Yes, and

I think in possibilities. I like to think that’s a strength. When a 59 year old has a spot in his vision I can think of all the possible reasons why and test most of them.

And still ultimately refer to ophthalmology.

When you’ve got belly pain we can come up with the 14 most likely scenarios and check them off one by one. Never fear that you will leave my office with the dreaded diagnosis “Belly Pain NOS.”

(Because at the very least you will have been diagnosed with “Abdominal pain – poorly characterized, which seems unlikely to be fulminating hepatitis or acute abdomen, and all the labs are normal and whatnot, and nothing about it sounds remotely like the gallbladder or kidneys or liver or pancreas or any known intraabdominal entity, but what the hell is it? Could it be gas? Anticipatory guidance for infinitesimally small possibility of catastrophic pathology in early developing stages given.)

It’s something I learned from my college Improv team. When you’re under the gun (performing in front of hundreds of bored college students vs. 1 terrified patient) and something is suggested, you roll with it.

Example from Improv:

Player 1: How nice we’ve gone out to sea on this raft!

Player 2: Yes. And I can’t believe we’ve fit a dinosaur on board as well.

= interesting. We all know where we are and hope we don’t sink.

Example of what not do to in Improv:

Player 1: Here we are buying carpets in Turkey.

Player 2: No. You fucking idiot. This is a night club and we are DJ’s. Is that caviar or boba?

= confusing. Where the hell are we? Also player 1 is an idiot, but player 2 is a jackass.

In Improv you never say No. You say “Yes, and.” It’s an exercise we do to warm up, and it’s a philosophy we live by onstage.

Thus, I have a really hard time with no.

Examples from more or less the last week in the Improv of my life:

Patient: I have a sore throat. Last time I had a sore throat it was immediately bettered by penicillin from Mexico. Please prescribe me penicillin from Mexico.

Me: Yes, and actually you have a viral syndrome and I don’t believe you need penicillin at all. I will now explain to you supportive measures for 10 minutes and hope you believe me.

Patient: I don’t understand.

Patient: I have pain in my arm. I need an MRI.

Me: Yes, and it turns out you have pain in your arm. And it turns out you have lateral epicondylitis which is tennis elbow and let’s all laugh together because you don’t play tennis. And it is not diagnosed by MRI but rather by me pulling on your wrist like so and you shouting in pain as you have just demonstrated.

Patient: I don’t understand.

Me: Shall I offer you a brace?

Patient: I fell over. I need an MRI so I can be cleared to go back to work.

Me: Yes, and. Wait. I don’t understand.

Patient: I have seasonal allergies. I need to see a specialist.

Me: Yes, and what if first we try some allergy medicine while we hope to recruit an allergy specialist to this county.

Patient: My back hurts. Generally I take 50 Lortab a day to stave off the pain and so please give me some.

Me: Yes and how about instead we discuss non-pharmaceutical measures we might take for chronic back pain. Here is a list of 15 other ideas we could consider.

Patient: No. I tried all of those.

Me: Yes and also you were taking cocaine the last time I saw you and so we will be avoiding the narcotic class of medications in the future.

Patient: I don’t understand. Give me Lortab please.

Me: Yes and actually I will not.

Patient: I was not taking cocaine myself, but unwittingly did visit my sister, who was smoking crack, immediately prior to my office visit that day.

Me: Yes and how is that related to our discussion?
Patient: Obviously I must have inhaled it from the room and so that is not my fault and please give me Lortab.

Me: Yes and it is unfortunate that as far as I know that is physiologically impossible.

Patient: Lortab.

Me: Yes and

Patient:?

Me: And no. (Dammit. No. What I mean to say is no. I cannot, will not give you Lortab. I could lose my license. It is not what you need. You have a problem. You need help. We have policies.) (I don’t actually say most of the portion in parentheses)

Patient: I don’t understand

Me: Yes and shall I print you a handout? I’ll be right back…

Dangerously Close

The first few months of medical school are consumed with anatomy, biochemistry, and cell biology. Histology, maybe, and the physical exam. Most of those classes are a hazy, pleasant-ish memory to me now. For example, the elderly pathologist who lulled everyone to sleep by reading directly from his overhead slides in an unruffled voice until one day he exclaimed “What’s this? Well by golly it’s a Howell-Jolly Body!” At which point I woke up for 5 minutes.

