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Contact Precautions April 17, 2009

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I don’t know how many times my mom was admitted to the ICU that month. Ten? Twenty? By the end of the second week, I had lost count. Occasionally she was transferred upstairs, to a “regular” in-patient unit, but that never settled my queasy belly. I knew I’d see her again the next day, a tube down her throat once more. I was told that it was helping her breathe, but really it looked more like a white plastic parasite pulling out her entrails. As a mere medical student, I felt like a child, her youngest son, helpless to do anything to save her. Sometimes she was admitted twice in the same day, and sometimes she died. It was never easy for me to witness, but I suppose it was much worse for the other members of the family – her blood family. Whereas I was just imagining my own mother in the hospital bed, hoping that her health would never fail her in this way, these people had to stomach the reality of their loved one sick, suffering, and dying. For the families and medical staff alike, every day was the same: hoping for the best, preparing for the worst, and never quite sure what to say to one another.

Worried “what if’s” swirling in my head, I would go about my work as a distraction, transcribing lab results or punting medical questions to my senior residents. During the afternoon, when my charting and procedures had been completed, I would sit and watch these family dynamics from the relative safety of the nurses’ workstation. Turning to each of the twelve rooms was like flipping the channel between twelve different soap operas, sitcoms, and “reality” shows, all playing out simultaneously. I tried to pay close attention, knowing that the next morning at sign-out we’d be critiquing each episode, like workplace gossip around the water cooler. In our discussions, sometimes we’d use names, but other times, just numbers.

“Room 14 keeps changing her mind about getting a trach,” one of the residents said one morning, between bites of a donut. “Whenever she decides she doesn’t want it, her family yells at her until she relents. She has stage IV metastatic ovarian cancer. Don’t they realize she’s a candidate for hospice care, not surgery?” I had seen this episode before: it was a rerun of “Father Knows Best.” I found it ironic that we, her medical family, were trying to impose our will upon the patient, just as her blood family had been doing. Did they understand her prognosis? Were we telling her to give up hope? Could the cliché of “dying with dignity” also mean dying on her own terms, fighting against the cancer until her very last breath? Under the supervision of the residents, each intern and medical student had taken ownership of two or three patients. Room 14 belonged to someone else, and so I kept these questions to myself.

If sometimes paternal medicine got the best of us, other times, we weren’t sure what to do. “I spent nearly 30 minutes on the phone with Mr. A’s son yesterday. He has Power of Attorney but clearly doesn’t understand what that means,” one of the other residents began, shuffling his notes. “He kept trying to get me to talk to his wife instead, but of course legally she can’t make any decisions.” Mr. A was one of my charges, and the biggest ethical challenge I had had to date. I had helped the resident admit him a few nights ago, when he had presented to the emergency room with delirium and profound anemia secondary to a large gastrointestinal bleed. After we resuscitated him with blood and fluid, we asked his son to temporarily suspend his “do not intubate” order so an upper endoscopy could be performed. In the period between changing the order and his scheduled procedure, Mr. A decompensated and, with no order to stop it, we had to intubate him for respiratory failure. Now we had become social workers and lawyers, arguing whether this was a “terminal state” and whether we should ask the son to have him extubated. “We should get an ethics consult,” I spoke up, breaking the fourth wall of this medical soap opera. “I don’t think this is what he wanted.” (How could I say that, having known Mr. A for only a few days, and never when he was conscious?) One of the senior staff shot me an angry look, and I closed my mouth. The decision was made to do nothing, and soon the team had moved on to talking about the next patient.

In retrospect, I still don’t know if it was a mistake to become emotionally involved. It was impossible not to see some element of my own life in each patient, and in each story. Indeed, I didn’t just see my mother embodied in the ICU patients, but other friends and family members. Was I treating these people differently, I wondered, spending a moment extra during pre-rounds or empathizing with their situation a little more, merely because they reminded me of someone? How could I play favorites with the critically ill? Would being detached instead allow me to deliver better care?

Once or twice I envisioned myself tied to the hospital bed, padded cotton straps tethering me to the side rails, preventing me from escaping or pulling out my breathing tube. (What if I wanted to self-extubate? Why had I lost that right?) How would my family react? Would they become an element in the room, an unstable piece of furniture to be treated with care until it could be fixed? Or would they avoid the hospital entirely, finding themselves a false freedom being out of the unit, but trapped by the knowledge of my illness?

As medical professionals, our dichotomous privilege and burden is knowing people in their most vulnerable moments. Though we’ve been entrusted with their intimate secrets, oftentimes we’re still just strangers, unable to say with certainty what the patients would want, or even what we think they should do. For that moment, it doesn’t matter how many other patients we’re juggling, we must temporarily become myopic and make them our priority. The egocentric view washes over us, too: we can’t help but fall back on what we would want for ourselves and our loved ones in that situation. After all, we work in a grey area, where nothing quite ends up like the textbook. Our boundaries are the law and our own morals, and, to be sure, Hippocrates’ call to “do no harm” can be subjective. How does doing what you think best fit in with legal and moral obligations, when in some situations the law seems to supersede personal beliefs, and in others, defaults to it? The most fair and responsible decision-making, I think, comes from recognizing and weighing personal preferences and interpretations in the context of the person we’re serving. They come to us asking for help, either explicitly, or by their inability to do so, and they’re the ones that have to live (or die) with our choice.

