its resilient beats.

The social work note said her children found it too hard to see her like that. A family friend was there with him for part of the time. The social worker himself stayed for much of her slipping away, comforting and listening to her husband. In his note he said they'd talked of God. The note ended with him dictating, "I have just been informed that the patient is expiring at this time." Time of death 2pm.

Ali had been working that night and tears were welling up in my eyes when I got back from the SICU to our medical ICU. I knew it was time for her to no longer suffer, but her husband was so "dear" with her, as one of the nurses who'd helped code her said. And soon she would be gone. Plus I'd been up all night and hadn't eaten since lunch the day before trying to admit two other patients and keep her alive a little longer. I felt wrung out. He kissed me before he left for breakfast. I still had to present the patients I'd admitted and finish rounding.

In debriefing the chemical code issue with the ICU fellow, she told me she didn't even offer pressors through a peripheral line, nor offer purely chemical codes. They had no long term benefit. The code had felt ridiculous from a medical standpoint. I knew it could only end one way and we were simply delaying the inevitable and quickly approaching end.

But sometimes, maybe delaying is enough. It made no difference to the patient, who I still believe had spiritually left months ago. But it made a difference to her husband--he was able to be at her side when she "passed." He'd told me he wanted to be there. I didn't stave off death for the dying, but for the living, for them to say goodbye in whatever way they needed.

It was a hard code for me, really the first I'd "run" alone--long and immediately unsatisfying in its outcome. But now, days later, as I talked it over with another of our interns, I think I would do the same if I had it to do again, though perhaps ask her husband to come in sooner. I'd still keep her alive until he got there, if I could. It's the least I could do.

I think if him hunched over her bed, holding her hand and kissing her face, whispering soothingly in her ear. Maybe she was there. Even if she wasn't it was testament to what she'd been, and what they'd been together. And what he would have to be without her.

Death is not a fight we win or lose, though it sometimes feels that way. And it's hard to meet the end of the known--and hard to send those we love, those with whom we thought we'd grow old, those with whom we'd shared a life off into the unknown away from us and alone.

2009-04-28T15:36:00.001-07:00

I wonder if radiologists see people in black and white.

A Daaaay in the Life

2009-04-23T19:04:00.000-07:00

Tuesday started off as the prior two days on heme-onc consults had generally started. I looked up the overnight events on my consult patients before heading to clinic. I had time to visit one briefly in his neutropenic precaution cave of a room. He has a new diagnosis of AML at age 77. He'd refused chemotherapy for days, but he seemed to be changing his mind as the new attending had explained to him, slowly and repeatedly at our 6 pm rounds the day before, the more gentle chemotherapy he could choose which would have a chance of holding the leukemia at bay for a bit longer. He was in his bed "sleeping," but he'd hope his eyes quickly when I came in and then close them again and not respond to me if he didn't feel like chatting. The ENT consult note for his lip lesion today used one word to describe him during their visit "annoyed."

I rushed down to clinic, wondering if it would be like clinic the day before when I did not see a single patient for the entire three hours so instead watched the poor med student get drilled with questions he didn't know the answers to. The attending did teach us a lot, so that was nice and sometimes I could get him talking about my consult patients long enough for the med student to google answers.

But clinic on Tuesday would be different. The first patient I picked up had CLL stage 0 and after I'd seem him, the attending told me I shouldn't have, even though his name clearly had the word "resident ok" next to it, which I'd, foolishly I guess, interpreted as meaning I could see him. But no. I saw one more patient and then had a nice surprise! One of my favorite patients, Mr. Jegan, from my intern year had an appointment that day. I'd seen him waiting and was thrilled when his chart was in the rack for the taking. Of course, it's not the best thing to be re-referred to heme-onc clinic at the age of 89. He had a recurrence of his ITP, the same conditions for which he'd been admitted when we met the first time. In the interim since then he'd been treated with dexamethasone, rituximab, and a long steroid taper which had wreaked havoc on his blood glucose control and made his neuropathy worse.

I remembered him mostly because of his blue sailors cap he always wore. I later went back to look at the notes I'd written about him two years ago and found that I'd mentioned in there. I remembered his platlets were lower than our machine could measure but he felt well the whole time and kept wanting to go home. And his wife was there a lot. They were very endearing together. And he wore the same kind of paler blue same-color jean pants that Pop used to wear all the time. He would tease his wife and she would smile at him and go on with her concerns over his health. She still worked and he got himself around the house pretty well. He'd put his hand on hers--wrinkled old soft hands entwined companionably and practically.

He'd grown weaker in the time since I saw him last. He demonstrated how he had to stand up and his legs shook underneath him. He was also having worse headaches. No bleeding that he'd noticed, even though his platlets were 41 (normal above 130).

In addition, he was still on the same blood thinner that I take: coumadin (oval-shaped multi-colored devil pills that they are). He'd had three separate instances of blood clots in his legs after his knee replacements almost 25 years ago so the was on "lifelong" anticoagulation. Since his platlets were low, the fellow had called him on the Friday before and asked that he stop the coumadin. We wanted to get an ultrasound of his legs to see if the clots were still there. He grumbled amiably about that saying it wasn't going to help anything.

That afternoon, I saw a new consult: a 72 year old Jehovah's Witness (who do not accept blood product transfusions) with the hematologist's perfect storm of clotting/bleeding. He'd come in for a toe amputation and developed shortness of breath the day after, which prompted cardiac markers with slight indication of heart attack and a relatively normal EKG. By a few hours later when they repeated the cardiac markers, they had risen and his EKG was showing signs of acute heart attack. He was started on a blood thinner by vein (heparin) then was rushed to the cath lab where two drug-eluting stents were used to prop open his mostly occluded vessels that take blood to the heart. With this and evaluation with ultrasound of his heart, they also saw a big clot in one of the main pumping chambers of his heart (mural thrombus). He was switched to integrillin blood thinner for 18 hours then back to heparin and simultaneously with coumadin to treat the clot in his heart. And then needed clodigripel and aspirin to keep the new stents in his heart from clotting off. Then his platlets, which for some as of yet unexplained reason live too low (around 100) began to fall. And fall. And fall, which gave him a large risk of bleeding. So they tried to reverse the coumadin with vitamin K. And heparin can often cause low platlets so they stopped that also and started him on argatroban, which complicates the transition to coumadin because it alters the test we usually use to see if it's therapeutic. And then he started having blood in his stools, ie a GI bleed. What a big confusing mess of confused platlets and clotting cascade in this poor man's body. And if he started bleeding profusely, he would not take blood transfusions.

I'm seeing this consult and the attending, who is perhaps the most thorough I have yet met, is going through his information and I know he's going to find more than I can in the short amount of time. And he does, which if fine, since he's the expert and he spend a lot of time worrying and telling me about special antibody tests we can run to see if it really was the heparin that's the problem and we talk with the cardiologists how need the plavix to protect their stents and the patient's heart and we talk more and we think more and we talk and talk.

And then we to go tumor board for two hours where they present the lung cancer patients first, who all have grim prognoses and for whom they try to figure out how to at least minimize symptoms. And then we talk about the other cancer patients and whether surgery or radiation or chemotherapy is the best approach. Or maybe everything. Or maybe some. I find it all sad and elusive as they bat around idea about chemotheraputic drugs I don't recognize and flash pictures on the wall of lungs obliterated with cancer. Or look at the microscope pictures of the malignant cells that have returned.

And then we finish and we still have to round on the inpatient service. So we talk and talk and think and talk.

Then I get a page about Mr. Jegan's blood clots in his legs. One of them which had gone away at one point was back. Crap. And we had him off of his blood thinner because of his low platlets. Did we restart it? Did we switch him to one that was more easily reversible. Did we need to bring him back in that night to be admitted? I didn't have the answers, so I asked the heme-0nc fellow. He wasn't sure later so, fortunately, though it was 7 p.m. by then and we were still working on our notes, our attendings were there--both the one who had seen Mr. Jegan that morning and the thorough clotting specialist.

The big danger with blood clots in the venous system of your legs is that they'll break loose and get pumped through your heart and end up trapped in your lungs where they block blood flow there and can cause death. We did not want that to happen to Mr. Jegan. So we talked and we thought and we worried and we talked. We ended up calling him and asking him to come in the next day to start intravenous treatment for his low platlets and subcutaneous treatment for his leg clots.

Then I went back to finish my notes. When I went to the ICU at 8:30 pm to get the most recent vitals on Mr. Perfect-Storm, our attending was still up there talking to him. While I had learned a lot that day and knew he would probably have something new to share, I was tired and left before he came out of the room.

Mom was home when I got there. Bryce is somewhere on his way to Colorado with his friend, Hayden who just spent a couple weeks with us. I warned her how tired and hungry and grumpy I felt and ate and went to bed, sorry that I'd signed up for moonlighting that night as I set my pager by my bed and switched it from vibrate to sound.

I laid there for 15 minutes, almost fell asleep when it went off: "Shawna, I have one patient on the floor for you, gastroenteritis, and three in the ER so far. Katy." What?! Being called in so early on a week night in April is quite unusual. And I was so tired! When I called her back to let her know I was on my way, she was all discombobulated with the speed with which she'd just heard about the 15 new admits in the last 6 hours. From being on her side, I knew that the beginning of my shift was a relief for her at least since she could pass off the insistent admit pager. I changed from my pjs to my scrubs, put on my clogs on the way out the door and was glad I had started to keep two white coats in my car, one for my day adult job at the VA and one for my night moonlighting job at Children's (with the heavy otoscope in one pocket and Harriet Lane in the other, it was by far the heavier of the two). The last few times I'd moonlit, I'd even started taking a blanket and pillow from my bed since I could usually catch an hour's nap in the limo-tinted back seat of my car before having to be back at work at the VA in my other coat.

There are parts of moonlighting I really like. And on nights when I'm no so utterly exhausted before I even start, I actually look forward to it. I like being able to think independently about what to do with the patients. I like working with the nurses as a team. I like the relative peace of the hospital at night. I like the surprise of not knowing what is next. I like the variety. I like the challenge of managing so many patients so quickly and I like it when it's a little slower and I can read and think a bit more about the ones that I do get. I like being the first to see them on the floor and trying to anticipate their hospital course. I like the experience. I like the extra funds it provides.

I don't like doing it when I'm already tired. I decided I don't like doing it much when I have to work the next day. I don't like not being there in the morning to see what happens next. I don't like not getting any feedback from people about the choices I make in the middle of the night, besides what I can glean from their records and discharge summaries.

Anyway, in I went. I realized on my way there that I'd forgotten my blanket and pillow. But I had a beach blanket and a fleece in the trunk that would do.

Donning my pediatric cape, I swooped in to write admit orders at the speed of light. The charge nurse caught me on my way in and informed me that another one was on the floor. And was I admitting the 6 month old with congenital glaucoma? And she'd just called in all their on call nurses cause the ER was packed (which I'd seen as I drove in). I caught up with Katy and she already had five that she knew of either there or shortly arriving (and one she told me about later that's she'd forgotten the first round, the 6 mo with glaucoma). And so I started admitting. Priority went to getting all the orders in and I had my routine: 1) patient has arrived to room page from nurse, 2) call nurse to make sure patient looks stable and let her know how long it may be before I get there, 3) get to patient, 4) review ER notes or outside hospital notes, labs and former dictations in the computer, 5) interview patient and family, 6) physical exam, 7) decisions about what to do, 8) tell them what they might expect, 9) write orders, 10) scribble a few reminders of their story on the history and physical form (which will have to be finished and dictated later), 11) NEXT. Depending on the complexity it takes me anywhere from 30 minutes to an hour per patient, and longer if I have time to review their past information more or fill out their growth chart.

And so the night went: an 18 month old with gastroenteritis, a 6 month old with congenital acute angle glaucoma, two teenage boys with pneumonia, one recently out of juvenile hall, a four day old with slow heart rate, two babies with increased seizure activity, a 9 year old with a liver transplant that might be failing, a 9 year old girl with possible small bowel obstruction, another baby with a fever without known source. Then one more.

The last one of the night, at 4:30 am, arrives from another hospital just as I get a page about three more in the ER and hope that they won't get a room until after I have passed off the hot-potato pager. It didn't sound that bad in the report I got: 11 day old with a fever. We call these "rule out sepsis" or ROS, and baby under a month get the full court press of antibiotics until the cultures from the blood, urine, and spinal fluid are negative for two days. Pretty standard stuff and the babies usually have a virus and look like a peach while we treat them just in case it's something worse.

So I was surprised when the nurse stuck her head in as I was finishing up with one of the other patients, "Room 246 is here." And again a minute later, "She doesn't look good." Uh oh. I remember telling Ali on my way in that I hoped I didn't get anyone really sick because I too tired to manage. I rushed over to the room which was packed with nurses and one worried grandmother. Running through my head what I'd heard about this baby, "fever, mother with possible syphilis, mother in jail, other prenatal labs normal." The baby looked bad. Grunting is never good and she was grunting and mottled (which is when the skin starts to get pale with red blotches). She was working to breath and the nurses already had extra oxygen on her and her saturations weren't coming up. And, they informed me as I hurried in, "She has red jelly like stuff in her diaper." What could it be? While I was trying to think, I asked for a blood gas to see if she was acidotic and a sugar level. Her peripheral perfusion was awful as I touched her cold feet so asked them to give her a 20 ml/kg bolus. I listened to her heart and had trouble hearing it well over her noisy breathing. He lungs didn't sound wheezy but they didn't sound good either. I couldn't hear bowel sounds much. I rifled through her papers from the outside hospital: her spinal fluid looked okay so far, her white blood cell count was high in her blood (possibly sepsis), her chest x-ray was clear, but her heart looked a little big. I wasn't sure what to make of the red stool yet, so ordered a STAT abdominal x-ray. And she already had antibiotics in, but no antivirals, so I wanted some of those, too. She still didn't look any better after the bolus and the VBG came back with a pH of 7.11 (normal is 7.4 and it's very tightly controlled and important). The x-ray techs still weren't there. Her breathing was worse if anything. I checked who the PICU fellow was on that night and it was one of the senior fellows who'd taught me a lot on my month with them. I paged him and explained the situation and what I'd done. "She just looks bad," I concluded. He would come right down.

When he got there, he wasn't sure what was going on either, but he asked for all the same things I'd already done and said it made him feel worse that that had all been done and the baby still looked so sick. He took her upstairs to the PICU. He paged me later to let me know they'd intubated her shortly after and that one of the senior surgeons was taking her to the operating room right then to see if her gut was partially dying or dead already.

I still had to write all of the history and physical forms for the other 10 patients I'd admitted before I needed to pass them off to the other teams at 6:30 am. I wrote frantically and finished 8/10 before I went to pass them off, which took about 20 minutes. I then wrote the other two and started dictating them all back to back, talking as fast as I could and marking the dictation priority so they would be in the computer by the time someone needed them that morning. I ran around putting the finished paperwork in the charts and finally I was finished with the night. Sigh.

I had been starving for hours so went to the hospital cafeteria, wondering on my way over what percentage of my meals are prepared and/or eaten in a hospital. Probably 66% at least. I indulged in hash browns and eggs and sausage with ketchup and then went to my car to sleep a little. The trick was getting into the back seat before anyone came along and thought I was leaving and waited for my parking place.

I slept for about an hour before my phone alarm startled me awake and I crawled into the front seat and tried to make sure I didn't have any blanket marks on my face before driving to the VA.

At least there wasn't any clinic that morning. Just my two patients to visit, review their overnight events and check to see of any new consults. No consults. Just as I was about to start my notes for my patients in preparation for rounds, Mr. Jegan showed up and the fellow had to go off to do something then get ready to do a bone marrow biopsy. He asked if I could see him. Of course.

They were glad to see me again, though not as excited to be back so soon. Since they were there earlier than expected we could get chemotherapy started. I visited with them and got them set up in the infusion center and let them know I'd come back to see them. We took guesses at what Mr. Jegan's platlet count would be that day. I like them. Their grandkids are lucky to have them.

I thought about Pop. He was a great patient. All the nurses in the hospital loved him. No matter what was happening, he always had a smile, or a joke, or a friendly word in his warm Rhode Island accent with a big-man's gentle pat of his worn hands. Even when he was tired or in pain, he hardly complained. I remember after he'd had his open heart surgery when he was 83 and I stayed with him for hours in the hospital until he could come home and I took care of him there, he was so glad to see me and have company. He slept part of the time I was there. I encouraged him to eat. His doctors and nurses and physical therapists visited. I bed they thought I was lucky to have him, too. I know I was.

There are certain people in your life who you just know are good. All the way good. People you trust completely with everything that you have. People who will love you no matter what you do. Grandparents are special that way. I was thinking today that we are all allotted a few of those people. And they are peeled away by age or distance or circumstances and then we are left alone. Or with memories of them. And perhaps the ability to meet new ones, but it's not the same as the core people--the first people--the ones who made you who you are and about whom you dream and who you feel even when they're not there. Those are special people.

I could tell Mr. and Mrs. Jegan were those kind of people to those they loved the most. I'd like to be one of their circle, but I'm not and that's the way it should be. I'm their doctor and that will have to be enough. At least I'm lucky enough to be in a position to help them and know them in some semi-intimate way.

So, while waiting for his platelet count to return, I worked more on my notes, went to noon conference cardiology review and then we waited for the attendings to show up and they didn't until late and there was some miscommunication and we looked at blood smears then, and bone marrow smears, and talked and talked and thought and talked. Then they had to go a meeting that would last an hour and then round after that, at 4 pm. I was not going to make it that long and we'd already decided what to do with my patients so I asked the fellow if I could go. I'm not sure if he was happy about it but I was too tired to care. I'd been working for practically 35 hours in a row and I was too tired to care.

I stumbled home, changed, put in my ear plugs and fell asleep. The deep solid sleep of exhaustion. Dreamless sleep where you wake up in the same position in which you passed out. Sleep that feels like it could go on forever. Sleep that only ends when you get too hungry to even lay still or when your bladder reaches critical mass.

I woke up at 9 pm and remembered I was moonlighting again that night and glared at the pager on my night stand, dreaming of the day when I would not have to dread waking up to the harsh "beep beep beep." And praying that I would not wake up to it later that night. I got up to go to the bathroom and take my medicines, realizing moments after I swallowed them that I'd taken my morning pills instead of my night pills. Oops, those included the prednisone. I didn't think the measly two milligrams that I take now would affect my sleep, but it's hard to tell. I found the cookie jar full of fresh-baked chocolate chip cookies and blessed my mom while eating three of them for dinner with a glass of lactaid milk before stumbling back to bed. Unable to fall back asleep, I fretted and fumed about nothing, tossed and turned, then read my book, "Hannah's Dream," for a while. The main character reminded me of Pop again, the way he called those he loved, "Shug" like Pop had always called me. The pager was still quiet.

I tossed and turned a while more. My feet were aching. Finally I must have fallen asleep. My pager woke me up, but it was light outside. I'd survived the night without getting called in. It was morning and the page was reminding me of our morning teaching conference. I was pretty sure I was going to be late. But finally, I wasn't tired.

Hymenoptera--Pollinators--Small Things

2009-04-05T11:45:00.000-07:00

When I was up at my brother's place (which used to be my parents' place), a wasp bit me. Becky had become distracted pulling weeds (and there are always more), and I had finished riding my mom's horse (because mine died while I was in med school). I was dirty anyway and weed-pulling looked like something to do. A big patch of Johnson grass (it's amazing how the botanical names of childhood return like familiar strangers) waved in the middle of the lavender and poppies that bloomed every year since our 90 year old neighbor had them in her yard (before her elderly son shot her and her sister and then himself--I keep the newspaper clipping in a small diary with flowers on the front). I told Becky I should get gloves (Pop had soft fancy leather ones he only wore occasionally because they were from his only son who had died of skin cancer just before Pop's 75th birthday). But I thought I could just pull one up and then get gloves (though the ones with my name on them in black Sharpie ink were in San Diego). I had barely reached down toward the root when I felt a pain on the fourth finger of my right hand. A wasp flew out of the clump of grass (just as upset as I was). My finger went numb and I doubled over for a moment as Colin got home from his job interview and Becky got me ice in a zip-lock bag. Small Things.

The bees love the flowers in my Mom's front yard. I felt a little worried walking home barefoot from the high school track today but the grass was so soft and the track so gritty and the pavement so hard. The bees in the midfield buzzed around the clover as they had in our field as kids. My brothers used to run as fast as they could to the creek at the end of the field so that the bees wouldn't sting them. If you move your foot fast enough they don't have time to see you coming. It worked for them most of the time. I'd scamper through on the balls of my feet only thinking that less surface area exposed would be best. That worked most of the time also. Our feet used to be thick with callouses and strong with un-shoed use. Small Things.

I finished reading "The God of Small Things" two days ago. It has "study questions" at the end. One about why Arundhati Roy ended it the way she did. The story line is a swirl between present and past, very non-linear--at least in a chronological fashion, but if you redefine the line, it can become linear as well. It rises between tragedy of reality and figurative reality where the twins, who are "we", read words sdrawkcab (backwards) and worry about their mom loving them a little less and feel the cold feet of their grandfather's moth on her heart. There are mantras in the book that climax toward the end which is the middle of an hour glass--the narrow part where sand squeezes through. It is the reaching down of the figurative to meet the reaching up of the literal. In the middle of Small Things like spider I rescued from the bathtub after I returned from two weeks of vacation and wasps and bees and moths and grains of sand. Small Things.

"Another world is not only possible, she is on her way. On a quiet day, I can hear her breathing." --Arundhati Roy

The Thing Is

2009-03-12T23:01:00.000-07:00

to love life, to love it even
when you have no stomach for it
and everything you've held dear
crumbles like burnt paper in your hands,
your throat filled with the silt of it.
When grief sits with you, its tropical heat
thickening the air, heavy as water
more fit for gills than lungs;
when grief weights you like your own flesh
only more of it, an obesity of grief,
you think, How can a body withstand this?
Then you hold life like a face
between your palms, a plain face,
no charming smile, no violet eyes,
and you say, yes, I will take you
I will love you, again.

