approach words with a scalpel.

“…and they tell you that your blood is purple till it hits the open air, well…”

2012-01-26T08:49:00.000+01:00

For New York, it’s an intimate-but-not-in-an-unpleasant-way venue. Bar, a few tables, a stage, good but not overly-imposing-or-meaning-to-impress atmosphere. The amps weren’t too loud. I was as close as possible – close – and the sound was right, and I could hear all the words.

After a day shuttling between medicine, public health, and poetry contexts, with many, many subways and miles of walking in-between, I re-learned what it means to be an artist.

Rachael Sage.

If I have a favorite musician – a singular one, one who is alive and performing and now, and who is not so very well-known or widely-played to be obvious – it’s her.

And it’s been her for the past decade – little more than. A friend gave me Smashing the Serene in the fall of 2001. It’s technically Rachael’s second CD, but it was my first. As I told her tonight (crazy, idolizing fan like I’m the crazy, idolizing fan with some of my poets): “I realized that I’ve had a relationship with your music for over a decade, now. That’s longer than with most of the people I know.”

It’s true. That’s formative years (aren’t they all?) Music, good music, can be both background and foreground. One of the four options (she gave) for her last/encore song was the first Rachael Sage song I ever heard. (“Sistersong,” Smashing the Serene). I know the words to that one and to many others. And the ones she sang that I’ve heard – but not memorized – brought the same knowing smile of familiarity, triggering memory and attachment.

That’s what it means to be an artist.

That’s what you want it to mean, to be an artist… to mean something. To get to be part of someone else’s story, in a way, to have given and shared that gift.

It’s the same with poets. Cyrus Console read a section from a book I love. I hadn’t memorized, not by a long-shot, but I was familiar enough with the words that they were little triggers. Anytime I go to a reading and someone reads a piece I love. Poets publish CDs, sometimes, of themselves reading. (see: Li-Young Lee, Behind My Eyes). There’s an art to that, to reading – and learning how to read (out-loud) poetry was an important part of my poetic education.

Digressing.

For any show, musicians have to include songs that are “known” with the new ones. Would we be…disgruntled otherwise? Maybe. But you can best, I suppose, develop a relationship with the new pieces through segue with the old ones. The nostalgia (and the triumph!) for older ones, knowing-the-words-ones, isn’t just for the piece itself but for whatever particularity it evokes.

Whatever life it has taken on, now, for the listener. Everyone owns a little piece, and each piece is now different. Poets often read from both published books and new, unpublished poems. (fiction writers – same. etc, etc). For the artist, it’s part of trying out the piece – does it work with an audience, what does it sound like in that context, etc, etc.

One of the best things about poets is that when you tell them you’re skipping out on a social event to go write – they not only understand but are excited for you. If it’s urgent, too, that means the Martians/muses/whatever are visiting, now, and something might be happening or about to happen. This happens to all of us, planned or unplanned. Poet-in-tandem, poet-interlocutor days. And poets-need-to-be-alone days. After a friend’s reading, one night, I told her she’d inspired me to write, and that I had to go home and do so. It was true – and I knew, too, that it was a gift to tell her that. The best response to a reading you can have, she said.

More recently, I sent a poem(s) to my workshop, for them to read before we met. One poet/friend replied to my email, saying the poems made her want to write again.

That’s an incredible thing to say to a writer, and from a writer who knows what it means.

I had written most of a piece about art school versus grad school, and what it’s like to be in art school, and … I’ll finish that soon. Later. Also. I’d been thinking about the process – and all of it is a process. More like a continuum. Like a day of medicine-public health-poetry.

***

At a health policy colloquium at a medical school, today, a Distinguished Professor introduced the speaker with the biography she’d given him and a little ad-libbing. “...where she majored in English. . .which is extremely related to medicine…” I would have been annoyed, had the colloquium coordinator not already told me that the D.P. supported and was very interested in people doing medicine and humanities. (He was less eloquent, later, “My son-in-law is a poet!”)