But somehow no one ever forgets the anatomy lab. It’s recalled with perfect distilled clarity every now and again when I catch a whiff of formaldehyde or phenol. Like, just the other day as I was ablating a portion of my patient’s toenail bed.

I turned my head away from him for a moment. “Es que este olor… bueno, nada mas que no me gusta mucho.”

Before my oblivious patient I was suddenly 22 again, in a room of dead bodies, drenched in repulsive sickly sweet preservatives. Immersion. Handed a scalpel. Told to cut. Against every instinct in my naïve little heart. White as the sheet that used to cover this respected elder who gave her body to science, to us, now lying naked.

Suddenly with a clipboard staring bewildered in the mid-term at tags tied to tendons. Rotating after each “ding” to the next cadaver, longing for my own, whom at least I knew. Willing, teleporting myself outdoors into the blinding heat and late-summer stillness just outside the window. Lost in the last dying days of my childhood. The days when I knew enough and knowing wasn’t everything, anyway.

Wishing there was some sort of mid-term that might test my knowledge of kitchen implements, or garage tools, so I might feel like I knew something at all. Then confidently I could write “This, Dr. Professor Sir, is a measuring cup. 1/3 cup to be exact. Exhibit #35 by contrast is a sieve.”

Staring into the abyss of What I Need to Know. At the crossroads of earnest interest and imperative mastery, the fear of failure gives you the courage to don a white coat and with it delude yourself into believing you’re impervious to pain and death.

I made it through the class.

Several months later we started Neuroscience. After a few lectures we were sent back to the lab. Nothing, not the white coat, not the desensitization of anatomy class, could have prepared us to see our lady’s brain lying neatly on a cutting board. A single serrated bread knife was on hand.

We were told to cut. Sagittal sections, about a centimeter apart.

Nervous laughter.

“So, who wants to cut open the brain?” I offered. No one took me up on it. “I’m not doing it myself.” The holy grail of humanity, the sacred seat of the soul, the great mystery of consciousness. We’d been told the consistency was like tofu, the extra firm variety.

Years ago on an ornithology field trip in the middle of a 30-mile salt flat a group of girls had to pee. Wordlessly we spread into a circle about 15 yards across. We faced in, and all went together.

Somehow subverting our instincts is easier when we do it as one.

I made the first cut. Then I passed the brain to the left, and my partners, in sequence, took their turn.

That weekend I went camping in the desert. We took a guided tour of some caves. In the dark among strangers, it was all I could do not to blurt out “Say, on Thursday I cut up a human brain.”

Why? It felt like a confession I needed to make. Like it might absolve me of the crime. Also I wondered a little what they all might think if they knew.

All I was trying to be was a doctor. I felt like a monster.

I said nothing.

Now there are a million moments like this that set me apart. Horrors we see and do every day that give us an air of mystery and a privileged place in society.

My landlady works with veterans, as a psychologist. She’s busy at the moment with the returning Iraq and Afghanistan troops.

She sat opposite me on the couch. “They are all suffering so much. So many of them have anxiety, panic, PTSD. They’ve seen such terrible things, it’s like they can’t be normal again.”

“Is it all of them?” I asked. “Do you think some will turn out to be okay?”

“Well, I worry more about the ones who seem unaffected. Those are the ones who do worse. Humans can’t see that kind of devastation and be unaffected. If you’re numb to it something’s wrong. Those are the sociopaths, the killers.”

The ones who can mutilate a brain and then casually go on a cave tour. The ones who can pump on a teenage chest for 30 minutes and then give up and have a sandwich. The ones who can look into the eyes of a heart that’s breaking and feel nothing, and glance up at the clock.

My God, what sort of “healers” might we be at the end of all this? To stay alive in this profession we’re strategically deadened. Afraid for our own survival, we jump through all these hoops. Some drop out. They’re “weak.” We’re worn down to exhaustion working night after night, so we never complain. Worn down to the point we’re relieved to see that the struggling cirrhotic has died overnight and we have one less patient to round on in the morning.

Did I just say that out loud?

Outsource the empathy to the nurses, folks, because there’s nothing left here. Nothing but an empty, encyclopedic brain and beating, mindless heart.

Can it be true? Has it all been bled out of me?

See the patients faster, Doctor, that’s not fast enough. They might cry, they might beg, but you’ve got others waiting. Give them a piece of paper, they’ll be fine.

You’re just trying to take on too many things. Set a reasonable agenda. Tell them to save the other 8 items for next time.