~ Ellen Bas

"negativity and the positivity"

2009-03-12T22:59:00.000-07:00

This body that we have, this very body that’s sitting here right now in this room, this very body that perhaps aches, and this mind that we have at this very moment, are exactly what we need to be fully human, fully awake, and fully alive. Furthermore, the emotions that we have right now, the negativity and the positivity, are what we actually need. It is just as if we looked around to find out what would be the greatest wealth that we could possibly possess in order to lead to a decent, good, completely fulfilling, energetic, inspired life, and found it right here.
Pema Chödrön

The Winter of my Discontent

2009-03-12T21:16:00.000-07:00

Every year, with the falling of the leaves, it sneaks up into bed with me. It follows me around and twists it's cool long fingers into my thoughts. It hides behind doors and comes out when I'm alone--when thoughts are idle. And then it curls up at my feet and follows me around like a loyal but loathsome pet. And I don't even see it's there.

Ever since college I get into a funk during the winter. At first I thought it was the grey skies of Tacoma. When nothing I could think of would make me happy and one morning I woke up and couldn't remember the last time I had laughed. So I moved to Santa Cruz. Then I thought it was the relationship there ending. It followed me from Santa Cruz to Davis--a shadow of dysthymia and disproportionate irritation. Then to Cincinnati when in the solitude of my second year I didn't go to class for weeks, showing up only for exams and slinking away afterward so I wouldn't have to talk to anyone. Hardening myself against the world from the inside out so I could at least function in my studies and my work. Taking the only solace I knew in doing well with my learning.

And here it is again, here, in Sunny San Diego. I've felt off for months. It came slowly up, like it always does. And had given me a year of forgetting and of lowering my guard and relearning sensation. I didn't even know it was there until today. But looking back I wonder how I could have been so fooled and so blinded to my own frigid bed partner.

Szilvie visited in January. She cried and wanted me to share more. I couldn't. I hadn't with anyone. Part of me knew that if I did it would all flood out in tears I couldn't handle and didn't want to start. So I reassured her that it wasn't her. I got angry and held myself further away, telling myself I shouldn't get close to people who care about me because then my aloof protection strategy hurt more than just myself. And I didn't want that.

Simultaneously, Ali started to get angry with me about not sharing with him--not talking--not smiling like I did. "For months, now," he told me last night, "your smile seems fake and wrong. You have a flat affect." He doesn't sleep well when I'm distant. He doesn't understand. I don't understand. "Nothing makes me happy," I told him at one point in an attempt to communicate. But he takes it personally and sees it as his problem and his failure. "It's not," I tell him, but I can see that he doesn't believe me. He doesn't sleep well a lot.

And all I want to do is sleep. I get to places 20 minutes early and the thought of dragging myself in and having extra time for people to ask me questions feeds the anxious doldrums, so I crawl into the back seat of my car, behind the limo-tinted dark windows and I sleep. I sleep for 15 minutes. I slept once for 21 hours in my bed. I sleep early and I sleep late. I tell myself it is my schedule. Or it's my lupus. Or my prednisone is dosed too low.

Or it's that I miss Pop (those times I cry myself to sleep). I dream about him a lot still. In my last dream, he tells me I've been sad for 37 days. He says I don't need to be sad anymore. In another he comes back to life, but he has tubes and lines in him and he's sick. I wonder now if he felt like he needed to come back to fight off the demons that always fled for me before his unconditional and infinite smile and joy just to share a few words with someone he loved. And he loved me.

Or it's about work, when I fret for days over something I think I should have done better. Something I should have known faster. Something I should have taught the med students better. Or done more to make call bearable for my interns. Or admit a patient on a moonlighting night who I wanted more time to evaluate before rushing on to the next four waiting for me to see them. Or, longer term, wondering if i should go on to study rheumatology (and see my own lupus magnified days after day) or endocrine, or stick with primary care and hope that I don't miss diagnoses.

Or I should do my taxes or check my patient list at the VA or go for a run or read more or write more or study more. I work myself into a fretting funk and the shadow smiles gleefully, feeding on my fears and my worries.

Bernie told a story that he'd heard in church the other day about two wolves in Cherokee tale (is it really always the Cherokee, or is that just the American Indian group who's name we can best pronounce and remember?):

"One evening an old Cherokee told his grandson about a battle that goes on inside people.

"He said, "My son, the battle is between two "wolves" inside us all.

"One is Evil. It is anger, envy, jealousy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego.

"The other is Good. It is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion and faith."

"The grandson thought about it for a minute and then asked his grandfather: "Which wolf wins?"

"His grandfather answered "The one you feed the most."

I was back in coumadin clinic the other day and my INR is way to high. Twice what it should be, which means that, while it's keeping the clots in my brian from getting bigger, it is also putting me at higher than necessary risk of a major bleed. Even as I was telling the clinician about my doses, I found that I didn't really care what they were. I tried to picture what I'd been refilling my pill boxes with and when I added up the milligrams, it seemed like I'd been taking too much for weeks without even realizing it. And I'd been forgetting the vitamin K I have to take at night to balance and counteract the effect of the blood thinner. I made excuses like, "I was on call for 30 hours." "I've been tired." "I didn't have time." "I've been sick." "I forgot." All of which are true, but tonight, when I step back, I see the fog has put my life back on the line. It has pushed and pushed and sneaked and contrived and grown so strong that bad things start to happen.

I knew something was wrong, despite feeling blind to cause, something has been off.

The other night my mom started crying and telling me that I don't share with her. That we're not friends anymore--not close like we used to me. I couldn't even remember a time when we were. My memory is shot. I couldn't remember a time when it was easy for me to smile and laugh. A time when I didn't cringe to be around other people who might ask me personal questions that I don't want to consider, with mom being the lead offender in that self-imposed isolation. When she started talking to me, I forced myself to sit down when all I wanted to do was run away. I listened, barely comprehending the words, and having almost all of the emotion lost on me--so distant had I become to myself even. She cried and I didn't even know how to begin to respond. I didn't want to be responsible for that. I can't even hold myself together sometimes. I can't be responsible for others' sadness too.

When my aunt, uncle, and cousins came over for dinner the other night, I had to force myself to come out of my room. I'd worked the whole night before so I had an excuse for being tired, despite trying to act normal and interested. I felt as if I couldn't remember how.

This weekend I tried to go a few blocks down the road for a pedicure and headed for the door a couple times only to turn around and stay in the safety of the house.

Today I had my biannual evaluation with my program director, the same one who pulled me out from the immediate post-strokes confusion and helped get me the help I needed and the eventual diagnoses that I never wanted nor thought possible, the same one who quietly supports me when I flare or fall apart. She read to me my evaluations from the last six months. "Shawna is a pleasure to work with. One med student commented that she is a physician role-model. She is thorough and thoughtful in her patient care. She is responsive to feedback." It felt like she was reading about a different person. It was nice to hear, but I just kept thinking of this last month on wards when I'd been so distant and easily irritated. I knew I was off, so I was extra careful with checking on the patients and the interns and making time to teach and be in touch with the right people. I went through all the motions, correctly, but the shadow tagged along, larger and stronger each day.

When she finished reading my evaluations to me, she said there was something else she wanted to talk about. They had had a conference about the residents at Children's-something I didn't even know they did--and the chiefs had been worried about me. She said the couldn't describe it, that my patient care was good, that nothing big or bad had happened, but that I seemed "off," or like I was "in a fog," or "flat." Very different from my demeanor in June. The attending I had worked with agreed. My program director asked me to see my doctor about it. Maybe restart the lexapro, or at least start it in October, the next time the monster was scheduled to slink into my life.

I left her office and wandered down to the cafeteria where none of the food looked good. I forced myself to eat something as it was hours past lunch time and went to check on a few patients in the computer, but had forgotten my log-on. I ate and concentrated on not crying, as I ran through in my mind all the things that I'd let slip away over the past months. I walked back to my car blinking furiously and glad I had dark sunglasses on. I sat in the front seat before again crawling into the back to sleep before journal club that night. I wasn't sure how I would be around people. I tried.

Ali called when I got home. I told him I wanted to write so he got mad again. I told him he doesn't understand and I don't have the energy to explain and I'm sorry. I am sorry. I'm sorry for feeling this way. I'm sorry it so affects the people who care about me. I feel foolish for not seeing it sooner. I worry that now, as I'm in a rotation that may lead to my future career, that I need to be at my best at I apparently can't even fake it anymore as people at work and home both see my shadow.

My only solace is that I've been here before, and before I've emerged, and so odds are I will again.

I need to somehow figure out how to feed the other wolf.

End to Beginning

2008-12-20T17:42:00.000-08:00

Five days until Christmas. Last Christmas Eve and Day I was in the University Hospital ER. Seems to be that only the very sick or very lonely come in over the holidays. No one else is motivated to wait.

Last night I was moonlighting at the Childen's Hospital. With the cold snap (ice on my car this morning!) in Southern California, seems that even the parents have been keeping their little ones inside and warm. I only had two admissions over the course of 6 hours. And the Children's Hospitals are usually busier in the winter with all of the respiratory viruses going around.

A couple weeks ago an unmanned F/A-18 with both engines out skimmed the trees on the hill above our house. And crashed into the new home of a Korean man and his young family two blocks away. His wife and two baby daughters, along with his mother-in-law were all killed. The pilot parachuted out and landed behind the house across the street from us. The neighbors who saw him said he was dazed and kept saying he hoped his plane hadn't crashed into a house.

My mom and brother, with whom I'm living now, were out for a bike ride and came back to find the whole area blocked off with emergency vehicles rushing to the scene. They didn't know at first where the plane had crashed and couldn't get to the house. My boyfriend, who had been working nights, was asleep in the house. With his phone off. Mom called me in a panic and told me what they knew at that point. I didn't know what to think. I called his number. Called the house number. Rushed to my car (I was walking toward the parking lot) and switched on the radio, scanning the stations for news of the crash, specifically where it had landed. It didn't take long for them to report the street names. Very close, but definitely not ours. My terrified thoughts of him in the rubble dissipated in a wave of gratitude and relief.

And then I felt concern for the as of yet unreported casualties from where the planed had landed.

I hugged him tight when I got home that evening, remembering those minutes when I imagined I might never be able to again. And I thought of the man up the hill who had lost the things in the world that mattered most to him. His grief is unimaginable to me--unimaginable in its reality.

Grief wafted through the hospital that month as I was on the in-patient service. More people under my care died that month than had in any other single month in residency. Some expectedly and some unexpectedly.

My first week there, I got a page to a phone number I didn't recognize. I called back and the receptionist mumbled something about "county medical examiner" and transferred me. They asked if I recognized a name they gave. It took me a minute since the name was not what she'd asked us to call her during her admission, but I figured it out. "She was found dead in her apartment." I was stunned. She'd looked fine when we sent her home. Breathing comfortably after her COPD exacerbation and telling us she didn't want to go home because she was lonely there or that she didn't feel right breathing still. She didn't want to go, but she was better from all we could tell. The next day I got the call because my name was on some of her prescription bottles. They wanted me to sign her death certificate--natural causes. She'd had many underlying medical conditions. I deferred to my attending. He called minutes after I'd hung up with them and filled in some of the information I'd been too stunned to gather: she was "found down." Paramedics tried to revive her for 30 minutes. There were empty pill bottles around her. Her oxygen was still on. I kept remembering her sister's voice as I talked to her on the phone. She'd sounded just like our patient.

The next week, an 84 year old man came in after months of complications following a hip fracture and fixation. He had recurrent pneumonia, worse everytime he came in, despite our strongest antibiotics. He had been bed-bound for two months. During his admission with us the orthopods left a note saying he could finally get up and start walking on his fixed hip. They must not have noticed that he was on the highest ventilatory settings we could do without intubating him (which he didn't want). Or that he couldn't even take off the breathing mask long enough to eat anything. Or that he didn't want a feeding tube yet. But they gave him permission to walk. He'd been waiting months for that. And he never would walk again.

Before he broke his hip, by all reports, he'd been an active independent man. Cantankerous, according to his daughters, and strong, tough, sturdy--as so many of his generation seemed. Stoic and strong and slowly dying off. The same generation as Pop. Almost the same age as him, too. He'd been a WWII vet also.

Since he broke his hip, he'd been depressed--unable to do the things he wanted. And probably feeling like a burden to the family members who visited daily and held his large strong wrinkled hands.

For three days we'd maxed out his BiPap--and uncomfortable mask that covers the nose and mouth and forces air in. He hadn't wanted to be sedated and have the tube placed in his throat to place him on the breathing machine. But then he changed his mind one morning. His daughter was there and another was on her way from Texas. He didn't want to wait for the second one to get there--he was running out of time and he knew it I think.

I called the anesthesiologist and the ICU team. Mr. A was alert the whole time--for all those months, he'd never lost touch with anything that happened around him. The anesthesiologist assured him they would take good care of him and pushed the sedating medicines before putting the tube in his throat. Once that is in, he needed to be continuously sedated to prevent him from pulling it out. When they sedated him for the intubation, that was the last time he was alert and aware of this life. He looked around as they leaned him back that last time. I couldn't read his eyes behind that mask, but mine began to tear up.

I imagined he knew, as I did, how sick he was and how this would probably end. I'm not sure why he changed his mind about getting the breathing tube. Dying without breath is a scary way to go. But he didn't appear scared. If anything, he seemed resigned, and somewhat peaceful as he looked around that last time--a island of quiet among the sea of activity around him preparing to force him to take a few more last breaths. Maybe he did it for his family, so they would know he tried everything he could to stay with them. Maybe he did it because he was scared at the end. Maybe he did it because he didn't want to face saying goodbye the other way--the awake way. Maybe he didn't want to wait for his second daughter because he didn't want to see them grieve. Or he no longer wanted to be conscious of his gasping breaths as they trickled away from him in that final countdown.

I'll never know what he thought then. But it seemed to me, as they tilted his bed back and adjusted his airway for the tube insertion, that the essence of him left. That last glance around was a farewell to this life. I wanted to be next to him, but it wasn't my place. I wasn't part of the pieces of his life that mattered most to him. I was only part of the end. His daughter waited at a distance for the fuss of intubation to be over so she could hastily brush away the tears she hadn't meant to shed and go back to holding his hand and being strong for him.

He died a few days later, on the ICU service. They, along with the family, decided the chances of any meaningful recovery for him were essentially zero. Even if, by some miracle he made it off the ventilator, he would never been the strong capable person he envisioned himself still to be.

Once patients are intubated, the are transferred to the ICU team, but I still went to see him the next day. His daughters were there then, looking at him sedated, intubated, now with a feeding tube in his nose also. "He would be so angry to see himself this way," they agreed.

I thought again of Pop and how lucky it was that he went so peacefully at home--the way everyone, among their chest of secrets and fears, wishes to die. I was glad he hadn't been in the hospital when he died. And I was sorry Mr. A had to spend the last months of his strong independent life in and out of care facilities, weakening gradually and dependent, in the end, even for food and breath.

The next day, they turned off the ventilator, and he died shortly after.

My third week brought another death--a 45 yo man who had been homeless for 22 years, and drinking heavily for 30. He had destroyed his liver but had somehow managed to make it on the streets, working odd jobs to pay for his beer for all of these years. That speaks to his resourcefulness. When he was admitted, I had a bad feeling it could end badly. The intern and medical student caring for him kept saying maybe he would make it through this admission. I tried to help them keep reality in mind. I saw no good way out of the hospital for him. Even our day-to-day plan was just that: plans to get us just to the next day, maybe the one after that. On rounds, we shied away from talking about his future.

The day of his admission, we ask, like we do with everyone, if he would like to have compressions and a breathing tube if his heart stopped or he needed help with breathing. He did. Even before he started bleeding in to his back, he looked scared. We had to collect fluid from his swollen abdomen to see if it was infected on that first day. He was scared of that too, but he tried not to show it. He thanked us for taking care of him and apologized for being such a trouble.

He would get intermittently confused during his stay there. He sometimes needed a sitter or restraints. But there were times when he cleared enough for the social workers to ask him repeatedly if there was anyone he would like us to contact for him--any single person in the world who would care that he was in the hospital--that he was very very sick. He said he'd think about it. The next day, he said, "No. There's no one." He had a daughter who he never knew because her mom was a heroin addict and had succumbed to HIV/AIDS. I imagine him during that night, searching in his head through all the people he must have known in his life, trying to imagine if anyone would care if he died. And coming up with, "No."

He had a large internal bleed and we kept giving him blood products but he was so sick that no one wanted to risk trying to fix it surgically. One morning, the loud-speaker which announces Code Blue (someone basically dead who needs attempts at resuscitation) crackled to life and announced a room number. Fear struck in my heart as the number sounded familiar and I scanned our patient list; it was his room. We ran down six flights of stairs with the ICU team shouting to them his underlying medical conditions and recent history.

We arrived out of breath to find him without breath or heart beat. Compressions, medication, and electric shocks got a heart-beat back. The shocks sent his body into temporarily stiffened awkward postures before his muscles relaxed again into oblivion.

He, also, was transferred to the ICU team. I saw him the next day and he looked worse than every: belly more swollen, skin the color of dried lemons, intubated, sedated, blood products still pouring in through his veins and pouring out into his abdomen. The following day, an ethics meeting was held and it was decided to remove life-support, without which he died quickly. With no one to notify. His death and his life made me sad.

I wondered with the med student who'd cared for him also if he had friends on the street and if they would wonder what happened to him when he never came back. If they would care. He thought they would accept that something had happened and move on quickly, too concerned with their own survival to grieve over another for long.

My fourth and last week on service brought another death--a 37 year old male with AIDS and pneumonia so bad it soon caused a hole in his lung which leaked air into the chest cavity suffocating him from within. Despite his out-patient doctor assuring me that he would just be in for a few days for some iv antibiotics, it quickly became apparent how very sick he was and how advanced his lung infection had become. Amid a flurry of discussion about his desires to be or not to be intubated, he became more and more short of breath and anxious. Once he'd reiterated his desire to not be intubated, we started morphine to relax him and enable him to say goodbye to his sisters and his partner. He died the day after I left, reportedly peacefully with his loved ones at his side.

And so it is.

I have been seeing more of the end of this cycle of life lately. Though I do not like most things about obstetrics, I do miss that part of the newborns--the "new" part. I miss the freshness and health and hope and potential.

I start back on pediatrics in three weeks, though I'll be in the ICU there for the first four weeks.

We can cure. And we did help many of the adults on my service last month--help them see more years of their lives, helped cure their infection, or ease their pain. There is help and there is service in this profession, but there is also grief--a tangible reality of grief in some ways akin to the man whose house and family used to live just up the hill.

In his stunned address to the country, he thanked those who had helped him already and he asked for advice on how to get through his pain. He said he knew others had experienced loss and he just wanted to know what to do. How to go on.

And maybe that is what we all ask for: help. Help surviving loss. Help accepting joy, even at ends. Help in gratitude for the blessings we have now. And help sharing with those in need.

I think of my cousin's Christmas card full of her peaceful and deep joy in her three children, one with a congenital heart condition and doing wonderfully well and two 12-month-old twins she adopted from a mother who lived on the streets. She shared a story of the oldest boy braving his vaccinations at the pediatrician but crying and pleading with the nurse to "not hurt his babies" when it came their turn for vaccines. And then showering them with hugs and tender words after their shots.

Indeed, new beginnings are everywhere, once we have finished grieving old ends.

May you and those you love share in the warmth and hope of your holiday.

I'm no Lance

2008-11-12T21:12:00.000-08:00

Not even a Lancet.

I had yesterday off. I love the VA on Veteran's Day. Not just because I get the day off when I'm on the out-patient rotation. Mostly because the flags are up all around the front and the patients have hand colored pictures in their room from school kids in the area thanking them for serving. I supervised a lumbar puncture today of a vet and while the intern re-identified the landmarks I saw the picture right next to the urinal. A fourth grader. It was very good.

So to celebrate, Mom, Bryce and I went for a bike ride to the ocean. That involves a lot of hills from here. Well, a lot for me. I liked the flat bike rides in Davis. Half way up one of the hills with my thighs and my lungs burning, I was composing craigslist ads to sell my bike. Then there would be a downhill and I'd delete the typed sales pitch in my head. We finally made it to the ocean at Torrey Pines. It was hard to believe it was November given the beautiful sunny day and the people scampering about the beach.

On the ride, though, I was thinking, "I used to be tougher." I used to be less eager to give up. I didn't give up, but I thought about it. Maybe I used to be more stubborn. Biking can be sort of scary, though. Especially when Ali had cautioned me to not fall over because I'd get really bruised. And the cars rush right by you. And the shoes are locked into the pedals so that when mom almost falls into me I can barely clip out in time to catch myself and her. It's not often anymore that I'm scared like that--a self-preservation sort of fear.

I'm not really sure I like it. It's pushes and stretches, but it's not comfortable. Maybe that's the point.

But.

I still have unhealed scars on my legs from my bike wreck last year. At least this time I wore a helmet.

White Bread and Missing

2008-11-05T19:33:00.001-08:00

I had a patient in clinic the other week who was deathly afraid of white bread. He is a 40 something man with panhypopit which means his pituitary doesn't make the salt, sex, sugar, or growth hormone regulators and he need them supplied externally. He had long hair and a small chin. And he was deathly afraid of bread. White bread only. "I just want to drive away if I see it, man. If I'm at a friend's house I say--I tell him--I just want the patty, man. I can't stand white bread. My mom used to tell me 'the whiter the bread, the sooner you're dead.' I guess I took it to heart.

I guess he did.

I've been reminded of Pop a lot lately, too, in my last few weeks at the VA. A nearly blind but otherwise healthy 85 year old man wore pants like him. His wife of 63 years did most of the talking for him. She remembered everything. "He's been such a wonderful husband," she verbally caressed him. They were adorable. "Like two peas in a pod," she said a few times. I believe it.

Another man in ENT clinic reminded me of him with the way he talked. Another WWII vet. He'd been in Europe in the ski troops. What a trip that must have been. I wished we'd got Pop hearing aids sooner. I wish we had been more diligent about getting the pain from his hip see to.

I wish he weren't gone.

I dreamt about him last night. He hadn't really died, but he was going to soon. He hugged me and said it would all be okay. I wanted to ask him what we were supposed to do without him, but I didn't get the chance. I didn't want to wake up and lose him again. I know he'd say to just do our best and try not to let it get to us. I still miss him. Everyday.

I know he had survived cancers and quadruple bypass, heart failure, and heart break. He survived with a smile for everyday. I wanted to as him what he thought in those quiet moments he had alone. Mom thinks he thought of us or errands or chores that should be done and that, those last years, he could no longer do.

He was an amazing man. I love him. I miss him.