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The Road from Home (abridged) April 30, 2008

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Wednesday afternoon in downtown Guayaquil: It’s hot and bustling as usual. Men in business suits and women in two-tone work uniforms are walking back from their lunch hours, filled up on fish ceviche or rice and fried meat or potato yapingachos. An English textbook in hand, I’m just now going to work myself. I’m trying to blend in with the packs of Latinos; I have on my stony street face (learned back in Brooklyn), but my blue eyes betray me. And if I were to open my mouth, well, then, all bets are off – my Spanish is on-par with a preliterate child. I sigh quietly to myself and keep moving.

Weaving between the street vendors who sell small red apples in large plastic bags, lottery tickets, and toothpaste to pedestrians and passengers on passing buses, I stop cold on the corner before my school. A body is sprawled out in the street, though it’s not garnering much attention from passers-by. A moment’s hesitation: Is this a homeless man or someone who’s had too much to drink? No, there’s a pool of blood forming around his head. No, this is not good.

I lapse into gringo EMT, kick into a sprint – leaving all knowledge of Spanish behind me – and try to explain to the security guard at my school that he needs to call an ambulance. (Oh, how I wish I still had those left-behind Spanish skills!) People have seen me running and now they’re curious. I return to the body with a small crowd. A second hesitation, this one moral: I don’t have a pair of latex gloves on me – should I act as a first-responder or stand back? Before I can answer myself, I’m already crouching in the street, checking for a pulse. As if in a made-for-TV movie, a woman steps forward to help me express myself in Spanish. The bleeding man is becoming conscious again, and he certainly doesn’t like that a tall white boy is trying to keep him from moving his head and neck.

Eventually Cruza Roja shows up and takes control. I slowly fade into the background, the people’s attention still focused on the bloodied man. I offer my name to a police officer, but am perplexed when he brushes me away. Did my efforts go unnoticed? Disappointed, I look over to the mob again and spot my translator friend. She smiles widely at me before disappearing into the crowd.

Ascension February 26, 2007

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          We could smell it on his breath. Less than 100 feet from where an Alcoholics Anonymous meeting was to take place, the priest had had enough red wine to lace himself in its sharp but sweet aroma. Diego rose from his chair to receive a cross of ashes on his forehead. We had driven to St. John’s Church in Waterbury for one of the handful of AA meetings that was conducted in Spanish. It also happened to be Ash Wednesday. I remained seated, my gaze drifting from each pane of stained glass to informal knit scarf that tumbled over the priest’s pot-belly. He looked at me expectantly, his thumb pressed into the ashes, waiting to mark me as well. “What are you? Pagan?” he asked in a half-joking tone that nonetheless implied I had no faith at all. He turned back to Diego to offer Communion: a broken piece of wafer as the body of Christ and a sip from a shared chalice of wine as His blood. I wondered quietly how an alcoholic could take Communion: it was ironic that the wine represented a life force, and it was something from which an alcoholic would have to abstain.
          The smudge of black on Diego’s forehead represented the dust from which we arise and to which we return. The symbolism was irreversibly tied to that of the Egyptian myth of the Phoenix rising from the ashes, though the order of events was reversed. As we walked back from the chapel to the meeting hall, I wondered what had caused the self-described alcoholics to “flame out” and to be reborn. What was their breaking point?
          Wooden folding chairs arranged in a rectangle quietly awaited occupants. Only two men were present: one seated behind a long table in the front, and one taping up an “Alcohólico Anónimo” poster behind a gurgling coffee maker. I think the actual etymology is different, but it’s fitting that, at first blush, the Spanish word for “sobriety” (sobriedad) looks related to the word for “over” (sobre). It gave me a sense of optimism that a person could rise above his or her addiction. I found it interesting, too, that the logo for AA featured a triangle with the word “recovery” along the bottom edge. “Unity” and “service” were along the diagonals, again suggesting a person could triumph over alcoholism, and that “recovery” did not necessarily mean “sobriety” or an end point.
          Indeed, unity was a strong component of AA. Originally, I could not tell whether the man seated or the one standing was in charge of the meeting. Both greeted Diego and I warmly, and both introduced themselves as alcoholics. It was a routine pairing for them, a reminder of their weakness but also that they as unique human beings came before their disease. I guess it was logical that the meeting should be run internally by an AA convert. Though each person’s story was different, the brotherhood was hewn from experience that an outsider could not fully understand.
          As the congregants filtered in, some made a point of greeting everyone, others said hello to and only hugged a few, and another set merely dropped papers on the front desk (ostensibly a form asking for proof they had attended the meeting) before sitting down. As the ritual started, the man who had been standing started to read the guiding principles of AA from his manual. The religiosity I had been told to expect from AA began to emerge: a small group of devout, like-minded people – with a few skeptics in the audience – gathered around a text that strongly encouraged a particular way of living. The reflexive call-and-response nature of personal introductions and the regimented structure of the meeting (guiding tenets followed by personal news, requests for help from those who were struggling, and then open discussion) helped to paint the religious canvas already supplied by the meeting’s location. By definition, it was religious, though not necessarily spiritual: a mix of shared beliefs and practices as well as individual faith. Though G-d was mentioned – sometimes in blame and sometimes in strength – He just represented another force in the universe. Those in the communion who spoke up stated that they felt ultimately responsible for their life, but that they weren’t alone. They looked to forces greater than themselves for strength. Their religion, instead, was AA.
          I noticed that Diego was the only one to have been marked with ash. Although it gave me a small sense of relief that these alcoholics hadn’t been tempted by the ash-and-Communion combination in the next room, it did make me keenly aware of standing out. We were outsiders to the reality of alcoholism: Diego, with a dark smudge on his coco-colored forehead, and me beside him, dressed in tan but ashen by comparison. In this group of 15 people, I was the only non-Hispanic. Did I actually stand out as much to them as I thought I did? This insecurity made me wonder if they, too, felt a similar anxiety when faced with non-alcoholics. Did they feel like they had a mark on their skin that betrayed their disease and their efforts to overcome it? On the one hand, they wore a Scarlet Letter that set them apart, but by acknowledging it here, in a welcoming group of peers, it lost some of its taboo.
          To this end, the open discussion was a group confessional. I wondered how many times the speakers had recounted their struggles, or if this was the first time the spoke the words aloud. The words came so fluidly from the three congregants that it seemed that they had been through this before. In each of their cases, going from “having it all” – a car, an apartment, a job, and money – to nothing and back to rebuilding, took several decades. They had had a lot of time to think about their choices in life. It still brought tears to the eyes of the only woman present. A Peruvian man spoke almost entirely to me, gesturing as he went to make sure I understood his words. Indeed, in both language and events, it was foreign to me.
          Though speaking was cathartic, it also seemed to be an effort to educate the newer recruits. It was what the more “learned” alcoholics could give back to their peers. Since the neophytes had probably already experienced some of their own drama and had at least recognized that they might have a problem, I wondered how story-telling could be useful. It was all a testament to the human comedy: circles of Hell and songs of joy. In knowing others had struggled and were continuing to face their problems, maybe those a few steps behind could find the strength to push on.
          A small basket was passed around – a collection plate whose charity supplied the meeting’s coffee. (I wondered, too, if the church requested payment for use of the meeting space.) It was another opportunity to give back, but it also underscored AA’s religious feel. And just like church, at the meeting’s scheduled end time, the attendees popped up and disappeared out the door and into the chilly night. I didn’t even have an opportunity to wish them luck in their journey.