At Poets House, later today. As the library was closing, and I was leaving, one of the staff (whom I’ve met before) came over to chat. He’s also a poet. I had the Collected of Wallace Stevens on the table, as well as Nerve Squall, by Sylvia Legris. He asked about the latter. “Oh…she writes using a lot of science, often botany, here fish and birds…a friend recommended her because I write a lot using medicine.” He nodded. Picking up the Stevens, he commented on how part of what he really likes about Stevens is that. . . poetry is one of the things he does, he’s not an academic poet, not trying to participate in the academic discourse of what poetry is, who, etc…(It’s funny to note that people often refer to Stevens as “an insurance salesman.” He was a lawyer who worked for an insurance company. Odd). I don’t know a lot about Stevens, but he did write about poetics, as well, some critical essays – but not much compared to his contemporaries.

He went on to talk about poets who aren’t also English PhDs and who just. . .write…and do something else, too. How he likes/appreciates them. We talked about a few other writers. Then – “what’s your background? undergrad? did you major in…medicine?”

And thus I reveal myself as aspiring to be, perhaps, a poet like one he admires – not-academic-but-that’s-okay.

***

Another poet/friend, today. We were discussing (“interlocuting”) what it’s like to write, for each of us, where poems come from, how they do, what we’re doing with them, what we’re reading and how that influences things…etc.

He said, “Being a poet sometimes feels like being a homeless person, when you never know where you’re going to sleep next/next meal is going to come from…”

It’s a curious analogy, but I think it’s okay because it’s not actually referencing or alluding to starving artists. Also not comparing the difficulty of either situation; more, I think, speaking to the unpredictability/ seeming lack of agency. I think. You don’t know where the next poem (or other artistic inspiration) is coming from, or when, or if. (With time, the anxiety of the “if” has lessened. A lot).

The “if,” though, has little remedies. Read poetry. Go to readings. It will come. For the ones giving the readings, then, it’s a gift they’re offering. Hoping, in fact, that will take, that anyone will take. If it’s a good reading, an amazing reading, I’m either writing lines down, madly scribbling ideas for my own new pieces, completely stunned and entranced by the reading, or I can’t find my pen and notebook. Any of the four are possible. (also – it’s not just the good readings that give ideas. In truth).

With another poet-friend of mine, after a reading we attended last week: he said he’d liked the second-to-last poet best. “The ones about high school.” (that writer is a high school teacher). “Oh...I don’t remember those very well…then again, that’s when I was writing the most, so I guess that means they were good?”

To a writer.

If someone is writing, they are thanking you.

If someone will remember your words next week and not be quite sure where they came from, they are thanking you.

If someone will put your line in a poem in a year and have no idea they didn’t write the line, they are thanking you.

If someone will need to read your book, they are thanking you.

If someone will pass that book on to another person, they are thanking you.

If someone will write now, tonight, tomorrow, next week, next month, in a year or in ten, they are thanking you.

Being an artist isn’t all about the art. The art comes from somewhere. It goes to somewhere. And you get to be the tenuous hands that have a part in that connection.

Why do you care about publishing, I’ve been asked. (“Why have a blog” is a similar/same question – or, actually, these days, I suppose we could debate the relative differences with other forms of publishing…) It’s sure as hell not altruistic to be an artist and to want to exhibit/publish your work. But even paintings should live off museum walls, and there’s a difference between printed impressions and the physical object. It’s what you see, how it makes you feel then and later.

If one person reads and wants to write, if one person uses a line of mine, if one person uses a line of mine, many years from now, because it’s been stuck inside them that long and they have no idea where it came from.

If one person thinks I must have written about exactly what happened to them, because it is what it means. If one person connects to a poem, thinks about it later, keeps it, somehow, is reminded about it by an experience that happens later.

If one person remembers reading my book and what happened at that time. If they reread the book (!!) and different things are more and less poignant, more and less meaningful.

(it’s poetry, it was never going to be about the money. Though the publications and the prizes and the fame and the money and the bookstores and the…would be nice…)

Enough.