I wish he could have met Ali. It would be different for him, but I know he'd like him. He'd like him because of the way he treats me--because of the way he spoils me. Because of the way he missed me when I was in New Zealand. Because of the way he tells people he's proud of me. Because he puts air in my nearly flat tires. Because he wants me to remember my pills and get better. Because he missed me and he loves me and he tells me. Because those are all things that Pop used to do. They're very different externally, but the heart of good men runs through time and place and culture and lives. Ali's at work now. Pop is only in my dreams these days. They're both with me, but I miss them now.

Life and Death are Grave Matters

2008-09-17T22:19:00.000-07:00

Flat line means his heart was not beating and yet he was not dead. The machine at his bedside saw to that. It pumped and oxygenated his blood which kept perfusing the organs which still worked. His heart no longer did. On Saturday he'd played in a soccer game for the best team in the county. Today he needed a heart transplant to survive.

The day before I'd talked to him for 20 minutes about the days leading up to the time when he passed out and was found by paramedics to have a heart rate of 26 and complete heart block. Three pressors (medications to flog his heart) were the only thing keeping him awake enough to talk to me and tell me about the mango he'd eaten and then thrown up and the Mexican remedies he'd tried that just did not make him feel better. He fidgeted the whole time with a wet washcloth on his forehead and taking the supplemental oxygen in and out of his nose. His parents looked dumb struck at his side.

The next day (today) I would find him on the machine that replaced his heart and lungs. He'd been taken to the cath lab to see if they could place an internal pacer in his heart but he'd gone into a dangerous arrhythmia on the table and died then had to be brought back to life and placed on the machine. He was to be transferred to another hospital where they might be able to find him a new heart. His was now broken.

His parents have lived in this country for 18 years. He and his three sisters had all been born here but they hadn't. And now every time they would travel they would risk being deported. They couldn't even go with their son when he was flown to a place which gave him his only chance for living longer--a place where he could very well die. His father cried as my attending spoke this them in Spanish. He asked if his son would live. He is very sick. His mother sat there filling out paperwork. Visibly numb.

Children's hearts are not supposed to break and yet this was the second I'd seen stop working. The first had been due to chemotherapy several years earlier. That child had asked to go home to God. He was tired of fighting. This one was likely do to a virus--a very common virus that usually didn't attack the heart muscle this vigorously. The test we have sent as the infectious disease service are still pending, but now they really don't matter much. The damage has been done. The bough has broken.

I saw in his father's eyes the terror at the thought of losing his son. The disbelief that this could happen. His pride in his smart, soccer-playing son for whom he sacrificed every day--for whom he worked in a restaurant to give his family a better life. Only to have him this close to death and not be able to be with him. And to not even care what else happened.

My uncle has a new baby who came with them to dinner last night. He's a beautiful healthy 4 month old child. Perfectly healthy. Yet, who knows what the future will bring. There are great risks in having children--the risk of loving them so much and pouring so much energy and care into them only to send them into a world that can hurt them or break their hearts, or both.

There are great risks in loving. I learn that again as I start a new relationship myself.

On call at the NICU the other night, I dreamt of Pop just before I was called to the delivery of a healthy baby boy. The cycles of life are profoundly present yet when I work so much they trickle just at the edge of meaning. There are connections there, if I only had time to trace them.

I leave for vacation in two weeks--to New Zealand with my mom, brother, and cousin. It has been a year since I was in Spain. Perhaps this trip will give me the space to sort through the broken half-thoughts of the past year also.

I gave my thirty day notice at my apartment today. I will move in with my mom. She'll like me being here and it's peaceful. It feels like the right thing to do for the time being.

Because the end can come suddenly and sharply, and time cannot be better spent than with those you truly love.

Part of me wishes I'd not talked with my patient for so long yesterday. His parents were there. He was in perhaps his last moments of lucidity. He should have been talking with them. But you don't think about saying goodbye when you're fourteen--just in case--until it might be too late. I think he knows they love him. I hope they know he loves them too. I hope they have many years to love.

Remembered

2008-07-01T21:45:00.000-07:00

Today was a good day. I like adolescents. They are lively.

One 15 year old boy who had been in juvie and now in a shelter/group home and who wants to work for UHaul relaxed enough to tell me about his dad being in prison until he was 10 and that his uncle died last year and that was why he had "RIP Boy" tattooed in scroll on his chest He smoked cigarettes still (after starting pot when he was ten and meth when he was 13). When I listened to his lungs, he said, "Pretty bad, huh?" They actually sounded fine, but it surprised and gladdened me that he worried; I saw that he wanted to know he was still whole. I saw then that I could validate his health for him. A heady and profound role. I told him they actually sounded good. Then I asked him if he wanted to listen to them with my stethoscope, like I do with the four year olds when they are curious and shy. He wanted to listen, too--this 15 year old boy who had grown up to fast and missed the curiosity and innocence of childhood He told me he thought he'd be a good father, but not a good husband.

The hernia/testicle exam was a little awkward, but now as much as the boys his age who hadn't had sex. After I presented him to the attending, and after we'd gone back in to talk together, I was leaving and he shook my hand as I looked him in the eye and wished him well and good luck with everything. This young man who had been through so much in his short life gave me a look as I left the room that seemed to say that things were going to be better and that some of what we'd talked about meant something to him--that he'd remember some of it. And that he'd remember me even perhaps. He could tell that I cared about him--that I wanted him to get the GED we'd talked about, that I wanted him to succeed.

The adolescent clinic is connected to the primary peds clinic where I'd referred one of the babies I took care of in the NICU on my very first month of residency. The mother saw me across the barrier and asked the front office staff about me. They asked me if I remembered the name. Of course I did. I saw them daily for a month. We talked about their born-too-early daughter and her slow progress toward health. I asked which room they were in and got away from the adolescents to say hello. The baby was now a toddling little girl. She told me that she'd been graduated from premie clinic--she was now a real girl. Walking, talking, laughing, spilling drinks on her self so that she could take her drink off because she liked to be naked. They had also adopted two small boys from Uganda who were politely curious next to her.

I gave her a big hug and she said she's asked everyone how to find me and she still carried a present for me around in her trunk to this day. They were planning on leaving for Indonesia where they would adopt another two children--twins perhaps. I felt so glad to see them; it amazed me that it has been that long since I started residency that those tiny tiny babies could be now toddling children. And it was so nice to be sought and remembered. Maybe the 15 year old would remember me as this family had.

A mom of a NICU baby stopped me on the street the other day. She remembered me and said I was still in their prayers.

I met the mother of an anorexic patient on the shuttle to the airport one day. She told me her daughter was doing well and that remembered me and the talks we had about the value of her life and of staying well and healthy.

She remembered.

There's something to getting to the most intimate details of someone's life within 15 minutes of meeting her that makes the constraints of interactions outside of the exam room somewhat less satisfying. What takes weeks or months or years to discover of someone you think you want to love takes seconds or minutes with strangers in the office. When they trust you and when they see that you really do care. And I do. I like my patients. I like the little ones growing. I like the older ones trying on their different skins. I like the at risk bashful eighth grade girl in a half shirt telling me about having sex with someone else while her boyfriend was in juvenile hall as she hid behind and played with her long hair with split ends. Her mother had brought her in for a urine tox screen which she'd agreed to. I also wanted to test for a uti, std, and pregnancy. And we gave her a depo shot.

I'm going to try to find time to write a couple grants--one for 0-5 year olds getting established with a pediatrician--and another to fund condoms.

What Goes Around

2008-06-25T21:17:00.000-07:00

The other night on my last call with my experienced end-of-the-year interns before the brand-new-med-student-one-day-doctor-the-next batch started we admitted seven patients. Since I had a new acting intern (a fourth year practicing being an intern) in addition to my two interns, one of them would have taken three. Which is normally how I would have divided patients except for one thing. Except for one patient. He was a resident, too. The ER physicians told me about him on the sly and after I staffed him and the rest of the early patients with my attending by phone, I turned around to see him sitting there, hunched over his own history and physical form, "I guess you're admitting me," he said, "I thought I'd just fill this out for you."

"You don't have to do that," I took it from him and took his history right there in the Doc Box of the ER. He was on call. He kept getting paged and wanting to go help with the pelvic fracture trauma with the intestines spilling from the vertically split pelvis (don't ride motorcycles, kids). I told him I'd have to do an exam, too but that we would wait until he go upstairs in a room. I got him a private room.

It was oddly familiar from the other side, being admitted to the same hospital where you work, being taken care of by colleagues who you see every day or week--residents on a different service, but still in your field--in the field of medicine. Taking care of our own. Reminded of our own mortality.

What he has could have been serious, but from the beginning, it probably wasn't anything bad long term. It was something that would stop him from working for a while but it is a disease that starts with "acute" not "chronic." It won't follow him around medically--only in hospital lore. His team rounded on him. Every time I had his information pulled up on the computer, one of his co-residents would look over my shoulder and tell me how odd that was to see his name there.

He paged me today to let me know he was feeling better and asking to go home. I'd anticipated this and had already passed it by all my powers that be. His stay was less than forty eight hours. He started to do his own discharge summary on his lap top; I told him I would do it. It wouldn't take long. I wouldn't even have to dictate his discharge summary since his stay was so short. This morning when I tried to round on him, he was sleeping, curled up in the small hospital bed with his girlfriend (a student, bartender and food server). I didn't wake them, but I remembered when Steve stayed with me all those days when I was in the hospital. That part seems like another lifetime--him being there--me being there.

Thinking of him there, I remembered how every lab value was a needle stick, how every set of vital measurements was a middle of the night wake up, how every measure of urine was pee in the ridiculous toilet hat, how every movement would be limited by the iv pole (though his only had normal saline, instead of medicine to keep him from stroking more). Last night when I got home, I spent hours on the computer reading about what he has. And I entered an order: "Okay for patient's iv to be hep-locked when out of room." Then he could be freer than I had been. I had to take mine with me to the shower. He wasn't there long enough to need a shower.

My attending had said that one of the interns could take care of him. It was true. It would have saved me some work and effort and note-writing and pre-rounding. But I'd been on the other side. Hospital morning consisted of being woken up first by the phlebotomist, then the med student, then the intern, then the resident, then the consult service resident, then the other consult service resident (by this time clearly one was already very awake) and then the whole teams with the attendings came around and filed into the room where you lay in be at a serious height disadvantage. Steve stayed with me then. I didn't care what they thought about him being there then, but I do wonder now.

At least if I took care of him by myself it would save him some hassle and some morning awakenings. Plus I didn't know how well the new interns would do. They're overwhelmed by the logistics still.

And I'd been there. I thought of him all night. I remembered when all my doctors got to go home at the end of the day and I watched them leave from my window or from the bench outside with my iv pole standing century above me. I thought of him lying in his hospital bed and I remembered being there.

When I discharged him today, he thanked me profusely, and repeatedly. It was a team effort--taking care of him--I was just the coordinator, the learner, the detail person. But I had done a good job. I'm getting better at this doctor thing day by day. And I remember being on the other side of it. I remember the patient thing, too.

Tonight he has dropped off my patient list, which means he is home. Probably still nauseous, using the sublingual zofran I gave him, hopefully eating better, but he is at home. As am I.

Tonight I made Trader Joe's seafood stew and baked bread and muffins and drank tea. I walked up and down stairs (which I could not do with an iv attached). I didn't have a headache. My knees hurt only a little. I talked to Victor, who told me he'd overhead my new interns say "how much they liked me and how awesome" I am as their resident. I try. I learn. I am alone. I am still a doctor; I am home; and I am alive, which, at certain points last year, are more than I expected.

Room 1123. Ten days. What goes around, goes around and around and around.

The Times, they are.

2008-06-19T19:19:00.000-07:00

Picture it, if you will. It is nearly midnight. I have been awake since 5:30 am and at work since as soon after as my Special K with Strawberries allowed. I'm the resident supervising my two interns and we have almost admitted our quota of ten patients. I have sat in the ER for hours figuring out all the new people and their history and medications and especially their acute illnesses. The interns have become so efficient at the paper work that they have it finished nearly before they see their patients. I keep asking the ER attending and chief resident if Ms. Joust is back. As I ask, "Is Mrs. Joust back? Any word from her yet?" I ask myself why I have spent so much time of what promises to be a sleepless night pursing her.

She has been on the service since soon after I took over from the previous resident, a third year who couldn't wait to pass off the patients and the pagers to me in his last month of inpatient wards as a resident. She came in through the urgent care initially with a chief complaint of "ear pain." After the resident has cleaned out her impacted infected ear, her husband shows up, a thin somewhat squirrelly stoned-even-when-sober type man with a pony tail to whom she will purse up her lips and blow kisses when we get her admitted. "Did you see her arm?" he asked the resident. "No," but then he looks. She has a golf ball-sized hole in her right upper arm. It oozes putridity. "I'm so embarrassed," she mumbles as she pulls her long auburn braid over her shoulder and cradles her arm. "Don't touch it!" She glares suspiciously at us. "He's so mad at me. I didn't mean to do it. I didn't notice it was there until four days ago." Excuse pile up. It's clear she has been skin popping again--the scars on the rest of her 50 year old skin reveal her familiarity with the technique and with the complicated abscesses which can result.

So this is what we deal with--me and the intern who primarily takes care of her. She ends up refusing the MRI we'd like to do to see if her arm is infected because the dye will "kill her kidneys." She refuses to go to a skilled nursing facility because it's full of "old people" and she doesn't want to catch something. Her husband agrees she shouldn't go because the places "smell like urine." One days I find her hunched over on her bed with the water running in her bathroom. "I shit myself. Why did I do that. He's cleaning it up. I'm so embarrassed." Her hair was not yet combed and braided or up in a bun held by a sparkling butterfly that morning. She hid her face in her hands and wouldn't let me see her arm again. "It's gettin' better," she insists. "Let me go home. I can't stay here. My kitty is fourteen years old. He's gonna die without me. Give me some pills to take." She pleads. But we are concerned that with the extent of her wound that the infection has spread into her bone--a problem which requires six weeks of intravenous antibiotics. And we cannot send her home with an iv to finish them because of her drug history. "I'm not like that! I ain't no criminal. You can't keep me here. I want to go home. Where's my huss-band? Just let me go home."

I want to. I do want to let her go home. And not only because the intern who follows her is frustrated; and not only because she adds to the numbers on our mounting census; and not only because she refuses most everything we try to do to help her; and not only because her treatment has lost all learning value for any of us: and not because of her frequent lamenting about her arthritis pain and her need for a special iv pain medication. I want to send her home because she is miserable. "What a miserable human being," one of my three attendings calls her. He means it in the way that she is miserable to be around, I thought. I see is as she feels misery herself. Because she does.

It is miserable to be in the hospital for any amount of time, for anyone who has anywhere else they would rather be. It is miserable to feel trapped in a supposedly sterile prison. I learned that patients cannot leave the floor for more than two hours without being considered "eloped."

Us doctors, many of us younger than many of our patients have to give them permission to get a bed upstairs. Before they can get out of bed to pee, we have to give them permission. "Bed-rest with bathroom privileges," we write in the "Activity" section of their orders. Before they can take tylenol or saline eye drops, before they can leave the vicinity of their room, before they can eat any food, we have to give them permission. All in the name of their health, of course, we take away their freedoms. And leave it up to them to remember what there is about life on the outside that is worth living. Because there are few reminders to them in the routine of the hospital life which blurs together into meal time, med time, sleep time, blood draw time, doctor visit time, radiology tests, etc. I understood first hand why Mrs. Joust wanted to go home. I had wanted to go home when I was there too.

Last Sunday, as I left at five after covering the team on my interns' day off and finishing a stack of my dictations in the deserted medical records office in the hospital basement, I breathed a sigh of relief and fresh air when the sliding doors opened to the outside world. Mrs. Joust was out there sitting on one of the benches leaning dejectedly over her iv pole with her head resting in the crook of her unattached arm. She had stopped wearing the hospital gowns on her second day there. She wore a loose white linen top with bead work accents and a loose tie at the neck. From lifting up the back of her blouse to listen to lungs over the past several days, I knew she didn't have anything on underneath it.

I said hello to her as I hurried toward my own freedom, thinking I still had time to head to the beach and put my toes in the sand and feel the waves wash up around my swollen arthritic ankles. She gave me a forced dim smile which didn't extend anywhere close to her eyes. It was an effort just to curl up the corners of her lips.

I remembered the day I sat on the benches outside the hospital with my iv pole at 5 pm and watched all the healthy people go home to their families or pets or plants or just their beds--point is, they got to leave. And I didn't. And because of me (and her arm and her history of drug use) neither did Mrs. Joust. Last year, when it was me, I rolled my pole back up to my room when dinner time rolled around or when it started to beep a warning that the battery needed charging to keep letting the blood thinner drip into my veins and keep the clots in my brain from getting any larger. That iv pole became my most constant companion. When I started to feel better, I rolled in around the back of the hospital and sat with it on the lawn. I pushed it down to the surgery floor to get scrubs for PJs (since the patient ones have all sorts of revealing holes and ties in them); or to the NICU to visit my friends and the tiny babies. I rolled around the grounds and downstairs to visit my fellow residents at noon conference. I rolled it outside to the administrative buildings to see my program director. I pushed it down unfamiliar hallways to arrange my follow up appointments in stroke clinic and coumadin clinic and hematolgy clinic and rheumatology clinic and primary care clinic. I learned that the battery lasted only a couple hours.

That was before I knew that I wasn't supposed to leave for more than two hours. But because it was me, and because I left my cell phone and pager number taped on the closed door of my room in case the nurses needed me to come back to adjust the rate of my heparin drip, I got special treatment. They didn't set curfews for me, or make me ask permission to go to the bathroom or ask permission to leave the floor or indoors or go to the cafeteria or gift shop. If I came back more than two hours later, they didn't discharge me and send the cops after me to take out my iv. They didn't kick me out of the atrium where I sat staring out the window when they had "confidential social work meetings" there. They didn't give me a roommate. I wouldn't let them collect and quantify my urine and stool everyday, but the nurses still sheepishly asked me to estimate it at the end of each of their twelve hour shifts when they got to go home. The didn't kick my boyfriend out when he stayed the night with me. They let my mom and friend sleep in my small eleventh floor perch when they visited and kept staring at me like I had actually died instead of almost died. Many of the rules of the hospital didn't apply to me.

But they did apply to Mrs. Joust. They did apply to Mrs. Sidley, my elderly homeless patient who has pneumonia and left for one hour and fifty minutes while the security guards scoured the cafeteria and the smoking area for her. Even with my special freedoms as a patient, the hospital was a decidedly un-fun place to live. I know why our increasingly demented and unstable HIV+ male refused to go to a nursing home. I know why Mrs. Joust cries when she pleads with us to just let her go home to her husband and her kitty, "I'm gonna die if you keep me here any longer!" Sometimes what I don't know is why they stay as long as they do and let us kidnap them in the name of their best interests.

Now return to the scene last night: sunset; my interns are finishing up the last of their paperwork and I still have yet to start a single of the ten notes I need to write; we have nine of the ten patients we can admit in a night. Earlier that day, Mrs. Joust has gone missing--for more than two hours. She "eloped"--that is left without permission. And she has her fancy PICC line in (an ideal conduit for infection and iv drug injections). All night while I hurry from one patient to the next in the full ER, I warn the ER physicians that I want to see her if she shows back up. I want to readmit her and I'm trying to save a spot on my service for her. She still needs four weeks of iv antibiotics to finish her six week sentence...errr, treatment.

Then I hear rumors that she has reappeared in the waiting room; she has started to check back in. I ask them if we can get her back quickly and find a place where I can talk with her and try to convince here to stay with us, and if not that at least get her iv line out and give her oral antibiotics. She comes back to the treatment area for a while but it is change of shift for the nurses and they don't communicate to the next batch that she has a line and is a flight risk. So she flies again.

I know she can't have gone far. She does have bad hips and it hurts her to walk. She uses her iv pole or a wheelchair to hunch over as she shuffles along. I have seen her gait as she goes out to smoke. I could recognize her even in the dark streets. So, that's where I go: the dark streets around the hospital. I am free to walk around without my iv pole now. I can take the stairs with impunity. I am much faster this way. I can catch her if I see her. And in the midst of it all, I can't believe I am doing it. It briefly baffles me that I have gone to school for most of my adult life to end up chasing an iv drug using woman with a hole in one arm and an iv in the other around the dark streets in the middle of the night, in my white coat cape weighted down with all the paperwork I need to complete before the sun rises and this amusing scene vanishes into the mild dis-reality of the dark night.

The security guard sees me scanning the street-lamp lit circles up and down the street for a glimpse of her.

"You looking for someone?" she asks.

"A woman with long red hair," I say.

"I think that's her," the security guard points toward the bus stop. I see her silhouette against the yellow street lamps. She is hunched over one of the ER wheelchairs shuffling already a block and a half from where we see her. As she enters one of the bright circles, I see something in her hand, too.

"Yeah," I tell the large female security guard, "that's her." She comes with me to go after Mrs. Joust. We quickly gain on her. Despite the physical therapy I ordered for her, she remains weak from her long stay with us. When we get close the security guard starts saying, "Excuse me!" loudly, but she ignores us and just keeps walking until we circle around in front of her. She sees it's me and hastily puts out what I now see is a joint in her free hand, after taking one last rushed pull at the rolled paper before mashing it into the ground and turning back to me.

"Mrs. Joust! Where are you going?" I ask, bending down so I can see her face.

"I'm leaving! I can't stay here. I need to get home. The bus leaves at 9:30. I need to get home to see my kitty. He's gonna divorce me. I can't stay here. My husband's gonna leave me. He can't keep coming in here. I need to go home! I just left for a few hours. I was outside talking with my attorney (about something else) and when I got back they said I had been discharged. See?" She pulls out the "against medical advice" form they'd had her sign when she left the ER (after being told by the floor nurses that she could not just go back to her room and that she would have to be completely re-admitted since she'd been gone so long).

I glance at it. "Mrs. Joust, I'd like you to come back with me. We will get you your bed back. I'll readmit you. You just have to be patient. Your arm is very infected. I'd like you to stay. Come on." I usher her into the wheel chair she has been pushing and the security guard pushes her back as far as her post and I take over from there. She has dropped her head into her hands again and I take her through the back door to the ER since I don't know where else to get in. I get a few irritated looks from the nurses when I roll past with her. There's no where to put her so I park her by the nurses station and go around to kneel down in front of her to begin a 15 minute long plea with her to stay with us. They move us over to the triage area so we're out of the way of all the gurney's with paramedics in tow moving back and fort. I try to call her husband to help me talk her into staying but there's no answer. I can't let her out of my sight because i know she's leave again. I try to call her emergency contact but no answer there, either. She lets me call, but only reluctantly.