The Blind Physician January 9, 2007

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          It was clear from her tears that she was scared. The white tissue veil she pressed against her face did not mask her pain.
          “He said the cornea needs to be amputated,” she said finally, rubbing both eyes with the palm of her hand.
          I stood there stupidly, quietly trying to piece together the story. I had no chart to guide me. I thought the reflexive response of “oh, it’s okay” was cliché and of little comfort – besides, it really might not be okay.
          One of her friends spoke up, embracing her from the side. “Wait until you go to Boston. See what they say there.”
          “Yes, I know,” the woman sobbed, “but the more I think about it, the more it makes sense. It was on my mind the whole holiday break. I just want some resolution to it now.”
          I still had no idea what was going on. I knew this was a stressful and serious life-event for the woman, but the vagueness of the pronouns left me with little to interject. She had been debating whether or not to have lasik eye surgery a few months ago, I remembered – the surgery must actually have worsened her vision, rather than helped it.
          I wondered what, in this moment, my role was: to play medical voyeur until I could make an evidence-based, scientific remark or to just become a confidant and offer trite phrases of solace? In deciding what my professional response should be, I simply froze up, following neither path, and thinking that that was worse than picking one extreme.
          “On top of this, he’s just such a jerk.” She was talking about her ophthalmologist. “My husband and I had to call him every day over the holiday to get an earlier appointment in Boston. He just sits on things.”
I hope it’s something sharp,” I thought to myself, simultaneously hating her eye doctor for being so blind (or, worse, apathetic) to her fears, but also wishing I could offer a sitcom punchline that would lighten the mood long enough for me to go back to the other patient I had left waiting during all this. Like the woman, I was as frustrated that there was nothing I could do now; only a second opinion from an eye surgeon in Boston would make the next step clearer.
          Breathing out slowly in an attempt to regain her composure, the woman picked up a manila folder from the desk and wrapped her stethoscope around her neck. Her eyes still red from crying, she stood up to see the patient I had started presenting to her 10 minutes ago. I followed behind her silently, somewhat confused that I had seen my physician-mentor in the role of patient, but also impressed that she was literally (trying to) leave her personal life at the door.
          She paused before knocking. “If it weren’t such a physical thing, maybe it wouldn’t affect me so much,” she said to the friend-colleague who had also followed us. “But every time I look in an ear, I have to think how I’m going to do it so I can see around my blind spot.”
          It’s an interesting dichotomy that we as physicians must look past our own shortcomings or biases yet pinpoint them in others. Failing to do this, or worse yet, failing to support the patient after problems have been discovered, is a particularly frustrating form of blindness. Though the myopic physician, overly focused on detail and not context, may be accurate, he is ignorant of what he fails to see, and his blindness instead presents a challenge to his patients. I knew that regardless of what happened to my physician-mentor’s eyesight, she would never be as blind as her ophthalmologist. Her dark eyes glistened from dying tears as she opened the exam room door and asked, “It’s nice to see you, Iris. How can I help you today?”

