Sunday, November 27, 2005

Giving Thanks: Five Things I'm Thankful For This Thanksgiving

5) Four (yes, 4!) consecutive days off (more time off than I've had in total over the past six weeks!)

4) The ability to sleep 14 consecutive hours when given the opportunity (sheer bliss!)

3) Homemade cranberry sauce (I made some on Thursday, adding some brussel sprouts and whole wheat couscous for a well-rounded thanksgiving dinner that wouldn't make *me* any rounder)

2) My grandma (who totally won our game of sing-a-long ball yesterday, demonstrating an impressive command of lyrics to songs like "My Bonnie Lies Over the Ocean" and "God Bless America", which edged her ahead of competitors Jean and Louise, her fellow nursing-home-bound-little-old-ladies-with-dementia; way to go grandma!!)

And most of all...

1) The Polish American Cultural Center in Passaic, NJ (yay for Poland, the source of 3/4 of me!) for employing the upstanding security guard who picked up the wallet that I dropped in Penn Station yesterday, and for welcoming me so warmly into its polka and cigarette smoke-filled lobby last night at 1am when I picked up said wallet from said security guard. (Just when I thought my life wasn't interesting enough...)

Wednesday, November 16, 2005

Curiouser and Curiouser

So this is it. For 20 years, I've been yammering about wanting to be a doctor when I grew up. Sadly, I haven't grown much more in the direction of "up" in the last twenty years (which doesn't matter in the hospital...since all the patients are lying in my being as short as I am only *enhances* our doctor-patient connection...or so I'd like to think) But here I am, spending every day (and I do mean every day--I don't understand how any resident survived when the work week was *more* than 80 hours--I'm not even a resident yet, but I do feel like I might as well stop paying rent at my official so-called residence) in the hospital, practicing the practice of medicine.

I realized yesterday, thinking back to my formative years, that I didn't actually have physician heroes as a kid. The most inspiring aspect of science was the discovery. The eureka. I wanted to be Benjamin Franklin discovering electricity through a homemade physics experiment. I wanted to be Leonardo da Vinci, dreaming up the helicopter centuries before the technology existed to make one that worked. And near the top of my list, in a group all their own, I wanted to be Encyclopedia Brown, Harriet the Spy, and Nancy Drew. A spy, a detective. I would people watch for hours in the local bookstore, taking copious notes on the minute-to-minute browsing habits (and underlying motives) of its customers. I made a 'spy magazine', a ladies' home journal that I converted into a secret armamentarium, complete with spy hole (so I could accomplish my people-watching while holding the magazine up to my face as if reading it), first-aid kit, pad and pencil, stickers (never know when you might need a gold star sticker), and other sundries I deemed essential to my success as a world-class spy detective.

Now that I am finally, after 20 years of anticipation, living my dream of practicing medicine (and yes, as scary as it seems, my days now actually consist of seeing patients, ordering meds, drawing blood, interpreting labs, and other doctorish duties) I realize that one of the parts I love best about medicine is the chance to live out that childhood dream: to be the secret detective who cracks the case of the mysterious symptomatology.

Thursday, November 10, 2005

How Do You Mend A Broken Heart?

In some cultures, the answer might involve warm milk and cookies, or a good therapist, or a few days of wild drunkenness and satisfyingly nasty revenge letters, or some self-reflection and journaling with a healthy dose of support from friends...but not in the culture of the hospital. When push comes to shove, and you've got more than 3-vessel blockage, we tell you that the best way to fix your heart is to crack open your chest, shunt all of the blood inside your body (which has been quite happy swimming through your warm little arteries and veins all its life) *outside* of your body through a complex system of tubes and cannisters that chills it down to about the temperature it might get to if you suddenly fell out of the boat while touring Niagara Falls in January...while your heart is literally stoppped cold, given its first minutes off of work in over *eighty-five years* (that is, if you happen to be 85), then repiped with pieces of the floppy spaghetti-like vein sliced out of the entire length of your right leg...and then it's all over and you wake up and POOF! you're fixed. Or so.

I held a man's heart in my hands today
yes my hands his heart

slippery smooth muscle covered in a layer of curly fat
not unlike one of those skinless boneless chicken breasts
wrapped on styrofoam trays at the supermarket meat counter
floppy and soft

the human heart is meant to be held
in the abstract:
hearts are regularly moved by beauty
touched by tender moments
but not by gloved fingers

sacred and profane tango together in the OR
the intimate blurs into the absurd and back again
are we saving a life or repairing a machine
it's not always clear

this heart lying in a pearly white bed of pericardium
did not lie passive during its respite
it pulsed
inexplicably, it pulsed
even though it had been medically stopped
no blood coursing through its chambers
its job contracted out to the venerable heart-lung bypass
a small area of the heart still pulsed
as if driven by a higher power
or energizer battery
to tell us I'm not ready to quit yet
sure, give my work over to your newfangled contraption
sure, fix me now
but I've done my job damn well
damn well
don't you dare treat me like I'm just a piece of meat.

Wednesday, November 09, 2005

New Plumbing

In the blink of an eye (seriously! that's about how much sleep I've been getting!), my first month of Internal Medicine clerkship is behind me, and I am already up to my elbows in Med 2. From the intellectual masturbation and pristine ivory tower-ness of Yale, to the...well, I don't really want to know what goes on behind closed doors among the scores and scores of men hospitalized at the VA. The one thing that hasn't changed is the age of my patients--almost all are still clocking in at over 65, if not over 85.