Finally she's tired of listening to me, "I've got to go home. I need to leave. I'm gonna have a breakdown if I stay here. You're stressing me out! I need to go home!" she gets lounder and louder.

"I know, I know," I try to calm her down, halfway thinking of explaining to her that I really did know what it was like to be a prisoner in this hospital in particular. But she wouldn't hear it. She's used something besides whatever was in that joint I think anyway.

The ER attending and nurses keep coming up to me pressuring me (and by extension her) for a decision. "Stay or go?" My intern walks past with his stack of partially completed history and physical forms and raises his eyebrows at me in amusement and amazement.

Finally, I give up trying to convince her to stay. In my heart of heart, I'd want to go if I were her, too. Heck, even as me, I want to go sometimes. "At least let us take that line out," I ask her softly. "Take it out," she agrees. I tell the charge nurse and attending the outcome of our negotiations. Not three minutes later he comes in having pulled the line; I ask him to send her with some oral antibiotics and he hastily scribbles out a prescription for some we can give her from the ER stash.

She told me she'd just wanted to go home for one night--that she'd be back the next day. But really, I doubt it. Once you regain a lost freedom, it's hard to willingly go back to confinement. I didn't really think she'd come back. I hoped her arm would get better and that next time I saw her, if ever, she would still have both of them.

I didn't watch her go.

Her admission spot on my service was now open and the ER chief resident already had a "favor to ask of me." She was a 53 year old female smoker who helped mentally disabled men live their lives. She had a chest x-ray and cat scan from an outside hospital which looked like lung caner. She had no insurance and if we didn't admit her (though she was clinically stable) she couldn't get the work-up or treatment she needed and she would probably go home to die. I stopped myself from telling him what even with the work up and treatment and hospital admission, she might eventually go home to die. And I stopped myself from thinking that may be better without all the struggles and pokes and prods. He, and she, clearly wanted to fight this likely cancer if at all possible.

I thought of Pop and how I still struggle with guilt about not insisting he went into the hospital that last night when he died at home in his sleep. How if he'd waded through the ER to get admitted, I could picture him on oxygen or getting CPR that would probably have saved his life--for a while longer, until the next admission or next illness or next heart attack or next bought with colon or skin cancer.

I mentally navigate the increasingly well-worn thought paths of reassuring myself that he'd lived a long life, that he was not able to do all the things he wanted at the end, that it was time for him to go, that he wanted to died peacefully at his sleep at home and not in the hospital. He hadn't wanted to be resuscitated. I circle through those mantras in my head and feel a little better. My eyes well up with tears of missing him but that is me selfishly wanting him to stay forever, despite the pain and frustration which I knew were increasing as he hung on those last few months or years to make sure we were all alright.

I admitted the woman with lung cancer, starting what I knew would be a physical and emotional battle for her against death. Death seen as the enemy, not as the end to something that must necessarily have an end. To her, I probably looked like a solider in the army against death. Little did she know, I'd seen him, and I understood him not as a defeat, but as a peace, a "shuffling off of mortal coil" of sorts. A place where she would not have to ask me if she could get out of bed to pee.

On post call rounds that next morning, my attending randomly asked one of the interns, "How do you want to die, Joe?" Once we wheeled into the elevator with not an iv pole, but our computer on wheels, he said, "Uremia," with some assurance. You just sort of fade mentally away over a few hours or days that way. "Really, you don't want to be really active until you're like 75, running marathons and stuff and then just go suddenly with a massive heart attack?" I could see that was the way she wanted to go. She looked at me for confirmation that her way was better. "I want to get eaten by a shark." She scoffed pleasantly, "Really?! Bleed to death out there in the ocean, with a shark fin coming up out of the water?" And she went into the Jaws theme song. "It would be memorable," I explained, only partially keeping up the story for effect. In truth, I would like to be in the ocean perhaps, with my blood running out into the water and the coolness surrounding me and taking me back. But who knows?

I'd warned her that the woman with lung cancer had been told it might be pneumonia--so she still had a little hope that it wasn't cancer. Her face scrunched up into tears when my attending reiterated what I'd said about what the round ball in her chest probably was. Our whole team was there, plus the dayfloat resident--a third year who taught and helped the team with a confidence I wanted to emulate--and the pulmonary fellow (a would have been third year resident who had started fellowship early and who I'd worked with in the CCU the December before). Her daughter was at her side. I handed her a box of kleenex as we all stood around watching her in the first realizations of grief.

I stayed more than my alloted thirty hours that shift. I tried to help Joe get his first successful lumbar puncture with Eric's help holding the patient--a neurologically devastated man after cryptococcal meningitis--but he got frustrated and I finished it. To think I used to pass out nearly at the thought of those and now Eric give me thumbs up and they eyebrow nod and says I "have the touch." I also stayed because I had my doctor's appointment nearby afterwards so I had lunch at the hospital at the new intern welcome party and talked with the incoming interns and the outgoing residents. I found myself, in my no-sleep haze, immensely enjoying the camaraderie of the residents. Many of them had matched into fellowships the day before and the air was giddy with their happiness at their soon-to-be new roles as cardiac or hematology-oncology or endocrine or hospice fellows.

I already felt nostalgic for the present, surrounded by these hard-working smart, caring, young doctors. Aware of the time, very soon, when it would all change again. When the new interns will start, terrified and unsure of themselves and grow into assured knowledgeable content residents. I enjoy these people. I admire many of them. I respect what they have chosen to do with their lives. It is a choice I made, and continue to make over and over again, every time I go to work.

Even though sometimes I want to run away from the hospital wishing for home and a husband and a "kittie," I keep coming back there. I return because I can't imagine a more ultimately meaningful way to spend my career than helping people survive illness, live life, and finally accept death.

Fly to the Moon

2008-06-12T23:34:00.000-07:00

Flies litter my windowsills. I don't have screens on the back windows and it has been hot, so when Szilvie visited we opened them. That was a week ago. I'm still batting at flies with the folded up glossy magazine filled with beautiful people who have time.

I have spent the last day and a half (my first day off in 14 or so straight 12-30 hour days) learning how to bring back people who are dead or about to die. I wish I could have done that for Pop. In my heart of hearts I feel bad for not going home instead of going to New York. I feel bad for talking to a friend instead of him in the few days before he died. I feel bad that I didn't go home more often. I mostly feel bad that he's gone.

At the end of days, I miss him. I find letters he wrote me. I see his picture. I rummage under my bed looking for my medical license and find the box where I have stashed his handkerchiefs and bow ties. They smell like him, even through my stuffy-from-crying nose. I have his special rabbit fur lined gloves in my dresser drawer. He used to keep them in is dresser too. Mom says his ashes are in his room now. In a wooden box.

I'm so tired from all the work and stress of balancing my interns and attending and med students and patients and schedule and responsibilities and lectures and what feels like a million other tiny or big things which crowd out the tiny or big things I'd really rather let in. Pop would make that better. I miss him loving me in life.

My cousin got married last weekend. I couldn't go because of work. And Bryce graduated college the weekend before. I never did make it back to visit him in New York. I'd planned to go that week that Pop died, when we both rushed home instead, numbed by the first disbelief of grief.

I ran into one of the almost graduating cardiology EP fellows when I walked into work yesterday. He will be moving back to where he grew up. His fellowship through cardiology and then electrophysiology is one of the longer ones. He talked about how he did it because he loved his job so much. And that he was single because it was more important to him than a relationship. My actions say the same lately, I suppose.

There's the theory of the "multi-hit" hypothesis where genes have several cancer protecting mechanisms and multiple hits have to take them out one by one until the actual cancer becomes uncontrolled. I feel like genes sometimes. Each time I thought I had taken enough hits, something else would come along. After the lupus, which literally does attack my genes, and in the months of adjusting to that, my parents divorce hit, my medical problems hit again and again, and then Pop died. That was the ultimate hit. The last one, I felt, that stood between me and a cancer of emotion and loss and loneliness and the ability to love and trust.

Some days I try to heard the flies back out the open window so i don't have to kill them with the glossy beautiful skinny girls on the magazine. Although the violent slams give me a miniscule outlet for unnamed frustrations.

And so I have taken a sleeping pill now and the words become blury and my headaches come back and I don't know what I'll wear for thirty hour call tomorrow since the scrubs I have have become too small as I have become cushingoid, like my bitter lupus patient or my renal transplant patient without arms or legs who is a breath of sweetness on morning rounds. Even on small doses of steroids, our faces become round. Moon facies. Full Moon.

Caps

2008-05-30T23:04:00.000-07:00

It's been two weeks since I've had a proper day off. But on the bright side, I have one off in a couple more days. If I don't crack up in the meantime.

We had our retreat for the med-peds program the other day and we asked anonymous questions of each other. I randomly picked our program director. I asked her how long she would remain director and why.

Someone wrote for me, something like, "I know you had a tough intern year. What about this past year has been your favorite thing." Spain is all I could think of in the moment. In reality I said something about learning from last year's trials. I was about to cry. I was crocheting blue baby hats throughout the meeting and I cut my comments short and said the best thing was also that it was not last year and that I didn't stroke again. I didn't know what to say. On the way back to work yesterday night after the meeting, I talked with Bryce and Victor. Cried to them really. Sometimes this is too much. In reality, this past year has been much harder than intern year. It's the adjusting that's hard. And the lack of time to adjust before something else happens. Emotional survival mode. Trying not to think about anything too much or for too long. I'll just look up Wiskott-Aldrich syndrome instead. Or stay awake to keep myself from dreaming.

There are the hat memories, though. I've been giving crocheted hats away. To lots of people. Some to my neighbors. Some to friends. Some to family. I had a stack of them at one point. I tangle up my anxiety into the yarn. People like them, though. Doug wore his made to order green and white one for hours on potentially the hottest day of the year so far. Not a knit cap day. Randy has been nicer to everyone since I gave him his camouflage cap. Victor wanted a cool "cal-trans" orange one to which I added black and green. Keith naps in his yellow and black Charlie Brown one. The grey/orange and red ones keep Scott and Cherie warm on our walk around the bay to the ocean. And there are the two baby hats I made for their little one on the way. Jackie was so pleased with her burnt orange one that she wore it home from the med conference where I'd made it--another hot day. Joe wears one of the early versions that is an odd mixture of colors even though it looks like a multi-colored mushroom. Colin's friend, Joe, says the one I made him is the perfect length and that he looks "hot" in it. Mom likes her collection. As does Jane. Karen says her multi-colored soft greens and blues hat matches her eyes perfectly. Dad has a thin black one for biking. And Bryce finally likes one--the brown and blue one I made that brings out his freckles and his eyes. He's visiting now. It's so nice to have him in town. If he doesn't get drafted, he'll probably be here for a while.

I think there are more.

I started another new rotation today. Team leading at the University hospital. I was up til 3 am learning about my patients and worrying--two things I have perfected lately. The first day went fine. I just never feel quite smart enough. I try to remind myself to not be so hard on myself. Victor tells me I'm one of the bravest people he knows. Brave or foolish has been the question.

Bob just called and told me his friend got jumped outside a bar, went into a coma, and died on Wednesday--in the ICU where I have worked.

Randy told me about his girlfriend's mom in hospice.

One of the patients I made comfort care last month is still happily demented and doing so well they're putting him in a more permanent facility.

I get wrapped up in lives outside. I wonder sometimes if it's to avoid my own.

But there are the hats. So I'll shower and try to sleep thinking of that. Back to work tomorrow to get more new patients and round on the whole team since it's the interns' golden weekend (two days off in a row).

Mom and Bryce went to a fancy party tonight; I was invited at the last minute, but was too tired to go. So napped for three hours when I got home--after Joe gave me a surprise present. Which is another happy thought.

I'm sure I'll feel better after more sleep.

Love your Live. Love your Liver.

2008-05-21T20:40:00.000-07:00

That's what the back of a man's shirt said as mom and I rode behind him on our return to my sunny studio after we swam in the 67 degree ocean. He had a basketball bungee-corded to the back of his bike, too. The letters on his shirt were green.

I was dreading coming to work tonight. I feel unsure and unsupported by myself in the last few ED night.

And I walk in to a bed surrounded by my co-resident, the ED attending and several nurses. Uh oh.

It's a patient with a sick liver. Very sick. With bad upper gi bleed. They make him comfort care within minutes of my arrival. Family continues to pour in.

Love your liver.

Moonshine from Sunbeams, May 2008

2008-05-20T14:08:00.000-07:00

The course of every intellectual, if he pursues his journey long and unflinchingly enough, ends in the obvious, from which the nonintellectuals have never stirred.
Aldous Huxley

We are here and now. Further than that, all knowledge is moonshine.
H.L. Mencken

God changes appearances every second. Blessed is the man who can recognize him in all his disguises. One moment he is a glass of fresh water; the next, your son bouncing on your knees, or an enchanting woman, or perhaps merely a morning walk.
Nikos Kazantzakis

The story is told of a holy man who lived in a large house on top of a remote mountain. Over time, news of the holy man’s greatness spread throughout the land, and many seekers made their way over the mountains in hopes of having even a brief moment with this saintly being. Each aspirant was greeted at the door by a servant, who ushered him or her into the house and guided the visitor through several rooms. After a few minutes the servant and aspirant arrived at another door, which led out of the back of the house. The servant opened the door and indicated to the visitor that it was time to leave. “But I was hoping to have even a few minutes with the holy man!” the aspirant would utter in frustration. “You just did,” answered the holy man as he closed the door.
Alan Cohen

If you don’t find God in the next person you meet, it is a waste of time looking for him further.
Mohandas K. Gandhi

But the important thing is not the finding. It is the seeking. It is the devotion with which one spins the wheel of prayer and scripture, discovering the truth little by little. If this machine gave you the truth immediately, you would not recognize it, because your heart would not have been purified by the long quest.
Umberto Eco

Many Roads to Happy

2008-05-06T10:23:00.000-07:00

One of our consult patient has the same rheumatologist as me. She has lupus, too. And transverse myelitis along with it. I'm finally able to get through more than a paragraph of information about lupus complications (although the 80% 10 year survivial rate at the bottom of my handbook still stings) and able to take in more information about it. I actually really enjoy rheumatology. I did before it happened to include me in it's disease spectrum and now I do again.

In clinic yesterday I got to do a joint aspiration--an ankle that we though had gout but probably doesn't because the negatively birefringent crystals weren't present. Then there was the 66 year old former boxer vietnam vet who has many manifestations of rheumatoid arthritis, including perhaps fluid in his lungs (plueral effusion). I'm intruiged again. I like this stuff.

I had a bit of an epiphany on Friday as I sped down I-5 on my way to the house staff meeting. I might sort of know what I want to do when I grow up. Maybe half time pediatric clinic and half time adult rheumatology. Unusual combination, granted, but the hardest part is dreaming it. And it may change, which is fine, too. There are many roads to happy.

Anniversaries

2008-05-02T11:35:00.000-07:00

May 3rd marked an entire year since I lay in the MRI machine for the second time in the same day, wondering why they'd called me back so late at night and knowing it must be bad. They saw the clots and admitted to the hostpial where I worked then as an intern. I find it odd to remember the change a year can bring. This year, on the anniversary of my strokes I was at the medicine department housestaff meeting, crocheting a hat and waiting for next year's schedule. The day before I'd started my rheumatology consult time and loved it. And this year, at the same time when I was having the MRV which showed the clots in my brain and finally a reason for my intractable headaches and numbness and vision changes, I was enjoying thai food at the ocean with new friends who just found out about her their pregnancy. What a difference a year can make.

It Rheumatology is generally known as the joint specialty but it also includes autoimmune diseases such as lupus and antiphospholipid syndrome. I didn't tell the fellow or attending that I have both, plus a prothrombin mutation. Not yet. Maybe not at all.

We have only one patient we spoke of on the consult service right now. A 52 year old man with repeated strokes and what looks like vasculitis on his angiogram (though he has a negative brain biopsy); he doesn't appear to have lupus, but he does have antiphosphlipid syndrome. We don't even go to the other hospital to see him together because his strokes have rendered over half of his body immobile. "He just lays there," says the fellow.

As she and I waited for the attending, I asked her if she ever has rheumatologic emergencies. She tells me about a disease I haven't heard of: Catastrophic antiphospholipid syndrome, CAP for short.

"Basically you start forming clots everywhere. This patient was in 26. She went into multisystem organ failure."

"Did she carry the diagnosis of anitphospholipid syndrome before?"

"No but she had had seven spontaneous abortions. She presented just not feeling well, with thrombocytopenia. She had bad pulmolnary hypertension."

Likely from all the clots in her lungs, I add in my head. "What sets that off?" I ask, glad now I have not told her that I have antiphospholipid syndrome.

"We're not sure. Could be infection. Anything can be infection." She's from Texas adn she says it with a bit of a drawl: "Cood bay infek-shun." Could be. She goes on, "We ended up recommending plasmaphorisis to try to get the antibodies out of her body but it doesn't really seem to be them that are pathogenic. It's the clotting that is the problem." I know very well that the clotting is the problem. Too well. "We gave her six rounds of plasmaphoreis, but she died."

"Oh." I didn't see that coming. Well crap. Time for me to change the subject. Thanksfully the phone rings and she answers it. I go back to the other computer and look up the stroke patient's cholesterol level--maybe it's just normal old atherosclerosis for him. Nope. His cholesterol isn't bad.

I remember that I had labs done recently again, too. All of the same labs we'd just recommended to check in him, actually. DRVVT, anticardiolipin, beta gamma globulin. And my rheumatologist has just repeated my double stranded DNA the week before. It's still positive. It's always positive. But this time it's 108 instead of 125. This time last year, it was too high for the assay to measure: >300 is all is says for the May 4, 2007 lab data.

A whole year. What a year it has been.

There is a list somewhere that I remember learning about which ranks events in your life according to how stressful they are. I thought of it this morning on the way to rheumatology grand rounds. It includes: death of a spouse, loss of a child, moving (check), changing jobs (every month I do something different), death of a loved one (Pop), dissolution of an intimate relationship (mine and my parents'), major illness (three, four, five? they all blur together), etc.

Managing stress became one of my biggest challenges over the past year. At the root of everything that went "wrong" (if we must qualify events as right or wrong) simply was my ability to respond to them. My body told me that I could no longer handle the level of stress at which I'd previously functioned. The external pressures would be the same, probably worse, but the internal response had to change--or else. And the "or else" actually had a antecendent now: or else I would get so tired I couldn't do anything. Or else I would not be able to walk because my knees would hurt so badly. Or else surfing, biking, running, playing would be completely out of the question. Or else the clots could again grow in my brain and block off the already too small passages draining blood to my brain. Ultimately, or else I could die, I suppose.

It's hard to imagine that last one now that I'm feeling so well lately. I've made it through my first team-leading month which went well--room for improvement; and it will be better next time. And I love where I live. The area and the people. I'm excited again to learn at times. I'm taking pictures and expanding again. I'm back to running and biking and swimming some.

Last year it was all I could do to maintain my sanity in my eleventh floor hospital room with Steve there worrying over me and the parade of consults coming in and out. Neurology telling me I had clots in my head and my RF was positive. Hematology telling them to keep me until I was theraputic on the coumadin. And Rheumatology telling me that they weren't yet sure, but I might have lupus. Still unable to read or write or work, scared and staring out the window, trying not to think too much.

What a difference a year can make.

With all of the struggles that this last year has brought, until March 24th I was comforted that no one close to me had died. And then Pop did. That kept me awake last night. I miss him. I was on call again last night for Children's--the kind of call where I stay home unless they need me which is somewhat anxiety-producing as I toss and turn and check my pager to make sure I haven't missed any pages after changing the battery to make sure it makes louder beeps.

I'd miss him when I woke up. I remember growing up when he slept just down the hall. I'd peak my head in to say goodnight. "Good night, Pop. Love you." "Oh, good night, Hon. Love you too. See you in the morning." It's still sometimes hard to believe that those mornings have passed. I think I dreamt about him somewhere in my fits of sleep.

Time marches on. Changes waits for no woman. No man. And really, thank goodness it doesn't. Who want to wait to live and change? Just that some years are harder than others. And what a year it has been.

The Other Day

2008-04-21T22:31:00.000-07:00

Joe snuck his camera out to the beach when I surfed the other day. It was beautiful. I know you can't tell, you'll just have to trust that it's me. A big clue is that I don't stand up well...yet.

A Good Man

2008-04-18T23:36:00.000-07:00

Today I
Missed Pop
As I drove home by the sea.

It was my only break of the day
Between getting my lower extremity dopplers done at 5pm
And admitting patients all morning and afternoon
And writing notes all evening at home
Which I have just now finished
With the evil "convenience" of home access to the hospital computer system.

I miss him
Because I would have
Called him then.
As I drove home by the ocean full of surfers and waves
Where I wanted to be.

He would have said,
"Hello, Shawna!!
"How are you, Hon?"
"I'm good, Pop. How are you?"
"Oh, I'm doing okay.
You know, Bingo doesn't listen much anymore."
Or
"I've just been out feeding the ol' hound dogs."
Or
"My hips been bothering me."
Or
"I'm feeling kind of punk lately."
Or
"Colin and Becky made potatoes where Becky cuts them up real small.
"I like them real well. They're tasty!"
Or
"What have you been up to?"

Oh, I'm just working.

Mom brought me and my team some of her homemade split pea soup the other day when we were on call. Gram and Uncle Bill came with her. Yeah, they came out to visit from Michigan; we had a great time; we watched these people fly gliders for a long time. But anyway, with the soup, the med students and I went out to get it and the rest of the party supplies from Mom. Everyone loved it. They couldn't believe that my mom had brought it all in. That plus a lot of other goodies for an "unbirthday" party I wanted to have for the team for boosting team morale and good bonding. You would have liked it. We had a chocolate cake, too. Not as good as mom's German chocolate cake or the lemon bars, but it was fun. (He listened even when I rambled; liked it even.)

"It sounds real nice, hon!
I'm sure you all had a good time.
You have to work thirty hours at a time, though?
Are you doing okay? Taking care of yourself? You're not too tired are you?"

I do my best.
I don't sleep well sometimes, but it's okay.
I love it down here. I watch the sunset when I can. Ride my bike to the beach. Surf.