Breathe, Relax, Re-focus November 10, 2006

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            I figured I’d give it a shot.  Though in the back of my scientific mind I wanted some paper proving efficacy, I took off my shoes and lay myself down on a padded table in the middle of the room.  “Have you ever done reiki before?” Dave, the founder of SPARK (Spirited Action Release and Kindness), asked.  “Yes,” I said, reflecting on a time in Ecuador when a friend of mine tried it on me as I was ailing from a stomach bug.  I didn’t remember feeling any different afterwards, really, but I had liked the warmth of her hands on my limbs.

            Now I’ve found CAM to be a little odd to discuss with others – mainly because it is on the fringes of medicine and because something as simple as breathing or touch (rather than massage) seems so obvious.  It also often finds itself, I think, joined to the “dirty hippie” or “eccentric aunt” archetype.  But like I said, worse to worse, it couldn’t hurt to give it a shot.  So, relatively open to the idea, I tried to envision light passing from my head to toes and then to be keenly aware of direct touch or even Dave’s hands held above my skin.

            Experiencing reiki is a hard thing to explain.  It is calming and yet perplexing, as I felt my muscles twitch even though they weren’t being used.  And I thought it strange that I could allow a total stranger to place his hands on my limbs and head for upwards of 15 minutes.  Stranger still that it felt like there was actually an energetic connection.  When he had finished, my mouth was very dry and I really felt pretty relaxed.  Skepticism remained (for quantitative proof) but overall I felt good.

            I had tried yoga a little earlier in the school year, again, just to try it.  Supposedly it was somewhat trendy and people claimed to be benefiting from it in some unclear way, so I thought I’d try it, too.  And thus, during the 2005 regional AMSA conference in Brooklyn, I woke up early to try more yoga.  Like my morning aerobics class, I figured different instructors certainly function and make me feel differently, so perhaps it would be good to explore another yoga class.   In this basic introduction, we worked on breathing and just focusing on that, as in the
CAM presentation I’d had in my clinical medicine class.  Maybe because I felt like I knew what I was being exposed to now, I gave myself fully over to it, thinking of the poise of Tai Chi.  In repeating a stretch 3 times, moved by breath, I was able to go further; I didn’t experience the tightness of stretching.  And when we sat down to focus on counting breath, I felt I “saw” a central, circular image with my eyes closed (supposedly the Third Eye).

            When a later speaker talked about charkas and pressure points and again had us focus on our breath, I did feel some tingling and calmness again.  I’ve been trying to do the “spirit in, smoke out” mantra while focusing to see if there is any positive effect.  And yeah, I think it’s kind of cool, and as funny as I feel speaking about the unquantifiable spirituality or self-healing, I wonder if it’s something I will explore more fully in medicine and share with my patients.

Playing Dress-up October 31, 2006

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            My first day to play dress-up doctor actually coincided with Halloween.  It wasn’t the first time I had donned the garb of a physician, however.  I had made my premiere in the fabled white coat (size 44) last year, just prior to taking the Hippocratic Oath with my classmates.  Soon after, I purchased a blue Littmann Cardiology III stethoscope, and – presto! – I was a doctor.  Or, at least, I looked the part.  Besides the cliché of wanting to help people feel better, there was little substantive knowledge behind the costume.  Regardless, there must have been some change, for when I stripped off the white coat to work at my pediatric clinic assignment, I was still – incorrectly – called “doctor.”  Children and their parents let down their guard and exposed themselves to me, both with their honesty and with their flesh.  What was it that, with only a piece of rubber tubing around my neck, elevated me to an expert, even when it had clearly been stated I was only a student?  Though this was part of my training, and I had been privilege to some difficult situations, our encounters were still make-believe.  I thought it was an eerie parallel that my first day seeing patients in a hospital was on a day defined by false costumes and playing pretend.

            My access card to patients at Connecticut Children’s Medical Center was not a white coat (a cloth specter that would have scared the kids – something I had learned in my out-patient pediatrics clinic), but a thin adhesive badge listing only my name and “hospitalist.”  Again I had been given a small white article that would serve as a magic key to open doors and – usually – other people.  As my classmates and I followed the multi-colored hallway, we noticed the “H” in the word “hospitalist” had been misprinted.  Laughing, we penned in the first stroke of the letter on each other’s nametags.  I quietly mused on the significance of only having part of the word show up properly: Were we going somewhere without knowing where we had started?  Were we running around with our heads cut off?  (Something that probably wouldn’t have garnered much of a response on Halloween.)  More optimistically, I thought maybe it was like feeling I had earned the first half of the “M” in “M.D.,” having completed my first year of medical school.  Three more to go.