Speaking of age, let me introduce: My patient. He's charming, he's sensitive--he even gives adorable answers to my mundane questions, like "am I in pain? I was until you walked in here..." (how come boys my age never woo me like that??) And so well preserved! He could easily win at one of those amusement park stations where they bet you your money against their stuffed animal that they can guess your age within 3 or 4 years. The guy doesn't look a day over 65, not with his full head of white hair neatly sculpted in Ken-doll waves around the smooth furrows of his face. Mature, maybe, but not old. And it doesn't stop at his neck: inspecting his non-gnarled hands for clubbing or cyanosis, poking his strong sock-suntanned ankles for signs of edema, listening over the broad expanse of his back for any lung crackles or wheezes; not only do I not find any evidence of pathology on physical exam--I don't really find much evidence that this is truly an 85-year-old's body! I'm almost tempted to call in the DNA experts to do whatever their equivalent of counting rings is.

Except...that he brings with him a story. They all do. This one starts at the end of spring--this past spring--the day he turned 85. "It was the beginning of the end," he mourns to me, and as quickly as he cracked a joke 5 minutes ago, I now see the glimmer of pre-tears appear glistening on his lower lashes. First, his eyes went bad. Then, his heart slowed down dangerously, and he had to get a pacemaker installed. And, now that it's beating faster than before, it seems that his heart has caught up with his chronological age and remembered its instructions from the CT surgeon god (or was it the riverdance goddes?): Get Clogged. In just six months, the poor guy has gone from running his own business and being completely independent, to lying in a hospital bed getting told that all 3 of his major coronary arteries have some major clumps of junk blocking them up, and--oh yeah, he's going to need triple-bypass, open heart surgery if he wants any chance of significant improvement.

Yes, owned his own business! And not just any old business; our man with the clogged up drainage system was working until the day he turned 85 as a self-made....plumber! So it wasn't hard to explain what the options were: (1) Drano, aka conservative medical management. Unfortunately, with blockages this big, there probably isn't a type of Drano strong enough to guarantee any longterm improvement, let alone safeguarding against major plumbing disaster. (2) Roto-rooting, aka coronary angioplasty or stent placement. Unfortunately, there are so many different blockages that to carve out and prop up the needed number of vessels/pipes would probably not be worth the investment of time or mone. And the big cahuna (3) Replace the pipes, which in this case means creating a detour of new pipes around the worn out parts of the old ones, aka coronary artery bypass graft surgery, aka CABG, affectionately known as "cabbage" in the medical world. (although, given that the surgery is a kind of makeshift solution, I think they should call the CABG surgery the "cabbage patch"! ha!) Right, so these are the options. Now, choose. By tomorrow. And if you want to go home to think about it for a week or so, we can't guarantee that you won't have a heart attack and die. Yeah, sorry.

What would you do? Or what would you have your father/grandfather do? On the one hand, he's already lived a full life as an airforce pilot, a husband, a father of two children, a self-made plumber--why mess it all up with a major surgery that will set him back at least 6-9 months, if not give him a stroke and set him back forever? What are we hoping to give him, anyhow--10 year survival outcomes for a surgery like this just don't become much of an argument in a patient who's already 85. On the other hand, his worsening chest pain since June has stolen whatever exercise tolerance he used to have--from crouching under strangers' sinks and traipsing into basements and sheds, he has been reduced to "a lump on the couch" who can barely cook his own meals anymore. Most of all, he can no longer do the thing that used to give him more pleasure than almost anything: playing golf.

So, it all comes down to one question (it always does): Is a rib-cracking, 6 hour long, highly risky, surgery in which your body is connected to a pump while your heart is stopped and the new piping is stitched in, a surgery that takes months to recover from and which may or may not ultimately improve your individual quality and quantity of that worth spending 1 day--your next birthday, say--just 1 day swinging your golf clobs out on the course, hearing the satisfying thwak of metal on white dimpled plastic, feeling the grass roll beneath your feet, the sun and trees brushing soft gusts of happiness through your neatly sculpted Ken-doll waves, and being able to walk--slowly, perhaps, but completely pain free-- to the next hole?

Sunday, November 06, 2005

A Posting About Composting

Over the past month, I have, on more than one occasion, shed optimistic light on my rather unfortunate plight by describing the hospital as my "cocoon", protecting me during my metamorphosis from caterpillar med student, swollen with knowledge stuffed into my head over the past two years, to physician, graceful as a butterfly in my clinical skills.

Well, forget that metaphor. It's way too glamorous. And it has much too close of a connotation to blissfully secluded sleep to do any justice to the kind of craziness that is actually my daily existence. A more apt description of what I'm going through, I realized tonight, is...compost.

Yes, compost. I go to the hospital, and my residents and interns throw me scraps of medical wisdom, my patients tell me the scraps of the stories they've already told to at least 3 people before I get to attending corrects me or gives me a well-intended but poorly-executed look that says 'you idiot'....and on a daily basis, I feel like, well, garbage. There isn't any time to sift through my reactions or emotions, or figure out what it all means--day after day, the work and experiences just get piled on, layer over layer. On the surface, I still feel like a doofus. But on rare occasions, when I have a moment to stop, and reflect, and dig down to those deeper layers to give them some air; that's when I suddenly encounter the rich humus that has become transformed by the remnants thrown to my psyche.