That baby just died? Here’s another one on the way. This one needs to be removed surgically. And the answering service has someone on the line who’d like to know what flavor of pudding to mix with ciprofloxacin.

She has cancer. He’s suicidal. She’s had her foot removed. Talk to them, sure, but no more than 10 minutes apiece.  She’s been kicked. He’s addicted. She doesn’t understand her diagnosis. His cat just died.

I’m neck-deep in charts and urinalyses. What the cadaver horrors didn’t drain from me the endless ticking clock will. This is primary care. This is the trenches. I’m dangerously close to numb.

Fortunately, so is his toe. It took a bit of extra lidocaine but the digital block worked. He’s smiling. The ingrown toenail was a pain. He’d tried to remove it himself with pliers. Apparently I did a slightly better job.

I believe I’ve killed the nail bed with phenol. My soul may yet survive. Maybe.

*Note: the suffering and death seen by most physicians pales in comparison to the trauma experienced by many veterans. I don’t equate our lot with theirs, and I give them the credit they are due. This was written merely to make an interesting comparison. And, mostly, to hold out hope that humanity and empathy can be reborn, even when all seems to be lost.

Fall Into Stars

I don't remember what anything means and the night is too dazzling to fall into dreams the words that are failing me fill up the void but no one but me seems to feel it.

Hard to forget that my work is to know and to do what it takes and to put on a show that will make you feel better at least til you go and alone you yourself have to heal it.

And all by ourselves we still gather and hover and tell all the stories and laugh with the others like all of the ways that I've sat and imagined I know what it's like to be in it.

So tonight go outside let the laughter be second to sounds from the stars as they recount the record the tales from the ancestors poets and priests and all of the fishes and all of the trees

Cause I want to remember the silence of meaningless want to sink blissfully into irrelevance want just to be and to know that I'm worthless and infinite just like the stars

And as much as I'd like to be given a reason I'll settle for just being part of the seasons and doing as much as I can and believing that living is more than just knowing and seeing

House of Scorpio

My last few calls had been cake. Not bad. Maybe I even thought I was just a super awesome doctor/efficiency master. And then I’d return to clinic, where reality would set in. But no matter: call was not so bad.

Then it was my Hospital Week.

At no time during Hospital Week did I have fewer than 9 patients to round on in 5 hours, and often more like 15. Most of them had pyelonephritis and were vomiting. Rounding on those patients was totally do-able. I am totally awesome at treating uncomplicated pyelonephritis and vomiting.

Except that I was also in charge of all 30ish-week twin pregnancies who may or may not have been in labor and needed to be evaluated and possibly transferred to the University for seeing spots and having their right hand spontaneously weaken vs. having their bag of waters rupture prematurely. Of which there were 3. During which I was also in charge of all placental abruptions at 35 weeks bleeding half of their blood volume into the bed. Of which there was thankfully only 1.  And of all of the babies who seemed to be doing very well but then immediately prior to discharge developed extremely high bilirubin levels. Of which there were also 3. Or 27. I lost track.

And also of teaching residents. And of taking the amniotic fluid samples to the lab downstairs 55 times because the bulb is out on the microscope on Labor and Delivery.

And of locking my keys in the car in the middle of the night with the car running and not noticing until I came back out after a delivery.

“It’s crazy around here,” I mused as I sat next to a nurse. She was scanning through the computer. “Yeah. It’s the Supermoon, which is in the house of Scorpio. Or something like that.”

Obviously. That explains everything.

Waiter

coffee

I read somewhere about endorphins artificially causing people to fall in love. Adrenaline, and then the presence of someone, can later cause you to feel that same rush whenever they come around again. This was probably not in a major medical journal that I read this.

Coffee increases adrenaline. I love coffee.

I need it lately. It may or may not need me.

I don’t remember what the surface of my desk looks like. It’s always covered in a pile of charts. Sometimes, on good days, I leave the office with just a single layer of papers, sticky notes, and refill requests covering it. On bad days…

Coffee propels me into a higher frequency oscillation. I dart in and out of rooms and my thoughts race just fast enough not to be bothered by the sheer impossibility of the tasks on my desk, or the puzzles awaiting in each of the rooms.

Inside the rooms, and in the waiting area, people wait. 5 minutes, 90 minutes. Mostly, they’re calm. Even the kids. Sometimes they wonder what’s taking me so long.

I wonder too. I’m moving as fast as I possibly can.

Maybe I do too much. Maybe we need to set a more reasonable agenda. Each patient has waited months or years to see me, the urgency’s there. But so are the other patients.