…red’s the only honest color, after all, we’re flesh and blood…”

- Rachael Sage, “Crack of Dawn” Smashing the Serene

Kevin in the elevator

2011-12-12T07:17:00.001+01:00

Dear Kevin-in-the-elevator,

Yes, I am using your real name. As told to me. Assuming you are real. Assuming I did not walk around 14 floors – as directed by the guards, this is a very secure building, with my large box of office supplies and binders with information on buprenorphine – and down, around, past more guards (how secure if I don’t have a badge yet?) – to end up on a not-real elevator in a not-real building.

But really, Kevin, imagine my surprise when the elevator door opened – me and my not heavy but awkward box, my colleague M with the dolly that refused to take corners well; we took turns with that and the box – and there you were. I’ve called it a folding chair when I tell this in person, but I don’t know what to say the chair was – nicer than a lawn chair, not folding, but the kind with spindly legs and textured plastic seat. I think. Did you even have a cushion? It was the Metro paper folded underneath – the free one. There’s very little light in the elevator.

We mentioned our surprise upon seeing you, me and M. And you responded, “Oh, I’m new, I’ve only been here since Tuesday.” It was Friday. Kevin, M and I had never taken the freight elevator, alone or together; you seemed to assume we’d known your predecessor. Or it was just another bad or awkward joke. She asked your hours. We were shocked at the – constancy of them. Eight to six, you said. Hour lunch break I assume. And every day. Who gets weekends? Or is there no health department freight on weekends?(the buttons, after all, are the pretty normal push-‘em kind, you know).

When we got back on the elevator, I remembered your name – M was impressed. How many men living in boxes does she know?

Name, man, elevator.

Market, N'djamena, Tchad

***

I could turn Kevin into a metaphor for Americans, or really for many populations or groups of people or myself in (formerly) microcosmic med school . I will endeavor to not be that ridiculous. Or not.

So, to Geoffrey G. O’Brien’s Metropole. Geoffrey G. O’Brien was, at the recent Berkeley police-against-peaceful-community riots, beat up. Unceremoniously, per the article, was recovering from broken ribs the same weekend we were assigned to read his book. And discuss it. That was the same Monday I went to my first protest since the anti-war ones. (There’s a poem in there, somewhere, about all the places I’ve marched and demonstrated and protested. Somewhere). This isn’t a place for explication – suffice it to say – the title poem, “Metropole”, moves through politics and protests in America. Writing about politics without polemic. (There would be more to say about the poetry, but, not now, and I’m not the one to say). I like the political poems. It’s damn hard to do well. Like painting in color or writing in rhyme.

The following seemed almost eerily prescient – I don’t know if this had happened to him before. But as I was reading it, it was happening:

“Outside the bedroom buses stuffed with passengers pose family unawares.

Pedestrians, commuters, worries pleased they’re happening, equivalent

designs. The square completely filled then drained, a battle neither can

afford to win. And banners, nightsticks, chanting, things with arms – from

over either shoulder daylight knows the march as angry signs but crowds at

night are demonstrations minus signs (portfolios). A struggle: fighting with an

absent force. The rally’s unknown number when divided by itself”

This contrasts with Mark McMorris’s Entrepôt, apparently (why contrast these two in particular? we read them, thus juxtaposed, in workshop). Which I read in a Politically Irresponsible Manner. I did not read the lines, abruptly shifting between end-stopped and enjambed, as explicating the ambivalence of relationship to archive and colonial trauma. I’m not saying the former isn’t in the intent of the poet and isn’t in the explication and close reading. But.

I didn’t know I was a Politically Irresponsible Reader until that workshop, after which, incidentally, I wrote the previous post . Do I hate being a poet when I feel like I’m not good at it or not getting it? More when – yes, I don’t understand and maybe it’s over my head and maybe it’s too much and maybe it’s over everyone’s heads – I’m not sure I see the point.