(I don't want him to worry; and I am truly happy here; if tired, too.
Some of the veterans I admit that night remind me of him.
One is 87 and used to be a stunt double for John Wayne;
He used to be a cad, I think, too. That's not like Pop, who was always kind and true with everyone. But he smells like Pop did when he got sick; he has trouble leaning forward as I listen to his lungs.)

"Sounds like you're doing real well, hon."

Yeah, I do alright. When I was taking the rest of the split pea soup home at 1am when I finally finished my work (was supposed to get out at 10 pm) it spilt all across my trunk and in the bag mom had brought (I don't tell him it's because I was driving too fast on the empty highway hearing the wind whoosh through the bike/surf racks I just put back on my car; he worries enough about me anyway; he would tell me to slow down and be careful. I never drove over the speed limit when I'd drive him to Chico for his doctor's appointments where he'd brag about me and then take me to lunch afterwards).

When I got home (I won't tell him that I parked illegally in our apartment parking lot, knowing I'd have to turn right back around at 6 am before any cops came by to care if I were there or not), I cleaned up the soup--sort of. I used the bathroom sink which was a bad idea because then it got all clogged up and I had to get out the pliers you gave me from your cool old metal tool box and try to pry the stopper out but they were too big so I had to use one of my little medical tools to get some of the carrot and ham chunks out first. It was pretty gross but I was numb and tired and didn't really care. That didn't work that well either and I worried about waking up Joe downstairs so I found my liquid draino and that finally did the trick.

I tell him I wish he'd been there to help. He always fixed everything like that. Took care of the details. He might have been miffed that I'd done something so ridiculous, but he'd still help me fix it with a smile; and he'd have good ideas about what to do to fix it. He'd love me even if I came home at 1:30 in the morning with split pea soup splattered on the legs of my scrubs and then clogged up the sink and tried to clean it out while laughing resignedly at myself.

He'd love me no matter what I did. He'd be happy to talk to me whenever I'd call. He knew I was busy and wouldn't call often so he wouldn't disturb me. I saved messages he left on my voice mail. "Ha-hi Shawna! It's just ol' Pop," He'd chuckle as he said it, "Just wanted to see how you're doing, shug. I'm just sitting here watching the ol' boob toob. Give me a call if you get a chance. I know you're busy. I love you, hon. Bye bye for now."

I'm logistically okay without him. I have been taking care of myself for a while now. Mom might have it worse. She asked how often to get the tires changed; or the oil; or how to use the coupons at Costco. Pop always took care of that stuff for her. And for me when I was around. He brought our lunches at school when we'd forget. He never let us fall through the cracks. Never let us fall if he could help it.

He always made everyone he talked with so happy. He was like the sun that never expected anything from the earth. Just kept shining and giving without expecting anything in return. Look what can happen with a love like that.

I try to be like that. In the midst of the sometimes disgruntled work place, I try to remember Pop and smile and say I'm well even if I hurt. Making other people feel better takes away some of my own hurt, too. It all works out in the end. "It'll all be okay," he'd say. "Don't let it get to you, Shug" and he'd pat me a little roughly on the shoulder with his big calloused hands which were fading with age.

I miss talking with him about the little stories of our lives. The patients he would like to hear about. Or the stories about the dogs or the horses or the cats or the neighbors he would tell me about home. The day to day events. And the way he made me feel. Loved. I miss that.

He left me his box of treasures in his will. I'm not sure why. It's locked. The key is attached to a leather fob that mom made him as a little girl. It's not very good, she says, but he kept it all this time. And he kept my letters and his important papers in the steel box. I wish I could have gone through it with him. I think we did once. He'd get it out occasionally. He left my brothers his guns and me his box of treasures. I guess there wasn't much that he owned at the end. Just mementos from a long life. Not many things, but he sure had a hold on many hearts. And a place in many memories.

I get letters almost every day still from people who loved him or love those of us he touched so deeply contributing to his memorial fund. I'm going to find a bench for him. Maybe a cement one like the kind they have at the ocean here. Something were we can sit with him in the sun. It's going to go in the garden at the river he helped plant before he took to his "supervisory" role when his hip and his heart kept him from participating as much.

He wanted to do more to help than he could those last years and months. He still fed the dogs and watered the horses and did the dishes in the days before he died. He felt good to be home and good to contribute; good to feel needed. Colin told him how much he appreciated him a few weeks before he died. He went to him and shook his hand and told him. Pop never wanted to end up in a nursing home; he thrived surrounded by lives he helped touch and create and influence. Both of my brothers told me separately that they thought about the type of man Pop was and that they wanted to try to be as thoughtful and generous as him. It's a rare man who is like him.

Rare and precious.

And missed.

I thought of him when I drove home by the ocean.
And then a limo driver pulled next to me in the traffic as we waited for the light the change.
His windows in front were even tinted but I saw him
Turn pointedly at me
Out of the corner of my eye.

I ate the snap peas I was having for dinner on my way home after my blood draw and dopplers.
I looked over at him.
He made strangling joking motions toward the many cars in front of us and smiled.
I laughed out loud and nodded
And the light changed.
I had to hurry to get over three lanes and pulled behind him at the next light.

He blinked his brake lights several times at me as he drove away.
I laughed again.
I think it was Pop saying hi.
I want to think that, so I will.
Just flashing red lights on the back of a car
Randomly spreading cheer and connecting with strangers,
Making the world a less lonely place.
That's what Pop did, wherever we went.
Everyone loved him.

They could tell
He was a good man.

It Lights the Whole Sky

2008-04-03T18:51:00.000-07:00

I love surfing. When I fall asleep now, worried about starting work again tomorrow in a new supervisory role, the waves lull me to sleep.

Yesterday morning when I went out, I met Pop there. He was young and strong and wanted to join me. He told me all about how much he loved my grandmother. He never remarried. He never met another one to top her, or even come close. He told me he's happy to be back with her. He told me not to worry about work tomorrow. He thinks I'm a genius and that I'll be fine. "Don't let it get to you, Shug. You'll be fine, Sis." Today after reviewing the patients I'll be covering tomorrow and surfing again and putting things into perspective, I believe him.

I was the only one in the water yesterday morning; the waves were little and it was early. There was one fisherman on the beach. I sort of liked having the place to myself; plus the paddling and practice are good for me. I thought about the patience it takes to wait for the right wave. I thought about how recognizing it for me is intertwined with fearing it. If it is going to break right to be caught, my emotional reaction is a combination of excitement and fear. That is how I recognize the challenge. That is how I recognize the right wave.

Those were the stanzas in poems which always drew me in when I used to write about them. The opaque transitions or confusing parts. That challenge is what drew me to medicine also. It's not all the scientific challenge, either. It's an emotional opportunity for constant growth and examination of life and self.

During my bike ride errands yesterday, I also got a haircut for the first time since November 2006. Yep. The hair cut lady (beautician?) was kinda shocked, too. It just hasn't been a priority for me. She said the ends were a mess. Granted. She cut two inches off. It was wet from the ocean, probably with some seaweed in it, when I took it out of a bun for her to cut. "Did you just shampoo it?" she asked noticing my damp hair. Not exactly. So I followed her to the funny sink with the neck dip in it.

Later, another bike ride when my neighbors got home from work found Jane and Joe and me running out on the rocks at the jetty again. I scampered ahead of them, barefooted and concentrating on each next step. I stopped to sit and stare at the water lapping gently over the rocks while they exclaimed over sea stars and crabs. I want to be scattered in the ocean. For a moment, I even found myself wanting to drown a little.

I made risotto for the three of us when we got back. It feels good to be cooking more again. Good to be trying new recipes and flavors and expanding. I felt like a threatened pill bug since the lupus diagnosis. Now I feel like me again. I'm going to play in the sun.

I'm in and out of peace. I remember it and seek it but I can't always find it. I just have to trust that it remains. I practice loving the world, and forgiving its indiscretions and my own peace becomes easier to find. And the sun rises--everyday.

Even
After
All this time
The sun never says to the earth

"You owe me."

Look
What happens
With a love like that.
It lights the
Whole Sky.

~Hafiz

Pop is Everywhere

2008-03-31T13:33:00.000-07:00

Thank you to everyone for your thoughts, love and prayers.

We are all healing in our own way and the help of friends and family eases the difficulty of the loss.

I have felt Pop everywhere since I have returned to San Diego. Mom found him in New York at Bryce’s baseball games. Colin hears his cane clicking along the ground to feed the dogs in the morning.

When I was home for the “Pop’s Party,” as Colin called the service, I went often into Pop’s room. Among his treasures were bowties from his square dancing days, handkerchiefs with his name embroidered on them, belt buckles, and billfolds he had made. And there were things from Ronnie, his son, his sister, his brothers, mom and his grandchildren. From me, he’d saved a tie dyed item I’d made in 1987 which still hung on his wall. On it I’d written, “you’re my sunshine.”

As I left I was afraid he would stay there and that I would need things—objects—of his to remember him and comfort me when I returned here to San Diego. I took some of the bowties and handkerchiefs. They smell like him.

But when I got back here, I found he was already everywhere. He’d already given me so much to remember him by: his great old metal tool box from the mine he gave me when I moved away to college, my set of pots and pans, the pancake recipe, notes he included with every package he sent me, walnuts in the freezer, the grilled cheese and tomato soup my neighbor suggested for lunch.

Most importantly, I found he wasn’t in the things at all. He was in the waves I surfed, he was in the car telling me to be careful, he was in the sunshine.

“May you live all the days of your life.”

Peace be with you, Pop

2008-03-24T23:58:00.000-07:00

My Grandfather, Robert Jackson, died this morning, peacefully in his sleep at home.

He was 87 years old and lived a long happy life.

He was born in Rhode Island on February 19, 1921 and despite moving away when he was 19, maintained his New Englad accent his whole life. In fact, until I was eleven years old, I thought barb wire was pronouced "bob" wire, named after him, of course.

He started working after he completed eighth grade and worked until he retired after that.

He served as a truck driver in the army for four years during WWII in New Guinea. He told us stories about eating onions like apples and making friends with the submarine guys who had access to all the good foods.

He loved deserts; baking won't be the same without his loving and appreciative sweet tooth. Lemon was his favorite, but then again, he had many favorites.

He married my mother's mom when my mom was six. They lived in a mining town in the California desert until my grandmother died when she was only 51 and Pop retired. He lived in Arizona briefly before helping my parents buy their first house in Northern California (with all of his savings) and moving in with them in January of the year I was born.

He helped raise the three of us kids. He was always there; always kind, always Pop.

Every Sunday he made us his special buttermilk pancakes.

For those of you who knew him, you are lucky. He was a remarkable, thoughtful, loving, and kind man. He will be deeply, deeply missed by many.

I don't know any details of the memorial service or anything yet. I'm still in NYC but flying home early tomorrow morning. The rest of the family is gathering, too.

The world is a better place for having had Pop in it. For that, and for all the love he has given to all of us, I am eternally grateful.

Spirits like his do not die; he stays with many of us. He stays with me.

Peace be with you, Pop.

And with you.

Surfing with the Dolphins

2008-03-20T15:14:00.000-07:00

This morning the dolphins surfed with me!!! A neighbor surfer saw them at the same time I did and pointed quietly to make sure I saw, too. I grined broadly and giggled into the peace, watching them as they cruised past.

Mom says it's snowing in New York. I love Szilvie and Bryce enough to brave it for the next ten days of vacation, though I'd rather they come here and surf with me in the land of sunshine.

I'm pondering the choices of involving other loved ones in my life; there are compromises that come with that intertwining. I almost said "saccrifices," and perhaps at some level that word is valid, too. I want to believe that people can integrate each other into their personal hallucinations and expand each other's worlds to something larger than either would have explored alone. That's my hallucination for today. It's about choosing to believe.

The Universe is Unfolding as it Should

2008-03-19T10:40:00.000-07:00

I spent the majority of the last few nights in the children's emergency department sewing. I knew all of that knitting and crocheting I learned in some other old life would come in handy in this one. Except these nights, I sewed skin instead of yarn or buttons.

One three year old dare-devil blond girl hit her chin on the tile floor; it wasn't until I put in the last tiny absorbable stitches on her stellate shaped gash that her mom revealed that she was an OB/Gyn and she never sewed up c-sections that carefully. The chin would never look the same, but considering the injury, it looked much better.

Earlier a boy had been playing alone on the homemade swing that reminded me of our barn swing when he crashed to the ground leaving a sideways check shaped gash lateral to his left eye that required finesse and layering to repair. That one took me a while as his parents and little brother sat and watched, mourning the loss of the McDonald's toy and wondering how exactly it had happened and glad he hadn't hit his eye.

I like sewing up skin lately. I find it satisfying to repair something so tangibly broken in a profession that often exists in shades of best guesses and protocols. Plus last night, I was utterly distracted for a while for various reasons and the quiet laceration repair rooms or corners forced me to concentrate on something physical and outside of my own concerns.

The other night I spent three hours sewing up an elbow. That young man had gashed his arm on a fence and torn a large triangle-shaped flap of skin away from his arm. The skin hung by one side of the triangle; the other two sides had to be reapproximated with the point aligned carefully. Deep and superficial layers on that one, too. I lost count of how many sutures, but there were probably 40 deep sutures and between 40-50 superficial ones. I quietly stitched while the tired family joked good naturedly with their son and teased each other about women and how he was going to look like Frankenstein when I finished. I stood the whole time and my bike wreck wounds started oozing serous fluid which I could feel drip down to my toes. Disgusting, but oddly fascinating in the same way it was fascinating earlier in the night to squeeze pus out of an abscess on a little girl's thigh.

Another chin laceration last night was the most straight forward of the evening--straight edges, easily matched, seven tiny stitches. This injury had been from a razor scooter crash into a curb. The mechanism sounded uncomfortably familiar to my bike wreck the other day. The eight year old boy twirled his hospital ID bracelet as I prepared the suture kit and turned my back so he wouldn't see me draw up the numbing medicine with the big 18 gauge needle, "Are you nervous?" I turned back to him, replacing the 18 gauge with a smaller 27 gauge and kneeling down to look into his down-cast eyes. "Yes," he glanced up at me briefly.

I took off the blue non-sterile gloves and touched his hand assuring him it would be alright and telling him that if it hurt, we could fix that, too. His mom moved over to him and took his hand. I changed the subject. He's in the third grade and studying division; he's on Spring break; he has a little sister. I told him a few stories from the farm and he started to relax a tiny bit. He stopped twirling his bracelet and started twitching his feet. His grandmother had just been to visit and he'd lost his previous razor scooter. She'd given him and his sister the choice of getting a razor or a bunch of other smaller toys. His mom said he was the more cautious of her two kids and had chosen the cornucopia of smaller treasures, but his properly indulgent grandmother had bought him the scooter also. He made out well, except perhaps having to spend his Tuesday vacation night with me.

The three, seven and nine year olds are not the only one getting hurt with the warmer weather and spring starting at 9:48 tonight. Colin teased me when he called the other night that I'm a 29 year old with skinned up knees from falling off my bike. It does sound funny. So far I haven't needed stitches, though. Just sunburned yesterday when I forgot to wear sunscreen during my yoga and writing at the beach. I look like Hera got into a fight with Apollo and the latter won. My feet are burned and bloody from the wreck and swollen from the fins I used while body boarding trying to give my knees a chance to recover (-ish) from the crash.

I don't know why I'm pushing so hard again; it feels great to be out and active and not afraid anymore. Perhaps I'm making up for months of uncertainty. Doctors can really have an impact by telling people what they should and should not do. I'm supposed to wear a helmet all the time. I'm not supposed to be in the sun. I'm not supposed to get dehydrated. I'm not supposed to forget my medicine. I'm not supposed to work long hours. Blah blah blah. Doctors are the worst patients, perhaps, but who wants to be a "good patient" when all it means is restrictions. I eat well, I remember my medicines most of the time. I want to live my life. Patients do, too. Living well is a compromise--it's about making good choices. Sometimes it is on the edge of living. And people get hurt at the edges of life.

When I used to race on the ski team in high school my coach said that if I didn't fall sometimes, it meant I wasn't pushing enough. Without the occasional crash, I didn't stretch the limits of my abilities. Johnathon Livingston Seagull learned that, too.

I left my last shift last night in a funky mood. Oddly, I would miss the sewing and slight chaos and constant flow of the ER. And it means I'm switching back to medicine yet again, as a team leader for the first time, which makes me anxious. And I'll miss the peds residents; they're a friendlier bunch over all than the medicine ones. Or perhaps I just click with them better lately because I finally feel a bit more comfortable in this new (sunburned) skin again. Mom tells me, "Shine, by beautiful daughter." It sometimes comes easily when I stop trying to hard.

And I awoke to my pager reminding me of Grand Rounds this morning (and reminding me that I should have turned it off last night). Awoke thinking of people who don't think of me and forcing myself to turn on NPR for the distraction of hearing it's the five-year anniversary of starting the war in Iraq. And remembering all the people who do think of me and thinking of Pop in the hospital and Bryce after his hard game yesterday. And thinking of the waves.

I went out for the first time on my own today. I figured out how to fit the board into my car without much trouble. And I found my Harriet Lane book in the process. I turned up the music and drove too fast, "go out beyond the white breakers, where a man can still be free (or a woman if you are one)/my my my it's a beautiful world/ i like sleeping with marie/ she is one sexy woman."

When I found my book (which I'd been fretting over losing for the past few days), I remembered also that my bike chain had fallen off the other day--right in front of the store where Mike had bought the bike for me for my 28th birthday. The brakes went out, too. I stopped with my feet and rolled it into the store where they fixed it for free. Best place for it to break. I went to the beach still and wanted to write in my journal, but had forgotten a pen. A man sitting in his car watching the waves gave me one. I saw him later setting up to go kite surfing; I'd finished writing and gave his pen back.

Serendipitous occurrences like this reassure me.

I tried a new break today; much less rough than the one Bernie and I have visited the last few days. The one where I saw the dolphins play the other day. The one where I scamper out on the rocky pier to watch the waves. I jumped in today. It was easier to paddle out without the rip tide; and the waves are higher and more rhythmic; I can read them better. They still smooshed me a few times, but I'd come up sputtering and laughing to myself. I made it out "beyond the white breakers", caught a few back in; still hard to stand for me (hurt knees plus inexperience). Being out there distracts me better than sewing skin.

It is beautiful. I balance on my board and paddle around, watching for waves to catch. Sometimes I catch one. Sometimes one catches me. The seaweed makes shadows beneath the water. I play with in between my toes as I straddle the board and feel the sun on my back; it is easier to look west in the morning. My feet bleed beneath the waves but I don't notice this until I'm back showering and pleasantly weary, changing into dry clothes under the towel behind my car, still watching the ocean. I'll be back, for lifetimes I will be back.

I drive with wet hair to the thrift store where I have been meaning to drop off things that make me feel old. The man at the Frosty Freeze lets me park in his parking lot while I drop things off. The Spring Breakers who vacation where I live have not yet awoken and the streets are empty compared to the past few afternoons when I have navigated them on my repaired and well-oiled bike. They will be full later in the day and likely into the night. As I drop off the old clothes and worn out clocks, I'm peaceful from the ocean but still obscurely pensive.

And then I laugh out loud, with very little provocation. I see a razor scooter in the drop-off bin. I remember the boy smiling after I'd finished sewing up his chin and saying he was going to get rid of the scooter as I give him the syringe to use as a fancy water gun against his sister. And this tiny thing makes me laugh. Seeing the abandoned scooter, I think of pushed edges and repaired breaks and getting back up after falling; and this makes me feel that the universe is unfolding as it should. This pushes me over the edge and make me fall back into joy.

Desiderata

Go placidly amid the noise and haste,
and remember what peace there may be in silence.
As far as possible without surrender
be on good terms with all persons.
Speak your truth quietly and clearly;
and listen to others,even the dull and the ignorant;
they too have their story.

Avoid loud and aggressive persons,
they are vexations to the spirit.
If you compare yourself with others,
you may become vain and bitter;
for always there will be greater and lesser persons than yourself.
Enjoy your achievements as well as your plans.

Keep interested in your own career, however humble;
it is a real possession in the changing fortunes of time.
Exercise caution in your business affairs;
for the world is full of trickery.
But let this not blind you to what virtue there is;
many persons strive for high ideals;
and everywhere life is full of heroism.

Be yourself.
Especially, do not feign affection.
Neither be cynical about love;
for in the face of all aridity and disenchantment
it is as perennial as the grass.

Take kindly the counsel of the years,
gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune.
But do not distress yourself with dark imaginings.
Many fears are born of fatigue and loneliness.
Beyond a wholesome discipline,
be gentle with yourself.

You are a child of the universe,
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.
Therefore be at peace with God,
whatever you conceive Him to be,
and whatever your labors and aspirations,
in the noisy confusion of life keep peace with your soul.

With all its sham, drudgery, and broken dreams,
it is still a beautiful world.
Be cheerful.
Strive to be happy.

Max Ehrmann, Desiderata, Copyright 1952.

I'm still going surfing!

2008-03-16T11:59:00.000-07:00

I'm working 4ps to 4as this weekend. Still managed to play a lot yesterday. Surfed! Ran out on the rocky pier. Grocery shopped on the bike. Biked all over, including the sidewalk (the herbed salad, carrots and yogurt only partially cushioned my fall). My thought soon after I hit, "I'm still surfing tomorrow!" I hobbled around the ER all night stomping out constipation one enema at a time and prying a plastic ring off of a newborn's penis with surgilube. The cops who accompanied the gunshot wounded child sniggered good naturedly at me every time I shuffled past unable to really bend my knees. Fortunately, Anya and the nurses had fixed me up with bandages and topical lidocaine. This morning, I have so far managed to get my wet suit on and will head out as soon as Bernie gets here. I think the cold water will be good for my knees; this will encourage me to not get up just on my knees on the board but rather stand all the way up. To every cloud.

Sean took pity on me and carried my groceries upstairs; he said his day had been boring before I got home. Oh good.

But determined to not let it slow me down.

After a night on my feet at work. So sexy.

This morning with the bandages off. They're looking worse.

Wet suit makes them all better!

I surfed

2008-03-10T20:41:00.000-07:00

I love my wetsuit. I caught waves and stood up. Thank you Bernie!

I rode my bike til my legs burned and then more.

I don't feel broken anymore.

I just feel tired.

Very tired.

And healed.

It's been almost a year.

I'm back!

Because of a Crow

2008-03-10T12:12:00.000-07:00

Because of a crow,
I am here.