            Sitting down in a conference room near the cafeteria, I could barely contain my excitement.  I was already thinking how maybe I should do a residency in pediatrics.  I felt comfortable interacting with kids, and the green dinosaurs and other figures that had been painted on the hospital walls made the whole situation feel a little less serious.  It was a hospital, yes, but its lack of sterility made me temporarily forget where I was.  Dr. Jung, a pretty young physician dressed as Little Red Riding Hood, walked in, handing us guides for our upcoming oral presentations on the patients upstairs.  Indeed, the photocopied papers were maps to get us through the woods – the jungle of kids in costume, locked away from Halloween on the street, but still eating candy in their hospital beds.  We were both caged: the children were too sick to leave, and I, if not escorted, could get locked in the stairwells.  There was no escape for either of us.  An unexpected wave of nervousness flushed over me as we readied to meet our assigned patients.  Jealous that Diego had been given a Spanish-speaking patient, I volunteered to go with him.  I must admit (with some embarrassment) that though I have a fondness for Latino culture, I also enjoy surprising people with my ability to speak another language.  I don’t think it’s incorrect, either, to try to contradict expectations made my first impressions.  My Germanic features were another part of my costume: what you see doesn’t always give away what’s behind it.

            Upstairs, more costumes: nurses dressed as lady bugs, doctors in Egyptian robes, and children in hospital gowns.  One lucky girl was healthy enough to put on overalls and stuff her pockets with golden straw.  Her thin frame made her a perfect scarecrow, but as she stepped out from the shadow of her room into the fluorescent-lit hallway, her frailness became apparent.  Angling myself to peer into another room, I saw a teenager curled up in his bed, coughing from a genetic disorder that filled his lungs with mucus.  My eyes were wide with sad curiosity.  I had read about cystic fibrosis, but to see its effects 10 feet away certainly was very different.  I realized this was the first time I had been witness to truly sick kids.

            The other students peeled away one-by-one to interview their patients, and Diego and I were the last students left.  We arrived at a closed door.  Soledad, a four-year-old girl, waited inside with her mother and father.  Hypervigilant to the prospect of communicable disease, the hospital staff had put her on “droplet precautions.”  A red cart outside her room contained disposable blue plastic smocks and yellow facemasks.  Ah!  My costume!  Unwrapping and untangling the hospital couture, Diego and I introduced ourselves from the doorway.  I slipped the textured plastic over my head, covering my orange tie and black pants, and immediately crouched down to be at Soledad’s level.  With my mouth covered, it was nearly impossible to show her I was smiling, let alone get her to give one in return.  I hoped my eyes, at least, were expressing a friendly warmth.  I tried to give her a high-five, but despite her mother’s encouragement, she stared at me blankly.  My small bag of “tricks” already used up, I shifted my attention back to Diego, who had been interviewing the father.  Diego’s crisp words contrasted mine: He was serious and efficient; I stumbled over my Spanish and got lost in the chronology of Soledad’s illness.  Despite my desire to interact with the patient and make her feel more at ease, I recognized the utility of Diego’s approach.  Grudgingly, I gave up on getting Soledad to smile and focused my attention on her father.

            This was the fourth time Soledad had been in the hospital: first for being born prematurely, then for a rare form of liver cancer, and now twice in the last month for pneumonia.  Though she had vomited last night in the emergency room, Soledad wasn’t in pain – she was just bored.  Silently she squirmed on the bed, positioning herself to get a better view of the telenovella on Univision.  In examining her, I was surprised to find her lungs sounded clear.  Soledad was totally apathetic to us revealing the scar on her abdomen, even though Diego tried to garner some rapport by noting he had a similar scar.  Apart from the hospital location, the history and physical exam were like any other I had done before.  The difference was just that we were invading the patient’s space, rather than her entering our office.  I felt a sense of accomplishment as Diego and I escaped the hot plastic outfits, washed our hands, and thanked the family for their time.  Outside the room we looked briefly at Soledad’s chart, confirming the vitals we had taken were accurate and recording the ones we hadn’t taken.  I wondered how I would have responded had she been “sicker,” like the young man with CF.

            After reorganizing our notes, we prepared to give an oral presentation to Dr. Jung.  Despite having had some practice with this in my pediatrics out-patient clinic, I felt some stage fright – that my words would again escape me when it came time to speak.  No option, I thought, but to just jump into it.  Indeed, I had to trust in my skills and not psych myself out.  As I spoke, I took solace in the fact that both Dr. Jung and Alexa, our Fourth Year medical student mentor, were nodding in agreement.  Once everyone had presented their patient, our game of playing doctor came to a close.

            On our way out of the hospital, we removed our sticky badges, part of our costume for the day.  One of my classmates folded hers over so that her name and “hospitalist” were on opposite sides, leaving one identity to be shown and the other to be hidden.  It finally occurred to me that I didn’t know what “hospitalist” meant.  Later, reflecting on the symbology of the day – in other words, the symbolism and the rituals associated with it – I looked up the suffix “-ist.”  Though “biologist” was an easily-accessible example of the suffix, I could not quite define “hospitalist.”  Wishing the word were actually “hospitalitis” – inflammation of the hospital – and shaking my head amusedly as I thought this, I found the answer: “-ist,” one who is engaged in, or one who believes in.  Ah, so a “hospitalist” is someone who believes in the institution of a hospital…  It’s someone who works in a hospital.