***

Dear Kevin-in-the-elevator,

The second time, on the return trip, M was impressed I remembered your name. She was impressed when I mentioned your name to A, our supervisor, too. Who else do I know who lives in an elevator?

When we got on that time, a group of people with food got on. Some meeting somewhere. And they got off – two different floors maybe, with ours being the third ones. The elevator doors opened, the silver (jaws, to you, or quicksand) doors slid open – reminiscent of my cousin’s Delorean, perhaps – and there was a flash of another floor, beyond another set of doors. Whatever might have been there? Elysian fields, Madison Square Garden, Point Reyes, a sandcastle competition, the set of CSI (one of), hot air balloons in New Mexico, another group of cubicles and some with flowers, a very large kitchen making nothing but pâté…

Whatever makes your day more interesting. There is a finite number of floors – have you assigned attributes to each? Are they mutable? And what about the people who pass through – what are they doing with whatever large box or tray of sandwiches? Where have they come from?

Etc.

Waza, Cameroun

***

There’s a story about Robert Duncan, in the H.D. book. He’s sitting on the grass at Berkeley, reading poems with some women. The bell rings for him to go to ROTC (mandatory in those days, whatever those days were, exactly). The women impugn (per his account) “You don’t have to go, “Stay with Joyce, “Rejoice with Joyce.”

And he stays.

Separating that moment from what ROTC was for, in those days, what going/being a conscientious objector might have meant…the point, more, as written, is about turning to the authority of a poem. Away from not just military but university and everything else. About poem as higher order. And how poets (in some views) cannot engage in politics and be both. That when trying to make poems do something in the world (can they?) they are defamed, somehow. That that’s not poetry. About this I don’t know enough. Yet – what I love about literature is its power to transform, transcend. But maybe that’s just it – if you focus on transcendence, then everything else is mundane. In a word.

And Kevin? The surreality, perhaps. That him being there seemed like it must be symbolic of something. The imagination in an elevator. More – you can imagine what’s outside the doors, without every actually seeing it. If you can sustain that. Less – well, no stimulation. Little.

I worry about poetry being inside the elevator. There are the conversations that take place there – whomever is passing by, whomever notices. And takes the moment to see it from that perspective – the elevator stops on someone else’s floor, and for a second, you imagine what might be there. Anything. A world that doesn’t have to conform to yours, and it could be an image, something whirling-dervish like (that’s a paraphrase of Ezra Pound – for another day) (and I have just thrown entirely too many poets into few pages). An engagement – or, an almost engagement – or, the infinite potential of engagement every time the door opens. Or not.

***

Dear NYC Department of Health and Mental Hygiene,

Kevin is in the elevator. I work on the Mental Hygiene floor. I don’t believe the elevator is very hygienic for his mental health, or for anyone’s. If you need a person to sit in the freight elevator – and again, I’m really not sure where you’re going with that – have them switch off. Like, every hour or two. And then do a job that involves running around the building. Or at least guarding something that is not the interior of a box. Let’s not be hypocritical, shall we? (Much like our syringe-return drop boxes (here – kiosks). You know we’re having trouble placing them in various places in the city, due to property lines, landlords, etc…is there a reason we can’t have them outside, here? It’s the right neighborhood. And there are certainly a lot of diabetics in the building – 24 floors? Yes. (…et al).

Maybe you’re worried because there is that big movie studio place (I’m assuming there are sets there) nearby? I mean, it’s easy to see, and I could definitely walk there during a quick break. I wonder what their security’s like. Or if they have anyone sitting in the elevator. If they do – okay, I’m picturing a fancy hotel – it should be made of glass and riding up and down in the middle of a lovely courtyard. There is a situation in which one can Sit in an Elevator. Much like subways, right? I imagine there’s a difference in mental health and job retention between those on more above-ground lines and those on purely below-ground lines, right? I know several do go above ground, at one point. Take the Q. Those drivers are probably doing a little better than, say, the 2/3/4/5. You see the Brooklyn Bridge, downtown, etc. That’s pretty. And the Q – again – and the 7, etc, the ones that go over the Queensboro bridge. Okay. And I guess the A train drivers sortof see the ocean (do they?) on the way to the Rockaways.