As I walked to my car this morning, with my load of laundry to drop by my mom's as I picked up the directions to the desert, I heard something, "Splat, spit, splat!" A visual accompanied the noise: giant white glistening spots on my already dusty red car. I looked up at the bird with amused frustration, "Crow! Go away!" It just sat in the eucalyptus tree admiring it's handiwork on the roof of my car. I laughed.

The laundry barely fit in the trunk. It's been getting a little out of control; I've been too busy playing. Without some sort of structure at work, the possibilities for days seem endless: hiking, swimming, biking, writing, baking, driving, visiting, reading, etc. Any number of distractions. The urgency I'd momentarily shed in Spain is back. I'm squeezing everything out of the seconds I have here, not so much afraid they'll end anymore. Just a feeling of constant expectation in my chest, "What's next?"

I hold up fine until mom asks me how I am. I want someone to play with me today. Not just anyone. A happily every after someone. I mourn briefly and brush the tears behind my sunglasses before telling her about the crow and my entertaining Sunday with Jane and Dad. Dad and I watched the drummers at Balboa Park. I laughed and he smiled. I think he's forgotten how to laugh and feel it. I remember. The dolphins taught me again the other day.

Early yesterday, Jane and I giggled as we ran along the beach intimidated by the waves and the abundance of surfers. She said they looked like a herd of wildebeast and I laughed so much we didn't need the bike bells to alert people as we rode up behind them. I dove in our pool when we got back and came up sputtering, "cold!" The three of us grabbed burgers. Dad and I drove around, him afraid he's going no where, me enjoying the wandering. He left and I couldn't fix him.

When he left, I went to check in with Jane who was furious with Sean telling her girls couldn't do anything. Ben and Bob and Adam had taken her bike and the sunset promised to be amazing, so we extracted my road bike from my closet of forgotten toys (backpack, sleeping bags, snorkels, fins, frisbees, etc) and she took my cruiser so we could chase the light. We made dinner when we got back. She likes the corner lemon bars. I ate enough salad so I didn't have to take my vitamin K pill last night.

It's hot today as mom and I catch up on her used to be brothel steps outside her apartment. The pictures she's showed me of the desert might be enough. I'm not sure I'm keen on leaving the water today. Plus she says her boyfriend might take me out surfing this afternoon so I get to try out the water and my new wetsuit!

And I might have time for a bike ride. Riding my road bike yesterday, I rememberd how fun it is to go fast and have real gears and brakes on a bike. One rotation of the pedal sent me flying; I like efforts amplified. I could go for a bike ride now while the rest of the world works and doesn't crowd the bike trails. I don't want to run over small children like mom almost did yesterday. I'll go fast until I have my own; they I'll get one of those bike seats and ride with them. Helmets all around. "Cosco" in Spanish.

I could visit my cousin and hold her babies or play with her little boy, but I might not be back in time to play in the waves. And it makes me remember that I want my own. Some other time. Plus there's the crow.

Szilvie says the word "shat." It's the proper tense and everything, but it's a funny word. I think of Poe and his Ravens. Evermore.

Music in my car: "My, my, my, it'a a beautiful day/I like dancing with Marie/She says she doesn't love me/but she likes my company/guess that's good enough for me."

I can't find a car wash so decide to risk washing it with my purple bucket and sponge on the street outside my apartment. I could get evicted for this, according to Randy. I'm such a rebel. It's hard to wash in the heat; the buckets of water I throw on it steam off and the soap leaves streaks before I can splash them off. It's not a perfect car wash, but it's better. And the crow's marks are gone.

Phil comes out to smoke and keep me company. He's taken love-life advice from Sean (bad idea) and tells me again about his lost soul-mate. I tell him Mike wants to see me. He asks me what kind of guys I like. "Nice ones," I should have told him. Instead, I evaded the question; it's too much to explain. But I know better now. He's going surfing and offers to take Jane and I with a day's notice. He likes sugar cookies, I remember from my Christmas baking.

Because of a crow,
I am here.

Because of a job,
Dad is miserable.

Because of a grief,
I found friends.

Because of the timing,
Life is different.

Because of a headache,
I learn.

I learn to stop asking for "becauses." I learn to remind myself of this; and have faith "just because." I remember telling Rick I must have gotten sick because I needed to slow down and take care of myself. "Why weren't you?" I thought I was, but apparently not, since I needed reminding. I start to believe life has a plan guided by something larger. Perhaps the signs are written in poop on the top of red cars.

Sunday

2008-03-09T22:52:00.000-07:00

I moved to So Cal

2008-03-08T21:31:00.001-08:00

Today I moved to Southern California. I mean really moved there--let the place into my being. In a way I never was able to move to Cincinnati, or Tacoma, for that matter.

It was a So Cal day. I spent about three hours in the car; half of it on the phone half of it listening to music probably a bit too loud. I sat in traffic on my way back from Redondo Beach. I drove 240 miles. Some of it faster than my speedometer goes (110 mph)--only on the toll road really early in the morning. And I loved it.

The day was beautiful. The sun was out. The palm trees waved at me from everywhere. The resort where I went to the rhematology conference sat next to giant yahtts with well dressed men in white skipper uniforms. I learned about osteoporisis, fibromyalgia, rhemumatoid arthritis, and osteoarthritis while I crochetted a hat at the end of one of the white-linened tables. I left before they started talking about anti-phospholipid syndrome or lupus.

I wanted to see Matt anyway. We had a date with the beach and all I had was my work suit so I stopped by to get a sundress and hat; hoping he had sunscreen. Spring has arrived. The lupine and poppies lined the highway on the drive north. In the book I'm reading ("My Antonia") sunflowers line the prarie roads of Nebraska, legend has it the seeds were scattered by the first travelers so they would bloom the next season and others could follow in their path.

The busy southern California highways don't need such a guide, but it's lovely all the same.

Matt told me I didn't used to be so anxious about things; didn't used to be so wound up. I remember that. I liked that. I'd like to "arrive where I started and know the place for the first time" again.

We laid on the beach, catching up, then walked along the board walk among the bikini-clad girls and shirtless boys and a man selling fitness tips on his pilates machine (business was very slow). College boys were throwing the football close by and the waves wandered in rhythmically.

I called Jane when I got back in the car. I'd seen her when I left early that morning (couldn't sleep again, tried the Ambien and it just made me feel like I was on a tilt table and my arms and legs had developed elephantitis). I'd missed the whole crowd at the apartment complex. It sounded like she was at a party when I called, but really she was two feet outside her door. With the warm weather everyone had come out to play and visit. I'd missed both "Reggae Breakfast" and the pizza Doug had ordered for everyone. I didn't mind missing events so much. They sounded happy. What was touching is that they'd missed me, "hurry back!"

And, I finally got it together to earn my ticket to the waves. Jane and Joseph and Laura had been to the Rip Curl outlet earlier that day and inspired me to get a wet suit at last.

The smell of neoprene wafted out of the store where the parking lot was full of trucks with surf boards on top and the store full of tanned easy-going surfers. The smell brought back memories of snorkeling in Mexico with my family during high school winter breaks. Bobby T was alive then; he and his family went with us. He would have liked the conference that morning, too. He was a rheumatologist; when he died suddenly, his widow gave me his stethascope and a hat that said "MVP-Most Valuable Physician." It would have been nice to have him these past years.

I walked in the store and realized I knew nothing about wet suits. Well, very little. Not enough to make any sort of selection from the huge wall lined with them. I wandered around waiting for intelligence to strike and fiddled with tags that meant nothing to me. I called Jane again (for the third time--I'd needed directions, too). She said to get a women's 3/2 thickness. I got up the nerve to ask one of the salesmen. He helped me pick a couple out and I remembered the slurp of pouring into the black rubber. The first one was too big--bunched under the arms--he said. The family there buying a wet suit for their son had been following my progress also. The husband asked me to turn around again to see if it fit. I smiled at the thinly veiled compliment and returned while his wife knudged him on the arm and teasingly called him a dirty old man.

Think I might actually be tired...; going to try to take advantage of that before playing in the waves tomorrow...

Bona Note

Leaving Marks

2008-03-07T06:46:00.000-08:00

Yesterday I sewed up a two year old girl's forehead. She'd fallen into one of her plastic chairs and the skin just above her eyebrows had split into a two centimeter vertical gash. It looked very red against the paleness of her skin and beneath her blond hair above her blue eyes that watched me warily as I came toward her with the numbing medicine and the needles. Her mother sang "The Wheels on The Bus" the entire time. Her grandmother wiped the blood and flush away before it trickled into her eyes. The cut was clean, but it would still leave a mark. The stitches I put in would leave some remnant of her crash. Her grandmother sweat under the bright light. I, for once, was calm and focused during a procedure. I'm getting so that I don't pass out as often.

The last laceration I repaired was also a forehead--of a convict. I didn't worry so much about the scar the left on him. He was held down like the little girl was papoosed, but instead he was shackled to the gurney in the loud adult ER. His guard didn't sing him "The Wheels on the Bus." I wonder if his mother would have.

The mother of a patient stopped me in the street the other day, "Doctor! Dutch Doctor right? You took care of my Mary. She is doing well," I glanced at the girl next to her, but I didn't remember her. It must have been another of her children. The mother looked familiar. I know I'd spent a lot of time with her, but I couldn't place the child. "You did a great job. We think of you often. You are in our prayers."

I woke up early yesterday morning and had time to do yoga. It concluded with putting my hands in prayer position to the "third eye center"--right in the middle of my forehead before bowing to the ground. The center I didn't yet know I would repair later that day for a little blond girl.

In the shuttle to the airport last year, another mother of a patient stopped me. I remembered her daughter. She again thanked me for the time I'd spent talking with her about her eating disorder. I remembered sitting with her and asking her what scared her. Because her eyes told me something did. They welled up and spilled over into tears that would cause her to loose just a little more weight, "Am I going to die?" She asked.

I'm going to see one of my many doctors this morning, the one who my mother stops in the street to thank for saving my life. The one who called the neurologist and who got me into the MRI before I infarcted any more of my brain. The one who first met me when I was curled up in her dark examining room with my mom afraid to touch me because every movement hurt and I couldn't talk or think beyond the pain. I still rated it as 9/10, thinking there must be something that didn't hurt this much, though I didn't know quite what. The one who direct admitted me to a private room in the hospital so I didn't have to wait in the wheelchair in the ER with the convicts waiting for their mothers to sing to them and for someone to sew up their wounds.

The Green Flash

2008-03-07T06:14:00.000-08:00

The other day we ran out on the rocky pier together.
Dolphins played in the water with the surfers.
Surfing the waves along with them.
I giggled aloud into a silence
Shaking with sounds of water and birds and the glee of dolphins.

I read you a story about wolves eating a Russian bride.
We both cringed at the thought of it.
I put the book away.
I preferred listening to you anyway.

Conversation wandered back to the present
And you started to tell me your stories.
Sad and happy, none of them as sad as the wolves.
Sometimes you felt lonely and I wanted to take that from you,
But I have learned that it is yours
And felt only glad that you had shared with me.

You were afraid I'd slip on the big irregular rocks
As we scrambled back with the sun setting behind us.
But I am sure-footed from chasing my brothers up and down the creek.
You learn this about me.
I learn about you, too.
As you let me.

You came with me as I rode my bike home alone at sunset,
Pausing before we turned east away from the ocean to watch for the green flash.
I wondered if you saw it.
I sometimes imagine I see it,
Just as I imagine I see you.
Imagine I know you
As separate from myself.

As the Neighbor Turns

2008-03-05T15:50:00.000-08:00

I finished on Children's ward today, with a call shift. My co-resident and I traded covering each other's patients yesterday afternoon so I got to come home and try (unsuccessfully again) to sleep. When I got home yesterday, my ex-pro surfing neighbor Phil was sun bathing on his back by the pool. I tossed and turned for a few hours before going back to work to be up all night admitting patients (although for the the first time getting paid extra for it since I got to be the moonlighter!). It was a pneumonia/asthma/abdominal pain night topped off by a pelvic exam at 4 am. Talking to worried parents and tucking in sleepy sick kids, I walked back and forth between the rehab wing (where I always get the Amy Winehouse song stuck in my head) and the main medical unit. Sleepy before the time I could leave, I finished my paperwork and drug myself home this afternoon to shower and try to sleep (only slightly more successfully). And there was Phil. By the pool. He'd flipped over onto his stomach.

Flarevoiant

2008-02-28T17:58:00.000-08:00

I told her about my lupus. She is doing well, or was yesterday. I didn't have the heart to see her today because I started to flare and had to leave work early. I hate not being able to do what is expected of me, even when I know the expectations are ludicrous. She has to start a medicine on Sunday that will make her hair fall out. She wants to be a film maker. She makes funny spoofs of comercials that I haven't yet had time to watch. She is bright and mirthful. She and her mom were glad I'd shared with them. I was too; I think it made all of us feel better.

I got home that night and thought I saw my own malar rash. I went to bed early but woke up too early and stared at the ceiling for hours like I have been almost everynight lately. If I called my rheumatologist, he would say to go back up on the prednisone. I called a therapist instead. And I called off on work. I want to think that it's just sleep I need.

Isn't it lucky

2008-02-26T20:08:00.000-08:00

I'm exhausted. I got a pass off patient today who probably has a new diagnosis of lupus. Just when I think I'm getting okay with having it myself, something like that happens and I remember again that I'm not okay with it.

She has lupus nephritis. Kidney disease. The most common cause of lupus-related death. My kidneys are fine for now. Blood supply to my brain, questionable. But kidneys, fine.

The rheumatologist I consult about her case goes over the lupus criteria with me on the phone, asking about arthritis (check), rashes (check), and all the lab work we would expect to be abnormal (check, check and check). I pretend with her those aren't checks for my diagnosis, but some obscure "other" between whom we can both put professional distance. I have a vivid imagination, but I can't pretend about those checks. Denial, at least, has passed.

I didn't tell the seventeen year old patient, or the attending about my disease. I almost cried when I walked into the patient's room. Gathered myself at the doorway. Kept it together while I was in there talking to her and her family and examining her joints, then almost cried on the way out. Good thing it was dark already when I got to noon conference late after talking to her before transport whisked her off to an eye exam to see if she had lupus retinitis which would herald cerebritis.

I'm tired.

I did have a good time with the hood last night, though. With a couple new additions. Bob's best friend forever, Adam, has moved into his studio with him and it was sort of an Adam welcome dinner. Jane and I had plans to go to sushi ourselves and avoid the scene. She was hiding out at a bar when she texted me on my way home from work to scheme, but then we both felt bad ditching the boys (the group isn't nearly as fun without us--or so we are led to believe). I was, as usual, tired and almost didn't go, but then Rick called after he finished surfing and met us there. Half price sushi with a group of friends is hard to beat.

Melissa, and now Rick I guess, are always surprised that I even know my neighbors, let alone hang out with them on a regular basis. Jane came running up to my place when she got home from the bar and found me passed out on my bed; she was escaping the boys who had invaded her apartment before she even had time to get home and pee. We giggled over a few shared girl jokes and she told me about her new super soft pillows before joining the male fray downstairs.

At dinner, having Rick there, I realized again how well I have grown to know these people who live on the other sides of my apartment walls. And how comforting I find it to come home to a place where they watch my lights to see when I come and go. And care when I come and go. Yet still let me wander in and out without expectations or restrictions. Just with an interest, and companionship or concern when needed.

When Libby visited, I also had that realization; seeing my life through the eyes of relative strangers, I realize the unity which surrounds me when I let it. The beauty of the place we live. The diversity of the people I know. The closeness of my family. The communities I join. The work I am able to do. The health I have regained. The lessons that journey continues to provide. The writing I can do. The books I read. The music friends have shared. The friends I care about, near and far. Realizing the help I can provide. The smell of the fresh cut grass when I climbed the outside stairway at the hospital in the 70 degree February sun. Two perfect "champagne" lumbar punctures in one call day. Patients recovering. Cautiously growing confidence in my knowledge and skills. Working on asking questions and forgiving myself and speaking "impeccably." Nurses greeting me with warm reality. Sunsets over the ocean. And soon, bed.

"Isn't it lucky."

Skeletons

2008-02-22T10:32:00.000-08:00

The first things I did when I woke up this morning, waking after ten hours of glorious comatose-like sleep to the sound of the rain instead of my radio alarm, was think about work.

I can’t seem to leave it alone. Yesterday I had a seven week old patient come in who is still at his birth weight. Now it is normal to lose some weight after birth—in the first few days baby’s can lose up to 10% of their birth weight—but by 10 days of life they should be gaining about 33 grams, or one ounce per day. This child had gained exactly 1 ounce in seven weeks. He looks like a tiny skeleton. His cheeks are hollowed out and the muscles on his legs have none of the baby fat to hide them; they tense with every frantic movement. His mom is adamant that he only be fed breast milk, without calorie supplements, without pumping and giving him a bottle. She may not produce enough (judging by the size of him, no where close) since she had a breast reduction 20 years ago so she has recruited other women to give him their extra milk, which she tries to give him via a dropper held next to her own breast. During my interview of her, he frantically sucks at the breast the entire time, using what precious little calories he gets trying to find more food. She nurses him for one hour every two hours. Nursing is the equivalent to running a marathon for a baby. Their only jobs are eating and sleeping. He spends so much time energy and time trying to nurse that he has none left over to grow, barely enough to survive.

When I have finished talking to the single mother who’s ex (father of the baby) has left her for another woman, as she coos over her tiny skin and bones first child, I order nutrition consults, social work consults, lactation consults, failure to thrive consults, pre/post nursing weights, hemoccult stools, vitals, limited time spent on the breast, and more with the donated breast milk; and I call her pediatrician. We share our frustration over the failed interventions over the past seven weeks, perhaps a combination of the mother’s insistence on giving him only breast milk (which isn’t there) and her midwife writing her notes saying, “Baby is doing great today!” which the mother shows to me proudly. Instead of worrying about this baby for the past couple hours, his pediatrician, Dr. Whitney has worried about him for the past seven weeks when he has failed to show up for several appointments while continuing to lose weight, “Worrying about this child keeps me up at night. I don’t know what else to do.”

And so it is. I now wake up worrying about this child. On my one day off, I roll over in bed, reach over my pseudo bed companion (two pillows I line up next to me) and turn on my phone. My first call is to the nurse. She reports that the baby is sleeping next to mom. “Good,” I think, “better than wasting all his energy trying to nurse. He needs to sleep.” I make sure I have added the lactation consult. The next call is to the California Newborn Screening project to see if he has any underlying metabolic abnormality that might explain his skeletal-like appearance. In bed, I remember his date of birth, hospital of birth, how to spell his unusual first and last names. These details already ingrained in my memory. His newborn screen is normal. So we’re back to calories. More in, less out.

The opposite of what I tell my obese adolescents, who I worry about too. Like the 87 pound second-grader with a family history of diabetes. I see his future health problems, if he doesn’t lose the weight and change his habits now.

This is not a profession easily left at the office. One of my residents in medical school told me that being a doctor isn’t a profession, it is a life. Now I see the veracity of his statement. And so it is.

It’s no wonder I can’t focus on anything else well. I have flashes of loneliness curled up to my pillows late at night in the seconds before I pass out from exhaustion. I feel guilty about the things I cannot do—about the things I do not know. I read “The Four Agreements” in the few minutes I take to eat breakfast in the gray dawn and remind myself to “always do my best” and forgive myself when I feel that my best isn’t good enough. I listen toNPR to remind myself that life exists beyond my small corner of concern. I blast my “happy” iPod playlist while I workout, trying to drown out the noisy thoughts of the things I should have done, or should do, or should review. I read “Three Cups of Tea” and realize how blessed I am to have learned what I have learned and know what I know. I think of dates I’ve avoided or men I have don’t take time to know, telling myself I’m not worth it and don’t have energy anyway. It’s easier to hide behind work sometimes. Is it because it hurts less? It hurts differently, somewhat less personally. Emotions in, emotions out. My personal life is an emotional skeleton. I wake up worrying about tiny babies, wondering what else I can do. Trying to fix things that someone else has broken, because I want things to be perfect. Because I want to be perfect, and I know I can’t.

Open Heart

2008-02-15T20:55:00.000-08:00

I am working back on wards at Children's Hospital. If I add it up I worked 96 hours in the past week. Or something like that. I'm too tired to really figure it out. I got home yesterday post call on Valentine's Day. I found a boxthat my mom had moved inside on my bed when she was over earlier dropping off the flowers book and pudding she got for me. My apartment is a disaster; all I do is stumble home and eat and sleep before waking up to "Morning Edition on NPR" at 5:30 am to go right back at it. The nurses asked me why I didn't wear read on Valentine's Day. It's cause I'd been there since 6 am the day before.

And my first admit was a 6 year old who was breathing 60 times per minute whenI walked in. He was almost not well. But we got him fixed up. He went home today. He had the flu and pneumonia. We abbreviate pneumonia "PNA"--the p-nah.

That along with bronchiolitis keeps us in business during the winter. I have the maximum amount of patients I can nearly everyday. If I don't by the beginning, then I do by the end, or some point in the middle since they come and go so frequently I have trouble keeping up with the dictations I'm supposed to do on addmission and discharge.

My last patient today was a five month old neurologically devastated baby. Her mother put her down for a nap a week ago and she had massive strokes; she will probably never wake up. I'm tired.

The present on my bed was from my dad. It was a silver open heart necklace. It took me a minute to figure out why he'd sent it. When I did, I cried a little. In some ways it's best that I don't have somone waiting at home for me when I spend 12-30 hours a "day" at work. In some ways it is best. In other ways--well the necklace and flowers and book don't care if I get home late. They don't care if I stop making my bed or don't have time to return the movie or pick up the dry cleaning. They don't care if I come or go. Sometimes it would be nice if someone cared. But if they did, I wonder if I could care as much for the strangers I help on those long days.

Give and Take

2008-02-03T17:18:00.000-08:00

“You never see a hearse pulling a u-haul,” Arvid said today in church, “You can’t take it with you.” His sermon focused on giving. No religion leaves acts of charity out of the accession to the divine—or accession to your highest and happiest self. Another of the ministers read a short essay by Isabel Allende whose 28 year old daughter fell into a coma and died after a year of silence. In her grief, Isabel realized anew the gift of sharing her stories and time and herself and found her daughters soft presence most with her when she gave. What do all of our gifts mean unless we give them away?