Diction, like a mask that covers only part of my face, like my white coat, is another small part of my costume.  Fancy words or foreign tongues, they are something I can, personally, hide behind, though my role in medicine shines through.  White coat or not, my future career is not something I can take off.  I am primed like Clark Kent – when I need to, I can revert to my alter ego.  So that begs the question: which is my costume and which is me?  Who is the real man?  Superman or Clark Kent?

Personal Demons October 24, 2006

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            Twenty-five minutes after: My mind is adrift, lost in a proverbial haze of emotion.  Yet, in considering what I feel, in trying to quantify and qualify it, I seem to be in more of an emotional desert.  My mind is dry, sterile.  There is something concrete – I can feel it – but when I stoop to pick it up, the sand pours through my fingers, and I am unable to construct a response or emotion from the tiny glass pieces.

            Without meaning to, I confronted my own mortality.  I also came up against a stereotype I don’t want to acknowledge.  Is it my own prejudice in assuming one word begets another – at least in the eyes of others?  Am I wrong for trying to be “better” than the majority to avoid falling into this stereotype?

            I am a gay man.  Honestly, it is not something I am always proud of.  Why would I want to celebrate something that has made me feel a slight distance from even my closest friends?  Why would I want to celebrate a non-choice choice – something I have to embrace to be true to myself, but something that makes me inferior in conservative American politics?  For all the struggling I’ve done over my sexuality, I’m surprised how quickly it can cut me down.

            Sexuality, I thought, was who you have sex with.  Apart from requisite boasting in the locker room as an adolescent, or the birth of an infant, why would this information be shared?  But I realized: I’m gay whether or not I’m pursuing what my body’s chemistry tells me is attractive.  I’m gay 24/7 – it’s an integral part of who I am.  So to this end, I feel most at ease with my so-called “own kind.”  They, too, share the same (potential) secret.  What other single issue would worry me more to reveal?  So pair me with another guy my age – that’s a start.  We share the same religion?  I’m feeling more at home.  If he’s gay, too, well, then, I feel an unspoken understanding.  As a future physician, though on the one hand I worry about giving unfair attention to people “like me,” I also feel a responsibility to protect them.

            And as a physician, there will be times when I fail to protect my patients.  As a human being, I will fail to protect my friends and peers.  Sometimes this will not result from anything I did (or did not do), but I will still feel awful.  Drawing the line between “fault” and “guilt” should be clear enough, so why have I taken on responsibility that is not mine to take?

            Sixty minutes prior: It all started because I was hungry.  Well, my insertion into this piece of history came as I was driving down I-84.  I didn’t know yet the lengthy prologue that hadn’t included me.  I was driving back to
Hartford to both appease my empty stomach and to see an old friend who had been incommunicado for a year and had just yesterday reestablished contact.  Two birds, one stone, I thought.

            Emerging through the drafty diner door, my friend looked like the day we first met – back in 1998 by the pond in the arboretum, two future homosexual teens deciphering their sexual orientation.  Either my memory of his past hugs failed me, or he squeezed me tighter than usual this time.  We proceeded to “sit down and catch up.”  Somewhat naïve to his evasiveness in answering questions the day before and mostly unable to add a word of conversation to his excited, stream-of-conscious monologue, I sat back and watched.

            Have you ever sensed when something is not right?  You wonder if maybe you’re being a little paranoid but you’ve got an uneasy feeling that can’t be attributed to the greasy diner bacon burger you just wolfed down?

            He kept setting me up for me to guess what had gone on in the past year.  I just interlaced my fingers and asked, “Is it something I’m going to get mad at you for?”

            And so he confessed: He had been using crystal meth, a drug that has gained somewhat recent notoriety for its use in the gay population.  A numbness crept over me, and I couldn’t shake the memory of my previous drug-addicted patient.  “Okay,” I was thinking, “I’m not sure how to feel.  This is so out of character… isn’t it?”  I wondered if I really knew my friend anymore.

            “That’s not all.”  The monologue looped back to something that had been mentioned earlier: He had been sick with meningitis.

            “The doctor said, ‘It’s not bacterial, or you would have been dead by now.’  And I appreciated his bluntness…”

            And I knew.  I knew.

            What other type of meningitis is there?  Viral.  Pair that with crystal meth, and I saw what he was circling around but not saying.

            He continued: “Remember back in May when I had a scare…?”

            Now in the gay community, this immediately means, “there was a chance I had been infected with HIV.”  I had had them, too.  I remembered vividly the question posed by a counselor when I went in for a routine check: “What would you do if the test came back positive?”

            “But it wasn’t just a scare…  The doctor called me up – she left me a message, actually – that we should discuss some blood work in the office.  Yeah, right.  Blood work.”

            Without ever saying that he had become HIV positive, my friend had communicated it three times, at least.  I was speechless.  Again I felt like a child, unable to offer a solution or even meaningful comfort.  I had known him “before and after” infection.  Two things could not be further apart in my mind – my friend and HIV.  I struggled to face the (un)reality.

            I felt badly for him and then got mad at myself for feeling that way.  I tried to decide if I should feel or act differently or if our relationship was the same.  It was and it wasn’t.