Waiting.

A man visits me for the first time. He’s anxious, heart racing, weak, edematous. He has double vision when he looks up.

The ER did part of my job for me. They diagnosed him with hyperthyroidism and gave him some methimazole, and told him to find a doctor.

Six months ago. He’s been out of the meds for a little bit.

I grab the retired neurologist with strabismus who hangs out with the residents on Mondays. Apparently I’ve forgotten the innervation of all the eye muscles. He’s nice to me and suggests an MRI of the orbit. Graves’ disease can cause eye muscle paralysis, apparently.

 A child has headaches. Turns out she recently fled another state with her mother, because her father was beating up her mother. In the shelter there are a lot of kids who don’t always share their toys. Now she had headaches. A man with diabetes forgot to see me for 4 months and now his foot almost rotted off. We decide we need to start insulin. A patient who visits me monthly for a tapering dose of the oxycodone he takes chronically arrives with a cut over his eyebrow from a road rage fight on the way to the clinic. We sew it up. I’m already late for the next appointment, with a young woman who is “having too much unprotected sex.” I provide an emergency IUD insertion at her request.

It doesn’t stop.

A longtime patient of mine comes an hour late to her appointment. I ask her to wait until the end of the day. She does. When we finally sit down she tells me her rib might be broken, because her husband kicked her. Two weeks ago. She went to the ER at the time but waited 12 hours and finally left without being seen.

She says she’s leaving him today. We make a plan, and a follow-up appointment. She says she loves him and he’s just really suffering from schizophrenia right now. But she promises she’s going to leave.

He needs her. She may or may not need him.

She loves him. Adrenaline.

I watch her turn the corner into the hall. Now it’s my turn to wait.

The Body

I don’t wash my car.

I don’t wash my car for two reasons.  One is, I think we waste far too much water on this planet.  The other is I don’t want my car to get the wrong idea.

This car needs to shape up a bit, see.  The other day as I was going around a corner, the door opened.  The drivers’ door.  The car was was trying to kill me.

To be fair, this is likely in retaliation for not changing the oil for the past 3 years.  I mean, sometimes I add oil.  But I haven’t changed it.  When would I have time to do that sort of thing?  Like, I’m a resident, working 90 hours a week and finally get a day off after 2 weeks and I say to myself, “I know, I’ll go straight away to get my oil changed.  Better yet, I’ll do it myself in the mud of the field while my children cry hopelessly in the background for want of time with Mommy.”

Please.

Also at one point the “alarm” wouldn’t shut off despite turning the key.  Which disabled the steering column, until we removed the fuse which supplies the alarm circuit.

Unfortunately said fuse also relates to the interior lighting.  And the clock.

But I like it that every time I get in my car it’s 12:00.  Adds an air of timelessness to my commute.  And it’s correct twice a day.

Sometimes when I turn to the right too quickly the horn spontaneously beeps.  Just to the right though.  So that’s fine.

Everything is manual in this car from the transmission to the windows to the locks to the seats to the defrost now that I can’t turn the defrost on without it emitting a high-pitched sound like a Doberman.  But I don’t mind that.

What I do mind is that after all this time together, my car suddenly quit.  First I thought it was just cold so I tried to start it again when it got warmer.  No go.  GB thought it could relate to the battery so he replaced it.  And added oil, because I was roughly 3 quarts low.  And power steering fluid. 

Then I noticed a hose that had broken off completely.  I ordered another and attached it.  Still no start.  Tried starter fluid.  Tried gas cleaner.  Nope.

And now I finally realize I’ve taken this little Jetta for granted.  Treated it like crap and expected it to fix itself.  And now I’m angry because I have to Figure Out how to Fix It.  Or Sell It.  Though the above might make a good ad.

People do this to their bodies all the time.  And then I’m supposed to fix it.  Hmmm.

Update: While driving 75 miles per hour down the freeway near Los Angeles, my car despaired of its unappreciated existence and flung from itself its rear wheel. The repair costs alone were estimated to be $1500, close to what this car was worth. It sits alone now, perhaps already deconstructed to its scrapyard bits, somewhere near 29 Palms, California.

We’re just a little bit lonelier now, the two of us. Wish we’d reconciled before it all had to end. What am I without my car? Like a spirit/soul flying suspended in time, no body, only air and light.

Or else someone who has to wake up 15 minutes earlier to ride her bike to work. One of those two things.