After church I visited the gym and read “Les Mes” on the stationary bike. As I near the end of the novel, Jean Valjean reminds me of giving also. A bishop gave him, a convict, the gifts of respect, freedom, recognition, and money which set his soul on a path of charity and growth. He passed these gifts onto those who needed his help on the cold streets of Paris.

I think of the 10 year old child we saw in pediatric cardiology clinic the other day. She emigrated here from the Philippines at the age of four. Born with a heart defect such that the two “great vessels” which take blood to her body and her lungs were switched, or transposed, she also a hole between the two sides of her heart that enabled her to survive, if barely. When she came to this country at the age of four, surgeons here repaired what they could of her heart, given the damage the inadequate circulation had already done. If she had been born here, they could have repaired her heart at birth, letting her live a long life with essentially a normal heart.

In clinic she looks thin and happy, shy and active. She swims for fun and enjoys her friends and school. I almost don’t want to know what her future holds, but once we have adjusted some medications for her pulmonary hypertension and left the room to dictate her visit, I ask Dr. Setzler what will happen to her, “She will get more and more tired and end up in a wheelchair by her late teens. She won’t have the breath or energy to get up and do much. Eventually, she will become home-bound, bed-bound essentially. On hospice. Unfortunately, that phase can last for 2-3 years sometimes, before she dies.”

I wonder if the active shy ten year old knows this about her future. They study the human body in her fifth grade class. Dr. Setzler asked her if she told them about her heart when they learned about the red and blue blood and the circulatory system. She only nods and smiles shyly and somewhat proudly. I wonder if she understands how her heart works. Even with the help of pictures I sometimes have trouble understanding all the shunts and patches and dilations and stents that redirect blue blood to the lungs and red blood to the body, or let them mix enough so that the tissues of the body can survive for a time. I wonder if she has trouble understanding how she has lived this long. And I wonder if she knows how she will die. I wonder if someone could have given her family money for a plane ticket when she was first born and saved her life.

Though most of the patients we see in clinic have repaired hearts or watched defects and live relatively normal lives, we see another patient that day, a four year old, whose life leans inevitably toward a premature end. Her mother speaks Korean and Spanish; my attending speaks English and Spanish. They get along reasonably well in Spanish, but the mother requests a Korean-English phone interpreter because she does not want to miss any of the discussion about her little girl. And she has questions for us—questions about giving.

On her last visit one month prior, my attending explains to me before we see the patient, her daughter looked very ill—end-stage heart disease and pulmonary hypertension, blue and exhausted all the time. He had added some medications but did not have much hope of them making a large difference. He had candidly explained this to her parents. I imagine an agonizing month for them, watching their little pink-bowed girl explore a world she would soon leave, loving her in the moments they had. At this visit, she has unexpectedly improved—not to change the course of her decline, but to slow it perhaps. Her mother, with tears in her eyes, still asks about organ donation. In Korea it has to be set up long ahead of time and she does not want to miss the opportunity to give away the healthy parts of her daughter so that others might live.

In the grief of this mother, and in the grief of Isabel Allende’s loss of her daughter and in the sometimes grief of simply surviving another day, salve for the wounds of living with loss comes in giving.

Jane has just brought me a bowl of homemade stew. On this blustery, drizzly, gray San Diego day, she brings me a gift of warmth and health and time. I try to think of what I can give. I think of the homeless veteran I remember from the Veteren’s day service at church. When the offering came to him, he contributed.

Arvid tells a story of Jesus and his disciples accepting rich offerings for God to the applause of the observers. In the midst of this, a woman in rags approaches and deposits the equivalent of a penny. Jesus tells his disciples that this represents everything she has and therefore more than the wealth of others in the eyes of God.

I try to think of what I can give. I can write. I can heal. I can listen. I can share. I spent a long time with an obese 10 year old and his family the other day. I approached the issue of his weight gently and told him about portion control and healthy snacks and no soda or juice. I tell him about exercise. I offer a few books in case the family (both mom and dad are busy working parents and heavy themselves) needs more structure to create diet plans. As I struggle with my own weight (prednisone induced, depression induced, winter induced, gene induced or some combination) I frame my counseling to him not as a criticism as much as an area where he can make changes to actively improve. The attending later told me that the family had thanked him for the time I spent with them. I can give that.

I gave my car to someone in Mexico I think—perhaps less than willingly, but it helps even to think of theft that way. Thinking of my stolen jewelry in Cincinnati that way, even in the midst of my grief over Michael, softened that pain a little, too.

Bob has just come by to visit on his way to pick up some food. He is short on cash at the moment with an empty fridge. I offer to share the left-over turkey from mom, or the stew from Jane, or the chicken soup from Loraine. As I rattle off the options, I realize how very much I have been given and remind myself of gracious gratitude. He refuses, but appreciates the offers, he says and heads out to get a Chipotle burrito. Given pride, accepting is much harder than giving.

For me, too. I find it very difficult to accept help, though easier perhaps than before my lupus diagnosis.

Yesterday in the NICU, after being up the majority of the night, and sleeping worriedly for the rest of my time on call there, I started to attempt an arterial blood gas collection on the newest and sickest of our babies. When I first heard of the mother arriving in labor with a premature baby (33 weeks, when term is 40) in our near future, I had the charge nurse page the attending, Emily, a resident who just graduated from our program last year and who my heparin drip and I visited in May when she worked in the NICU of the hospital where I spent my ten days as an inpatient. By the time I was attempting the ABG, she had arrived. Under the lights, I sought the tiny vessel in the tiny wrist without seeing the flash of blood which means success.

I saw flecks of light instead, then darkness at the edges of my vision. I asked her to take over the procedure and sat down where I could. The nausea and weakness came over me too suddenly to do anything else. I couldn’t focus and even sitting down I felt like I might collapse. I made it over the nurses’ station and managed to ask one of the nurses to bring me my water bottle. She took a closer look at me and noticed my pallour and diaphoresis (sweating) and got me juice and wet wash clothes instead. They only take care of babies so they didn’t know what to do with a sick big person. I told them I needed to put up my feet and it was probably orthostatic hypotension and that it had happened before. “But it hadn’t happened since before May,” I thought to myself. They didn’t know about my lupus or my strokes. Only Emily did.

When she finished with the baby, someone had gotten me a cot and she wheeled me over on one of the desk chairs. I felt too miserable to feel ridiculous. Lying down helped me after a while. Emily brought me juice and a cookie and asked me about why this happened. I wanted to chalk it up to sleep deprivation and nerves. I had taken my pills that morning, so my stress hormone level should be okay. I had inhaled oatmeal breakfast just before the call to the cesarean section for the premature breech baby boy so my blood sugar level should be okay. I didn’t want to think it had anything to do with the many clogged vessels in my brain.

When I told her my mom had moved to town, she looked relieved. I said she’d moved down here after I got sick in May. After my brother had said, “Shawna shouldn’t be down there alone!” I texted mom to come pick me up. She came in worried a half hour later, by which time I felt better, and whisked me off to home and bed where I slept for a petrified six hours.

I used to feel worse about asking for help, or even about recognizing when I need help. In April, I let my headaches go on for an entire month before telling anyone about them, by which point it may have nearly been too late. I ask more easily now (on some levels). I know when I need help (sometimes). I ask sometimes. Mom says she considers it a gift to be asked for help. She considers it a gift to be able to give to me.

I still struggle with pride, which tells me I should take care of myself. I practice asking for help and feeling graciously grateful for gifts given to me. In frustration at times I still crave complete and total independence. I don’t want to feel obligated to anyone or indebted to anyone. I give with fewer qualms than I take. Taking, I feel exposed. Giving leaves me free.

In a pensive mood the other day, I wrote, “I can bear this when I do not bare. Give me sorrow, grief, work, pain, illness. But ask me not to give you mine. I can bear yours only if I do not bare mine.”

I continue to remind myself to give generously of my talents and time and resources. And I must remind myself that taking enables others to give. And that pride offers no cot or cookies or wet washcloths before a fall. I must remind myself to ask for help, to learn from my teachers, to cry to my friends, to love with my family. I must remind myself to let the world in, so that I can share some of its secrets and wealth with you before whispering into your ear, “Pass it on.”

Bare Eyes

2008-01-24T00:19:00.000-08:00

Tomorrow my eyes will be examined. The plaquinil I take for lupus can damage my eyes. It probably won't. But it could. And the birth control nuva-ring I had in probably wouldn't cause clots in my brain. Probably won't. But it did.

The eyes have it. I crochet a hat for my dad tonight. It's all black yarn as he requested--thin to fit under his bike helmet. I don't tell him that my mom used a hat I knitted her to fit under her bike helmet. They don't talk much anymore after the divorce a few months ago. The woman at the yarn store next to the laundromat where I did eight simultanous loads of laundry told me that black yarn is hard to work with, "hard on the eyes," she said, "but you have young eyes, so you can't use that as an excuse." No, I can't. I don't think the medication has damaged them. I will spend three hours at the opthamologist tomorrow to find out for sure. My eyes see clearly now.

Even with the rain gone. I thought I could make it when the rain was not gone. I thought I could see clearly when Jane was here playing Johny Cash and watching me cut plastic bags into plastic strips to knit into another type of bag. And when we ordered pizza and the delivery boy showed up soaking wet in the rare Southern California downpour. For a few moments I saw clearly. With the rain not gone.

I won't let anyone love me.

I get prickly and difficult inside and make excuses at the first glance of interest, "It probably won't work out anyway because of my job or my illness or my body or his love of video games or a million other reasons we'd discover if we started talking about anything real. Besides I don't want it anyway. So there."

I text Steve as I'm reading Les Mes--the part where Marius and Cosette are in their first throws of innocent and uninterrupted adoration--I tell him I can bear illness and death and sorrow, as long as I'm allowed to not bare my soul.

Seeing him today reminded me how lonely I am. How lonely I try to forget that I am. How I tell myself I don't want it, perhaps because I'm afraid of the risk, perhaps because I'm insecure, perhaps because I don't want to dissapoint anyone who I might be able to love, perhaps because I've had my share of hurt and because I expect more than my share of understanding, perhaps because I don't always love myself, and why then would anyone else love me. How could they? How at the end of the day, I sleep alone and tell myself that it's better that way. I sleep better that way. I don't have to deal with the love part or anyone snoring. I tell myself it's better that way.

I lie to myself, and tell myself it's better that way.

Sunbeams January 2008

2008-01-23T23:43:00.001-08:00

After twelve years of therapy my psychiatrist said something that brought tears to my eyes: “No hablo inglés.”
Ronnie Shakes

Depressed? Of course we’re all depressed. We’ve been so quickly, violently, and irreconcilably plucked from nature, from physical labor, from kinship and village mentality, from every natural and primordial antidepressant. The further society “progresses,” the grander the scale of imbalance. Just as fluoride is put in water to prevent dental cavities, we’ll soon find government mandating Prozac in our water to prevent mental cavities.
M. Robin D’Antan

One loses the capacity to grieve as a child grieves, or to rage as a child rages: hotly, despairingly, with tears of passion. One grows up, one becomes civilized, one learns one’s manners, and consequently can no longer manage these two functions — sorrow and anger — adequately.
Anita Brookner

He . . . treats his emotions like mice that infest our basement or the rats in the garage, as vermin to be crushed in traps or poisoned with bait.
Marge Piercy

Why is it that people who cannot show feeling presume that that is a strength and not a weakness?
May Sarton

No matter what you’re feeling, the only way to get a difficult feeling to go away is simply to love yourself for it. If you think you’re stupid, then love yourself for feeling that way. It’s a paradox, but it works. To heal, you must be the first one to shine the light of compassion on any areas within you that you feel are unacceptable.
Christiane Northrup

Don’t look forward to the day you stop suffering, because when it comes, you’ll know you’re dead.
Tennessee Williams

This body that we have, this very body that’s sitting here right now in this room, this very body that perhaps aches, and this mind that we have at this very moment, are exactly what we need to be fully human, fully awake, and fully alive. Furthermore, the emotions that we have right now, the negativity and the positivity, are what we actually need. It is just as if we looked around to find out what would be the greatest wealth that we could possibly possess in order to lead to a decent, good, completely fulfilling, energetic, inspired life, and found it right here.
Pema Chödrön

If my life were not a dangerous, painful experiment, if I did not constantly skirt the abyss and feel the void under my feet, my life would have no meaning and I would not have been able to write anything.
Hermann Hesse

During a recital in Berlin, Andrés Segovia’s guitar was heard to emit a loud cracking sound. Segovia rushed offstage and, cradling his instrument, kept repeating, “My guitar, my guitar.” It was soon learned that the man who had built the guitar had died in Madrid at the exact moment in the concert that Segovia’s guitar had split.
Bartlett’s Book of Anecdotes

If you’re really listening, if you’re awake to the poignant beauty of the world, your heart breaks regularly.
Andrew Harvey

You think your pains and heartbreaks are unprecedented in the history of the world, but then you read. It was books that taught me that the things that tormented me were the very things that connected me with all the people who were alive, or who have ever been alive.
James Baldwin

Many people feel guilty about things they shouldn’t feel guilty about, in order to shut out feelings of guilt about things they should feel guilty about.
Sydney J. Harris

I like the snot to run a little, the tears to accumulate a bit before I reach for the handkerchief. Then I know I’m really crying. Crying just isn’t crying unless it’s messy.
D.H. Mondfleur

No amount of fine feeling can take the place of faithful doing.
William Barclay

It is said an Eastern monarch once charged his wise men to invent him a sentence to be ever in view, and which should be true and appropriate in all times and situations. They presented him the words: “And this, too, shall pass away.” How much it expresses! How chastening in the hour of pride! How consoling in the depths of affliction!
Abraham Lincoln

When you are sorrowful, look again in your heart, and you shall see that in truth you are weeping for that which has been your delight.
Khalil Gibran

At least I have not been run over by a jeep

2008-01-22T21:50:00.000-08:00

I heard the following story on the news the other morning. When I texted it to one friend he said she must have had a sinking feeling about that. Another friend said you don't hear that every day and asked how I was. I wrote back, " I have't been run over by a jeep."

Some days that's all you can hope for. Although lately days in pediatric cardiology clinic and my continuity clinic have been much better than that. Way beyond just escaping a jeep, I talk with patients and feel sometimes competent and always find some way to help, even if it is just letting the trying to recover alcholic "bend my ear," as he calls it. I told him not to feel guilty about it; and to do his best every day. "You just take it one day at a time and do your est with every moment you are given. And be gentle with yourself when your best consists of barely hanging on," like I told my friend in LA.

Sunbather Accident

Fresno, CA: (Jan-21-08) Sarah Bouvet, a 24-year-old woman, brought a lawsuit against the city of Coronado, after she was run over by a lifeguard truck while sunbathing on the beach in 2005. The suit stated that as a result of the accident, Bouvet was hospitalized for two days with injuries to her lower body after the right tires of a lifeguard's truck ran over her as she lay on her stomach near the Hotel Del Coronado. Following her recovery, her legal counsel claimed she still had minor residual physical and psychological problems. Records show that her lawsuit sought monetary compensation and a change in the city's lifeguard practices. As part of a settlement reached, sources confirmed that the city of Coronado has paid $141,000 to settle the lawsuit. [FRESNO BEE: SUNBATHER ACCIDENT]

2008-01-19T15:23:00.000-08:00

Child's Pose

2008-01-19T14:28:00.001-08:00

In child's pose I smell the seaweed
As my nose hovers milimeters above the grains of sand
And my toes spread into the gritty earth.
Between my legs I see broken seashells.

I woke up happy today.
I don't know why
But I'll take it.

Perhaps because of the miso soup and sushi
With Jane and Doug last night.

Perhaps because of the beautiful man who gave
Jane and I whiplash as we turned to notice him.

Perhaps because I laughed and it was easy
To remember how to interact.

Perhaps because my cousin Chad called last night
And we imaginied and laughed and it too was easy.

Perhaps because Jean ValJean and Cosette are safe
For now.

Perhaps because I ate chocolate
And silenced the guilt.

Perhaps because I had dreams
I don't remember.

Perhaps because my kitchen floor gleams
From the manic prednisone cleaning.

Perhaps because I found papers
I thought I'd lost.

Perhaps because the sun is shining and the birds sing.
Perhaps because today is a day.
And I am alive.

October 2005 Sunbeams

2008-01-19T14:13:00.000-08:00

The sun shines and warms and lights us and we have no curiosity to know why this is so; but we ask the reason of all evil, of pain, and hunger.
Ralph Waldo Emerson

If we will be quiet and ready enough, we shall find compensation in every disappointment.
Henry David Thoreau

That some good can be derived from every event is a better proposition than that everything happens for the best, which it assuredly does not.
James K. Feibleman

Nothing bad’s going to happen to us. If we get fired, it’s not failure; it’s a midlife vocational reassessment.
P. J. O’Rourke

Oh, my friend, it’s not what they take away from you that counts. It’s what you do with what you have left.
Hubert Humphrey

Since the house is on fire, let us warm ourselves.
Italian proverb

I know God will not give me anything I can’t handle. I just wish that He didn’t trust me so much.
Mother Teresa

I bear a little more than I can bear.
Elinor Hoyt Wylie

Perhaps this is why it is man alone who laughs: he alone suffers so deeply that he had to invent laughter.
Friedrich Nietzsche

Joy, happiness . . . we do not question. They are beyond question, maybe. A matter of being. But pain forces us to think, and to make connections, . . . to discover what has been happening to cause it. And, curiously enough, pain draws us to other human beings in a significant way, whereas joy or happiness, to some extent, isolates.
May Sarton

Sorrow has its reward. It never leaves us where it found us.
Mary Baker Eddy

I read about a man who’d been sentenced to die, saying or thinking, the hour before his death, that even if he had to live an ocean somewhere high up on a rock . . . with all around precipices, an ocean, an endless murk, endless solitude and endless storms — and had to stand there, on those two feet of space, all his life, for a thousand years, eternity — that it would be better to live like that than to die so very soon! If only he could live, live, and live! Never mind what that life was like! As long as he could live!
Feodor Dostoyevsky

If you break your neck, if you have nothing to eat, if your house is on fire, then you got a problem. Everything else is inconvenience.
Robert Fulghum

How can they say my life is not a success? Have I not for more than sixty years got enough to eat and escaped being eaten?
Logan Smith

Some of the world’s greatest feats were accomplished by people not smart enough to know they were impossible.
Doug Larson

Do not free a camel of the burden of his hump; you may be freeing him from being a camel.
G. K. Chesterton

I took a deep breath and listened to the old bray of my heart. I am. I am. I am.
Sylvia Plath

The best years of your life are the ones in which you decide your problems are your own. You do not blame them on your mother, the ecology, or the president. You realize that you control your own destiny.
Albert Ellis

The world keeps ending but new people too dumb to know it keep showing up as if the fun’s just started.
John Updike

Heart Fillings

2008-01-16T11:45:00.001-08:00

The ritual filling of the purple pill box occurs every 7-8 days. I had this morning off and I’d taken my “T” meds yesterday morning so the filling happened this morning, “W”. I’m back to cutting the 5 mg prednisone pills into quarters. I think to myself that it might be the same amount of medicine if I just licked them a few times. The little pieces of devil are tiny. At my rheumatologist’s appointment last week, he said I’d gotten too eager with my self-designed prednisone taper and wanted me to take 8 mg instead of the 7.5 mg. But I’m trying to set up mail order pharmacy so I can get three months supply at a time and they are taking a while to get the 1 mg tablets mailed to me. So I slice and dice with my super sharp pill cutter. I try to convince myself it is cool to have a pill cutter and a trendy purple pill box. It’s not cool.

I also started taking bid hydroxychloroquine—“bis in die”—latin for twice day. I suppose it is fortunate that I already had to remember my evening dose of vitamin K to balance out the coumadin, but the twice daily dosing still makes it harder to remember and plan ahead for taking meds along on long call shifts. Ah, the life!

One of the attendings in pediatric cardiology clinic talked yesterday about how much he likes one of the rheumatologists. “It almost makes me with I had a rhematologic disease,” I overheard him say to the fellow. That still stings. I forget about it for a while, but comments like that and I remember. At its worst it’s like waking up the morning after someone you love has died. In those first hazy moments, you don’t remember, but then the awful reality comes rushing back and you just want to fall back asleep until the pain abates—or maybe forever.

“You don’t want a rhematologic diagnosis,” I look up from the heavy cardiology text book on my lap that I read between patient visits. I haven’t told them about my lupus. I get tired of talking about it. “I said ‘almost,’” he replied with a light-hearted grin and turns back to the fellow. “Which one would you have?” the fellow asks him, “Arthritis? Psoriasis? You should have psoriasis on your legs. You always wear pants so it wouldn’t matter that much.” He retorts that he does wear shorts when he’s not at work; he surfs and wears trunks then.

I’ve been wearing skirts to work more because my pants are still tight despite running and working out a couple times a day and fretting over my prednisone-increased appetite and weight. It’s good I don’t have psoriasis on my legs—the swollen arthritic knees are easier to conceal.

These past few days I have enjoyed cardiology clinic; I am learning a lot. I can hear murmurs that I could not have heard before. Another of the attendings reviews a thorough cardiac exam with me and tells me that the med-peds residents typically have better accusatory skills than the categorical pediatric residents. I hear them more and more accurately, and work on translating those noises into diagnoses and treatment plans.

We talk a lot about ventricular septal defects throughout the day. It is a hole between the two bottom chambers of the heart and the most common congenital heart abnormality. In one clinic day I see it in many of its stages. We have a baby come in with a classic murmur of a small VSD—holosystolic, harsh, best heard at the left mid to lower sternal border. A four year old Hispanic boy comes in with a history of VSD and a loud murmur, “solpo,” but he also has a fever which makes the sound louder than when he feels well. We will see him back in a month when he’s no longer sick. I listen to an older child who has the blowing sound only through part of the filling cycle of her heart beat instead of the whole cycle--nonholosystolic. The muscular part of the septum between her ventricles closes off the hole for part of the beat which is why I don’t hear the murmur throughout systole. We look at another child’s ultrasound of the heart (echocardiogram) that shows one of the valves covering the hole for part of the cycle; this will sound nonholosystolic as well.