            He pulled out a card from his rubber band-looped make-shift wallet and showed me the black numbers that recorded his CD4 count and viral load.  I wished to have some emotion – any emotion.  I worried that a gay man with HIV was fulfilling a stereotype.  I was angry for his choices and angry how that reflected on a minority community that had to bond together, but then recognized the futility, thinking “water under the bridge” – what I had thought when I accepted his apology for ignoring me for a year.  As soon as I realized I felt something, I deemed it “inappropriate” and tried to cast it away.  I didn’t know what to do.

            “I love you,” I said before driving home.

Twelve and a half hours later: After leaving the dichotomous road-side diner and confessional, I had called one of our mutual friends, spoken with one of my roommates, and written to another friend whose brother had died of AIDS.  Whereas my friend had had months by now to get used to his new “status,” it was a heavy surprise for me, and I didn’t want to bear the load alone.

            “That’s how I felt at first,” the third friend wrote me back.  “I was numb, too.”

            I imagine my thoughts will change eventually.  There is something unique to a personal friend who acquires an illness.  It nails you to a railroad track of empathy where you are bound to get crushed periodically.

            All I could do was take note that the weather had gotten warmer and the violet crocuses had come out.

Aftershocks October 4, 2006

Posted by Benji in Journal.
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It was a morbid thought.  My classmate had informed me that 15 minutes after I had left the ER, a patient (who had previously walked in under her own power) died of a heart attack.  I wished I had been there.

“I don’t wish anyone harm,” my inner monologue quickly defended to itself, “but if someone is going to get sick, I want to be present and learn from that experience.”

I also had a certain distance from it all – both in terms of space and time.  When I was taking the emergency medicine elective myself last year, the last patient on my first shift came in without a pulse and, after a nurse, fellow student, and I attempted compressions without success, she was declared dead.  I had never known the woman alive, so it was hard to make the connect between cadaver and, well, mother.  Her back-story only made it worse: She had complained of chest pain during dinner, and though her adult-age daughters told her to go to the hospital, her husband (a physician) dismissed it as indigestion.  I vividly remember him standing against the cabinets in the trauma bay watching as his wife lay on the table, her body moving only under the force of chest compressions and a bag-valve mask.  Yet, as I learned in gross anatomy, the situation actually didn’t affect me that much if I kept my hands busy.  If I had a task to perform, my emotions couldn’t take over, and I could remain cool and collected.  The ER attending tried playing every card she had, including getting a radiograph of the heart even though the patient had been clinically dead for over three-fourths of an hour.  It was what I later called the “death dance” – choreographed movements that, at least in this circumstance, were just for show.

The last “show” was after the woman had been pronounced dead and the caregivers slowly walked away, peeling off their purple nitrile gloves.  The miscellany tubing and wires were removed from the woman, her hair was combed, and her hands were neatly folded atop a blanket that covered her nakedness.  Given how well I remember how the trauma bay was dressed up into a viewing room for a wake, I can’t even imagine how the scene was burned into the memory of her daughters.  They cried and threw themselves across the clean, white sheet that covered her.  I guess it did make sense – to present the best possible image for a last memory.  Somehow I expected the body to almost be abandoned like they show on “ER” – left alone in a dark room with gizmos still attached, a lifeless hand hanging off the table, palm-side up for effect.

Now, if entertainment doesn’t reflect life, then why is it a short segment from my time in the ER keeps playing?  The “stop” button is broken; “pause” provides only a short respite.  It’s been a little less than a year since I experienced death for the first time in medicine, and I feel like some of the scenes from that night are better fixed in my cerebellum than my experiences with death outside of medicine.  I recognize that death, as an observer, is something I have to experience.  So, in principle, I was interested to hear about my classmate’s experience with her first death in the ER.  It sounded markedly similar to mine, if not a little more intense: The attending brought her with him as he informed the family, and the attending himself had just returned from the funeral of his grandfather.  The student was also left to do a large part of the clean-up of the trauma bay after the team had failed to revive the patient.  And yet I was curious.

What keeps replaying, though, is not my own experience with death (those are mostly snapshots and discrete memories – points of metacognition), but my experience with life.  Within 12 hours of learning of my classmate’s experience, I was informed by another student (a former high school colleague and current Fourth-year) that a patient we had discussed in the ER had died soon after.

Numbers October 1, 2006

Posted by Benji in Journal.
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“Excuse me.”

No one moved.

“Hellooooooo…”

I knew we were being watched, and I felt bad.  We were being critiqued for our unresponsiveness – or, perhaps, our apathy.  The patient’s silent frustration gave way to periodic outbursts.  A glance at the large monitor above the triage desk gave me a two-word synopsis: “Alcohol detox.”

Trailing behind the ER attending, I passed by room 14.

“Hey…”

The attending didn’t stop, so neither did I.

“That’s great…  Nice job following the Hippocratic Oath…”

The sarcastic words wafted from the room and stung me like Lidocaine.  Trying to focus on the task at hand, I inwardly knew that to succeed in emergency medicine, I must become numb to such venom.  And yet, I mused, what a poetic observation: me walking in the steps of both the Greek idea of ethical medicine and its apparent manifestation in that of a bearded, Russian physician.