One eleven year old girl who comes in pouring over her book report on “Where the Red Fern Grows” and in a hurry to get to her soccer and then her cotillion classes has no murmur any more. I listen carefully, making sure I don’t hear it. Her heart sounds normal to me. Lub dub. Lub dub. No lub-whoosh-dub. Not even a soft one. I ask her if she wants to listen. She looks at me with disbelief, “Really?”
“Sure,” and I put my stethoscope in her ears pointing the right direction for her to listen. When I do this, kids get a sort of trance-like look on their faces—lulled by the beating of their own hearts. Intrigued and soothed at once. I think it might be a reminder of their time in the womb when they could hear their mother’s heart and a simultaneous realization of their developing autonomy. This young woman loved it. I took off my stethoscope and she had forgotten about the book report and plans, “That was so cool! I’ve always wanted to do that! Wow.” Her mother smiled and told me I’d just made another doctor.

I went to present her to one attending, but Dr. Seltzer caught me first—the one who “almost” wishes had had a rheumatologic diagnosis. He had an interesting patient for me to see with him. I remind myself that it usually is not good to be the “interesting” patient. And in this case, it does not take one to know one. Though maybe it does take one to more fully empathize.

I quickly present the eleven year old to the first attending, who has been teaching me about VSDs all day, “Eleven year old female, VSD diagnosed as an infant, no cardiac symptoms, playing basketball, soccer goalie, no fatigue, on exam, no cyanosis, equal femoral and radial pulses, murmur has resolved.” It would be a confirmatory test for me to see if he doesn’t hear the murmur either. He asks me if I want to go with him to see her, but I choose to head in with Dr. Seltzer and his “interesting” patient instead. I would find out later that he agreed with my exam. “Diagnosis: closed VSD,” he scribbled on the billing sheet before dictating the visit.

I come in part way through the history. The baby is largely covered in the stroller but looks about two weeks old. The baby’s mother is overweight beyond the normal post-partum physique and I compare my body habitus to hers. Many people struggle with their weight; I’m not alone in that; I’m not even alone in having prednisone make it harder. Sometimes those thought bring comfort, sometimes not. When I went for a mid-day post 30 hour work shift jog on the warm Sunday beach day everywhere I looked I saw thin couples. The arthritis in my knees started hurting despite running on the soft sand and I walked home hanging my head and suppressing frustrated tears. Frustrated with this disease and frustrated that I cared so much about how I looked and frustrated that it made me feel like this longest non-relationship period of my adult life may still stretch far into the future.

Back to cardiology clinic, though. The baby’s father, a thin bearded red-headed kind-looking man was there, too, adding to the history and listening attentively. When Dr. Seltzer later told them their baby’s heart had problems, he would cradle her gently and repeatedly stroke her bundled small left foot while acting brave and trying to ask the right questions.

Their little girl had three heart defects: supravalvular aortic stenosis, pulmonary stenosis, and coarctation of the aorta. The first of these and sometimes the combination of especially the first two make pediatricians suspicious that she may have William’s Syndrome, a genetic disorder of chromosome 7 causing people to have variable expressions of Elvin facial features with “cocktail personalities,” shorter stature, high calcium, mild to moderate mental retardation and an unusually well-developed sense of pitch. Dr. Seltzer drew the cardiac defects on a diagram of the heart and told them that she would probably need heart surgery. He then explained that the pattern of her heart defects might mean that she has William’s Syndrome. He told them gently and reassured them that his William’s Syndrome patients were some of his favorites; he told them it could be lucky that she has this chromosome disorder passed on from one of them; that William’s syndrome children are very special. We referred them to a geneticist to see if his suspicions were real. Their beautiful baby girl with the full head of hair was not perfect—or perhaps she became a different definition of perfect.

Just now I listened to an NPR story about a teenager with William’s Syndrome. He feels very lucky to have it because it defines him; he seems to feel he would not be himself without it. But there in the exam room with Dr. Seltzer, these two parents with their first child, could not be other than mourning. The mother would start crying discretely as soon as we stepped out to get them a handout. The father looked paler than usual beneath his freckles; his eyes were wide and veiled and protective. The repercussions of this 30 minute doctor visit would spill far beyond that day. Perhaps they would spread only over the next months as she had her heart repaired and the genetic test came back negative. Or perhaps the diagnosis would fill the years of her life, defining and shaping her future in a way different than either of young parents dreamed.

Dr. Seltzer had been right, though. She is an “interesting” patient. Maybe one days she will be interesting enough to fill her own purple pill box, too.

2008-01-13T21:57:00.001-08:00

In the end, we will remember not the words of our enemies, but the silence of our friends.

Martin Luther King Jr.

Wait, Wait, Weight

2008-01-02T21:22:00.000-08:00

I loath prednisone. Its latest torture is cushingoidizing me. Cushing’s diasease is when your body produces too much of its own stress hormone (cortisol) which does all of the awful things that prednisone does to you when taken exogenously. It redistributes fat in your body; it gives you “moon facies.” I hate that most right now. My cheeks are round. I feel trapped in a body that has betrayed me and now doesn’t even look like me. I avoid mirrors anymore—the first-born who used to love the camera—and when I glimpse myself I wonder for a moment who I see. Because that person doesn’t look like me.

I’ve taken the prednisone since before I was diagnosed with lupus and blood clots. The neurologist recommended it first as a treatment for possible vasculitis (vessel inflammation) in my brain. They started me with a “burst.” 60 mg daily. They didn’t tell me about the mood swings. It amplifies everything. The highs become crazy manic rolling on the floor yammering away about nothing, or scrubbing the outside walls, or baking long into the night. The lows become tear-filled hours alone worrying about how to get through this, or thinking about mistakes I once made, remembering forgotten regrets. Full nights of emptinesses. They didn’t tell me about that. But now I know.

I know also about my face looking rounder. My cheek bones disappearing into the flesh that accumulates where it never was. I don’t like to meet new people anymore. I don’t feel like myself. I don’t look like myself. I don’t know this self. I don’t want to be this self. I want to be even-tempered and joyful and thin and active. I don’t want to have to worry about being in the sun when I go sailing with Jane on New Year’s Day. I don’t want my knees to hurt every time I start to get run down. I don’t want my friends to tell me they “know” what I’m going through. I don’t want to be buried yet.

My bones are probably not in the best shape either. I’ve taken the wonder devil drug for over seven months now. It thins bones. And skin. But it increases appetite and makes you gain weight.

And it’s not dosed for a resident’s schedule. Your body has normal ups and downs of cortisol through the course of a day, but extra prednisone overrides all of that. It masks your own fluctuations and gets you through a day (sort of) but then doesn’t last the night, which is a problem on thirty hour call shifts. I try to taper and I flare so I go back up on the dose. I haven’t been able to get below 10 mg daily since I started taking it. For a while I cut the 5 mg tablets into quarters and took 11.25 mg which is a ridiculous dose—no one goes to two decimal points on their prednisone dose. But at 12.5 mg I acted crazy. And at 10 mg it took all of my energy to get out of bed and the brain clot-feeling headaches came back.

I stared at my round cheeks the other day, after I’d struggled to get on pants that used to fit, and I let my tears roll down those foreign full cheeks long into that night as I reviewed this last year of my life. Fretting over every dark thought that seems exponentially worse in the wee hours of the morning: my lupus, my parents’ divorce, medical bills, work on Christmas, my stolen car, my new car payment, my lack of funds, my brain clots, far away family, friends I’ve hurt or lost, a lost stylus, a clinic patient with breast cancer, far away friends, lack of enough knowledge, loneliness, weight gain, empty bed, lack of time, shape-shifting future.

Even now, by the light of the computer screen, the list doesn’t seem as bad as it did that night. It still brought back tears, but they’ve dried already. It’s very warm in my apartment tonight. For that, I’m thankful. I’m knitting up my worries again, into caps and scarves. I live in a beautiful place. I ran along the water today. Overall, my body actually works pretty well most of the time—compared to a lot of bodies I try to treat. My brain works. Bryce is in town. I have missed him. I have wonderful friends. I still feel like I’ve misplaced my spark. I can’t find that happy thought that lets me fly with Peter Pan and Wendy. I’ve ridden these waves enough to know it will turn up. In the meantime, I try to eat less. And I reduced my prednisone to 7.5 mg. I hope I don’t flare.

I Dreamed a Dream

2007-12-26T22:10:00.000-08:00

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

2007-12-24T00:55:00.000-08:00

“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

2007-12-21T23:38:00.000-08:00

“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"

2007-12-21T23:04:00.000-08:00

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"

2007-12-21T22:36:00.000-08:00

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

2007-12-15T14:14:00.000-08:00

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

2007-12-04T20:17:00.000-08:00

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...

2007-11-29T21:32:00.000-08:00

The essense of all beautiful art, all great art, is gratitude.
~ Friedrich Nietzsche

Gratitude Here and Now

2007-11-29T18:17:00.000-08:00

Yesterday I had another doctor's appointment. Our team was on call (which means admitting patients if any need help) but it was quiet so I got away for a while to see my neurologist. The first thing he did was apologize for the neuroradiologist who told me I was on the wrong medicines and that he would go into my head and pull out the clots. Apologize profusely and repeatedly and said if it were anyone other than the person it was (ie a neurorads fellow or resident instead of the director) he would try to get him fired. Yikes. I work with these people. But when I told him who it was he said this doctor was old and had been there forever and thought everything he did or said was right even though it was based on little to no evidence. Little to no evidence.

Dr. M, my neurologist, was livid that I had been told that I should get the clots removed mechanically. And Dr. H, my internist, call the radiologist, "full of shit." They both felt badly about the misinformation I had recieved and that had stressed me out so much I flared again. I do have a good team of doctors, who care about me immensely and try very hard to get me through all of these changes--physically, and mentally as much as they can. The mentally, I'm more in charge of; that makes it much harder. I find it hard to look at sometimes--in its entirety.

Dr. M went over my MRI with me and showed me that it is actually better! I have one important brain vein (the straight sinus) that has at least partially opened back up whereas it was entirely clotted off before. The inferior saggital sinus that is supposed to drain into the straight sinus is still entirely blocked off or was never there; and my transverse sinuses are less than gigantic, but the overall drainage seems to be adequate. The coumadin only helps clots from forming; it's my body that has to clean up the ones that already formed. He also said I probably bought myself a lifetime supply of coumadin therapy (except if I get pregnant because it makes babies bones form wrong--I'll have to do two lovenox shots a day if/when that happens). I figured I needed life-long anticoagulation; and now, stopping the coumadin would worry me, too. Every time I get a headache I worry I'm starting to stroke again. And he said this shouldn't affect my ability to process information. My thinking should be clear as long as I'm healthy and not flaring and not stressed out by radiologists. So many caveats to my existence now--but I suppose everyone has some of their own.

So far this month on wards at the VA, I am managing okay. We've only had one overnight call so far and those are usually the problem for me. I'll have another on Sunday. But in between those I'm working 12-14 hour days with just one day off in the two week stretch. Normally I would work four 80 hour weeks in a row, but they switched my schedule around so I work only two. That should help. Somewhat. The prednisone still makes it hard to sleep. And the thoughts about everything I forgot that I should know about my patients keeps me up hours after that (until I started taking medicine for that, too). "Did I order labs for the morning?" "Why is he anemic?" "How come his sodium keeps falling?" "How should I respond the next time my antisocial personality disorder patient calls me a liar?" "Why didn't I know the answer to that question when the attending asked?" "Where can I find that information?" Etc. etc. It's not all the medicine part that stresses me out. It's everything; it really is too much--for anyone.

Fortunately, my attending this month is fabulous. He's an infectious disease specialist; and he'd talked with me some about my illness before we started this ward shift, "Let me know if I can help," he said. And he means it. Today I went to take him a lemon bar after everyone else had gone home (I'm still baking like crazy trying to calm myself down). He accepted and then stood up and looked closely at me, "How are you doing?" I told him a little about the sleep problems and the prednisone and how hard it was to deal with mentally and about the changes in my MRI and that I keep considering other options. He said that is probably a good idea: other options with better hours. He's suggested pathology when we talked before. I like path, but I also like patients. He said I was doing well; that I care about the patients and am enthusiastic about medicine and that I seem to know my stuff and will only get better. Only get better. In more ways than one, I hope. He also said he thought I was a very brave woman. I think he meant brave to keep going, in spite of the lupus and the strokes and the clots.

People have called me "superwoman" through this. Others have said that I'm either a hero or a fool. Aren't they sometimes the same thing? Maybe I'm both. Maybe neither. Maybe I'm just doing what I can with this life I've been given, knowing now more than ever that it is indefinably finite. I don't know when all of this will end. All I know is what I can do with today. Hopefully tomorrow. Hopefully many days after that. But I don't know that for sure. No one does. The termination of here is more palpable to me than before. It makes me appreciate the here and now.

It makes me want to visit my WWII Navy vet who served on a submarine. He is featured in the veterans' calendar from last year and was proud to show me. He talked about illegal immigrants, too. I may not agree with his politics, but he is a remarkable man. This morning he told me a story about how his eyes used to be so good that he could see a boat on the horizon before any of the others or the electronics could detect it. "They're signalling to us," he told his captain. "They're firing at us!" And his submarine turned around. Perhaps he saved those men from dying that day. Lives change in instants like that. In the heres and nows that have been--and can be.

The vets spend more time thanking us than any other patient population. I updated the far-away brother of my liver disease patient on the phone the other day and he spent minutes thanking me and apologizing for taking up my valuable time. "It's my pleasure," I told him over and over. It is a pleasure to talk to the people who know and care about the patients you only meet in passing, sometimes as the candle of their existence flickers. That's where the humanity enters to make medicine more than science. That's where all the effort and learning and trying meet something that really matters.

Another of my patients wrote me a card that he gave me when I saw him first thing in the morning and told me I could read later. Just getting that card was the highlight of that day. The rest of the day was pretty awful. I came home a complete wreck and cried when Joseph and Jane so much as asked me how I was. The day had been too full of new patients and no time to get everything done and both I and the other intern had to go to clinic so we had only five hours to finish easily 10 hours worth of work. And Keith's package I'd mailed to him from Spain was wrecked. It was a terrible horrible no good very bad day--that day.

I didn't remember my patient's card in my white coat pocket until I got home, tried unsuccessfully to sleep off the frustration, only making it worse, and cried some more. In it, he said he had been in many hospitals, but never had it had such an enjoyable time as with me taking care of him. He said he'd learned a lot (we'd made a new diagnosis of type two diabetes for him and I spent time explaining what that meant for his lifestyle and changes to make) from me. And that he wishes that I were his doctor. Very high praise. I cried again. This time with elements of gratitude and relief mixed with the exhaustion and feelings of ineptitude.

"When our perils are passed, shall our gratitude sleep?" (George Canning)

I remain grateful to be alive--almost every day. I am grateful to find my car where I left it. I am grateful to have learned about iron storage today from our attending. I am grateful to be able to try to help people. I am grateful I finished work before the sun went down so I could stop and walk along the ocean and watch the sun setting in all its red and orange and pink glory over the ocean. I am grateful for where I live. I am grateful that two of my favorite people called tonight (even though I missed the calls; I'll call them back). I am grateful that I tried a new recipe last night (not baking!) with chicken and onions and red peppers and balsamic vinegar that is very fast and tasty. I am grateful that I have bananas that are almost soft enough to make bread or biscotti. I am grateful I found a Whole Foods market right by the VA. I am grateful I have Saturday off. I am grateful for a yoga class in 30 minutes. I'd better start getting there, in fact. I hope you have many things in your life for which to feel grateful.

Banana Bread Instead

2007-11-25T19:40:00.000-08:00

Call was long.
I'm just now going to bed.
Have been baking instead.
Trying to turn off my head
And silence the dread
I felt when my thoughts fled
Or my liver patient bled.
So I bake banana bread.
Instead.

I'm very tired. Very tired.
Uninspired.
Short wired.
Mired.
Retired.

So I made cranberry sauce
lemon bars,
and invented lemon rosemary biscotti.

It worked. I feel better.
Less bothered by the histrionic patient who quizzed me before I left after being up dealing with cross-cover issues and my new patient all but two hours last night.
Visited Jane. Joseph visited.
He had a rough four paramedic days, too.
He ate lemon bars and banana bread.
Instead.

I hope I can sleep now.
Instead.

2007-11-23T17:47:00.000-08:00

I GOT MY CALIFORNIA STATE MEDICAL LICENSE TODAY!!!!

(You get your license after med school and all three USMLE licensing exams, the last of which you cannot take until you have completed your intern year, sooo you can't apply for your medical license until after that. I finished intern year. I took the two day exam. I passed. I applied. And today the mail came. So now it is official, official!!!)

Thanksgiving: Rice and Beans from the Drivethru at Roberto's

2007-11-23T13:20:00.001-08:00

A memorable Thanksgiving, involving walking through a Mexican drivethru for dinner. I kid you not.

Mom and Bernie and I had planned on going out for a Thanksgiving dinner. Mom thought, in particular, that a fish place on the ocean would be open. I preferred an Italian place I'd been to a few months before. And our back-up was our favorite Greek restaurant. Nothing traditional, but the year had not been normal either, so it seemed to fit--the first year when my parents are not together, first holidays after Colin and Becky are married and living in the house they bought from my parents, first year with my lupus diagnosis, and Bryce can't make it home from New York so he planned on driving to Michigan with his girlfriend to see our extended family there.

I want to start by saying I feel extremely thankful for many things this year, having survived being high on the list. And many of my wonderful and unconditionally loving friends. Spain. My family. Lemons. My apartment by the beach. Visits from friends. The blue and white table cloth. Showers. Yoga. The gratitude goes on; I keep thinking of new things and adding to the list I started in my long-hand journal.

And I'm thankful that I got Thanksgiving Day off for the first time in two years. Once I'd slept in appropriately, I woke up, started my "thankful" list (which I might try to do more often than once a year; it recalls happinesses well), and decided to take a bike ride to the beach for some yoga. I invited mom to come along and by that time Jane had returned from Ben's where they'd started the Turkey and we talked about Thanksgiving memories and how we both tried to keep discontented or angry people out of our lives or create a protection against the ones we couldn't help but interact with. I have trouble with that still. Like when Sean was drunk (again) and yelled at me for not picking him up from the airport (even though I was at work and never agreed to do this) I felt oddly responsible and like I'd somehow messed up. Even now, I have to keep reminding myself that his anger is not about me.

Thanksgiving day here was beautiful. Beautiful! Sunny and warm and happy. We decided to ride our bikes over to a place that mom was thinking of buying for the family beach home (when she wins the lottery maybe?). As we're riding and ringing the bells on our cruisers and singing and chatting and crunching through fallen red leaves and laughing and wishing everyone happy thanksgiving, the smell of turkey and stuffing wafts out of every house.

The house mom has seen on the internet needs a lot of work, so that we didn't pursue that option, but she finds another few fliers of possible places. From there, we went by Ben's place to check on him and the turkey. I tried guitar hero for the first time and got booed off the stage. Oh, my breaking heart.

Straight to the beach next. I started to do my yoga routine with mom keeping up for a couple minutes, and Jane immediately into the corpse pose and rolling around barefoot in the grass. We felt like kids. Giggling and stretching and taking pictures and pinching ourselves to remind us that it is November and the waves are crashing below in full sunshine (don't worry, I had spf 45 on to prevent the flare). Yoga felt good as always. And I surprised myself by enjoying the company also. I love Jane and mom, but I usually like solitude during yoga. Teaches me to let happy people in more.

We all felt somewhat cold and tired by the time we'd finished so we rode back along the ocean to our apartments for snacks of crackers, cheese, smoked turkey, grapes, lavender biscotti, rosemary lemon cookies, ginger cookies and Jane's special tea ball tea. Yum all around.

After our snack and three-way chat, Jane left to visit some friends and mom and I had a chance to talk about a few of the changes in our respective social and physical situations in the past year.

Bernie showed up around 6pm wearing a sport coat and fancy shoes for our night out. I still hadn't showered so hurried to do that and get a little more spiffy myself. I wore the scarf Keith got me from Spain--reminders of more thankfullness. And then the great Thanksgiving Dinner Adventure of 2007 began.

Dr. F had recommended a restaurant down the street from my apartment: the one I could rarely find so drove up and down the amazingly quiet and rather darkened main street at least three times. I didn't find it, but got close. We found a great Spanish restaurant nearby--for another day. Closed for Thanksgiving.

I began to think this going out to eat might not be such a great idea. But, within walking distance of the Greek restaurant, we decided to assess our options there. Even from 500 yards away, we could see the darkened interior--closed also. "This was a nice walk!" I said.

We tried the fish place on the beach next. Found a great parking place and walked along to the rhythm of the waves to find that restaurant also dark and closed for the evening. Hmmmm. I offered the salmon in my freezer, and reminded them I was well supplied with home-baked goods. Maybe a home Thanksgiving dinner after all. We decided to drive a little more just because we were having so much fun listening to Jens Lekman sing about falling in love with a punk at the anti-war demonstration. Seven-11 was open. A few bars looked open but not busy and very TV heavy. I think Denny's was open too. And Roberto's taco place still had their lights on and cars moving through the drivethru.

After a couple more tours of that block, we parked to go inside Roberto's, but the door was locked. The drivethru window was open and the little metal box squawked, "May I take your order?" Keep in mind we are not in the car. And so ensued the decisions to get tacos or enchiladas? How much rice and beans? Did we want the horchata? Anything else? Chips? All done while reading the outside menu and bending down to talk to the little metal box on the side of the building. Mom and Bernie had to do the ordering since I was laughing uncontrollably by this point. And the men inside the restaurant chuckled persistently and spoke good naturedly in Spanish as they watched us, as Jane would say, "act like tools" outside. What fun!

Our order in, we stood outside the drivethru waiting for them to get it together. An SUV drove up with a surfing video playing inside and Bernie sidled up to it to watch through their back window. The owner of Roberto's came out to the take out window to explain that he had locked the door a couple hours earlier because someone came in and tried to rob them--at gunpoint! Scary stuff. We told him we were thankful everyone stayed safe. A drunk man came up to us as we got the bags of food and Bernie headed him off before he got too ugly.

Thanksgiving?!? Rice, beans, and tacos? We kept reminding ourselves and laughing.

We drove by Ben's place to visit with him and Jane and Bob. They'd had the traditional fare and were packing up the remains. They offered to share, but we had our feast in styrofoam so we drove back to my apartment to enjoy it on the blue and white checkered tablecloth with a bottle of Kenwood 2004 Merlot I found in my cupboards. And the cookies for dessert.

Not your traditional "Turkey Day" but a fairly fabulous celebration all the same!

I hope you enjoyed a holiday filled with gratitude, friends, laughter, and love.