Anxiously I awaited the requisite re-crossing of room 14.  To my momentary relief, no verbal stones were pitched.  But I did feel a continued, awful sense of helplessness – a frustration that I could do nothing for this drunk.  I approached the other attending.

“You know what you could do,” he said.  “Is give him the cordless phone and have him arrange a ride to Alliance.”

“What’s Alliance?” I asked, ignorant.

“He’ll know what it means.”

I hesitated, feeling like a Christian about to be fed to the lions.

“Don’t worry.  I wouldn’t send you into a lion’s den,” the attending added, reading my mind.  “Alliance is a rehab center.  It’s a better option for him than prison.”

In stolen glances to the patient (and, earlier, to the monitor), I had seen he was only a year my junior.  I felt oddly presumptuous in entering his room.

“We’re not ignoring you,” I began, simultaneously dodging the expected bullet and passing the buck.  It was a weak attempt at an apology.  I didn’t want to offer more, lest he think his previous remarks were an acceptable way to get attention.  They had, of course, affected me, but I wasn’t about to let him know that.  I wanted to give off a focused, professional demeanor.

I wasn’t the only one putting up a bit of a front.  To my absolute surprise, the patient turned out to be a nice guy.  Physically, he looked a lot like the boyfriend of one of my classmates.  In fact, other than the white hospital bracelet around his wrist, there was nothing that warranted his separation into the role of “patient.”  The faint smell of beer lingered in the room, but he was no longer drunk.  He didn’t even look sick.  Outwardly, he was an average guy.

My first few minutes in the room blurred into a period of unexpected bonding.  He acknowledged he probably hadn’t conducted himself in the best way – this was his half-way apology.  I agreed, and we moved on.  I realized I had been pitying him: a contemptuous sadness for him, the situation he had ostensibly created for himself, and how that in return made me feel.  I was frustrated by the choices he had made and that I had become emotionally involved in them.

“So what happened?” I asked, searching for the story behind this parallel image of myself.  I had known nothing when I entered the room, and now that I found myself sitting bedside, acting more like a brother than a student doctor, I was curious.

           “Well, I like heroin way too much,” he said openly, almost amused by the statement.  Fragments of his life’s story came pouring out, like the pieces of a jigsaw puzzle that had been dumped on the floor.  I tried to fit my perception of this young man into the frame he had just created.  “Homeless.”  I rotated the piece between my thumb and index finger; I turned the word over in my head.  He was clean-shaven and seemed well-nourished.  “I’ve never met a homeless person before,” I thought, before casting it away with other naive statements like, “Oh!  I’ve never talked to an alcoholic before.”  Sure I have, I just didn’t always know it.

           A few more pieces followed: The rehab clinic won’t take in a simple heroin addict.  The potential admission must be an alcoholic, at least.  Whereas alcohol withdrawal warrants medical intervention, addiction to other drugs does not.  I thought back to the frustrated words of a worker from the Hartford methadone clinic: “We tell addicts to save a little money for cheap alcohol so when they decide to quit the harder drugs, they can be admitted to a rehab program.”  And, after being rejected once before for being sober, this is what my patient attempted to do.  His mistake, however, was driving there.  He was charged with DUI by the police and somehow ended up at the hospital.  The prospect of prison – and the people therein – weighed on him.  He was anxious and wanted a cigarette.  He began to pace the room.

I looked at him, searching for some meaningful piece of advice that would carry him through rehab, something he could recount in what I hoped to be his future years of sobriety.  “I’m sorry,” I concluded.  “All I can do for you is pray.  I don’t really know what you’ve gone through.”  I looked at him helplessly, unable to offer the solution I so badly wanted to give.

He fished a gray hoodie out of a plastic bag.  “One thing you have to understand,” he said, slipping the sweatshirt over his head.  “This world isn’t as far off as you might think.”  He paused.  “You and me, we get along.  Me and the average car thief, not so much.”  It sounded like he spoke from the kind of experience only earned in bruises.  He pulled a wool hat over his head, turned the brim to an angle, and sat down on the bed.  “I guess this is just bored Connecticut white kid shit.”

I blew a breath out through my nose, as I do when someone makes an interesting point.  The patient and I had similar roots and yet our paths were so divergent.  In bits and pieces over the course of two hours, we had gotten glimpses into the other’s life – a temporary respite from worrying about our own future.

Having alternated between the roles of supportive parent and learning child, I found it difficult to let my peer leave.  I walked with him outside.  As the cold night winds lashed at our faces, I realized I would probably never know if succeeded or failed in regaining control of his life.  The closing of the taxicab door seemed final – a Hollywood-ending to my medical vignette.  But, on my side at least, I knew the exchange would somehow last beyond that night.  Perhaps it was a lesson in understanding another human’s experience without experiencing it, in digging beneath the surface, in investing in a person and showing kindness.  Even upon later reflection, it is hard to express what the ultimate significance was.  Knowing, while it was happening, that this interaction was important had sent my brain into overdrive.  There is not always an answer.  Medicine attempts to ground itself in fact and evidence, but mankind is less predictable.  I had stepped into the unknown and learned some facts, but was left with other things I would never know.

This journal entry was an honorable mention in my school’s essay contest.