You are concerned with my mental hygiene, perhaps. From my floor – the Mental Hygiene floor (only one of, I hope! but am not certain) – we have a panoramic view of four boroughs; with binoculars and imagination, we can likely see Staten Island, too. Across from my desk, I see midtown, the Citicorp building, and, craning a little to the left, the UN. If I go to the printer, I can see La Guardia, with fewer planes ascending/descending (visibly) than I would expect. I can see a lot of the Bronx, which is good, as we have many projects there. And, these days, I’m in the office when the sun sets - we all walk toward the window, for moments. Staring west. Reds and yellows and reds.

BUT KEVIN IS IN THE ELEVATOR.

***

Dear Kevin-in-the-elevator,

Perhaps, next time, I will bring you poems. If you’re still there…

Recursive in print

2011-12-07T07:03:00.001+01:00

Addendum: By comparison with my other friends in other grad schools, I've often felt like a very lazy student. Like I'm not working much at all. And then I realize - if I add the hours of writing, the hours-upon-hours per poem, the reading of poetry - it could even be more. But I don't count that as work. It's what I want to be doing, anyway.

(approx one week ago - true, then. don't hate it today. more to write, soon)

Some days, I hate that I’m a poet.

As I’ve said before, it’s not a choice. Do I wish I were…a novelist? a journalist? a documentary filmmaker? an influential blogger?

Maybe, maybe, I could do the things I want to do, then.

Thing is, I’m a poet.

And today, I hate that.

I was speaking with one of the program admins/alums today, turning in poems for a scholarship application. She asked me if I like the program (MFA) better than med school. I replied with a decisive “No.” What I didn’t say, the background voice, is that I think I like med school better.

Problematic.

I saw a friend from med school last night. And standing there, on a street corner, discussing the aesthetics of science and the unbelievable, incredible elegance of development, experiments that can show that… I wasn’t an imposter. Not then. Med school friends are coming through for residency interviews. It’s a view of an alternate life, the path I could have been/could be on…but even discussing that, the medicine, how absolutely incredible it is, the privilege, to be a doctor… feels right.

Right.

I’m supposed to be getting an education in poetry. I think. My tutorial (one-on-one) prof said to me last week that I should take her class next semester, on 20^th century American poetry. Because my ignorance, my naiveté shows in my work. (True? sure). One thing – that would mean 3 classes with her this year, which is too much. Second thing – it’s the same poets we’ve been discussing in this semester’s workshop. Third thing – I just can’t make myself care, enough. Right now.

There’s another course I could take, on more contemporary poetry – and this does actually include a number of poets I know and like. But then there are the comparative literature-type classes…*

*which explains that though I have a BS in Creative Writing, I have little to no education in poetry. I took the workshops, I did the one-on-one writing work, I wrote the thesis. I read a lot, I did. But I don’t have the background, and except for one course in France, I’ve never had that sort of formal study. Ever. And the one required course on the Western Canon, which is the only reason I’ve read (and loved) Milton. I wrote things with a lot of religious imagery, that semester – the influences, yes, are important. But I took comparative literature courses for everything else. It’s more what I care about. Literature in context.

So do I eat my poetic vegetables, so to speak?

I don’t want to.

I’m working 20 hours/week at the Department of Public Health, now (that’s DOHMH in NY – Department of Health and Mental Hygiene. I’m actually in the MH part. Haven’t quite figured out what the “hygiene” bit is).

And it’s comfortable, easy to walk in, easy. I get how people are. I speak the language and I want to – I want to learn more, I want to learn so much more, I want to be part of that conversation, so to speak.

A few weeks ago, we did a training on buprenorphine, for doctors, so that they can prescribe it to patients. (It’s similar to methadone in that it can be used to help with heroin addiction, treatment, etc). I decided to go and help with it, though I didn’t have to – partly, yes, because it’s good form for work (to do semi-extra things), and partly because I was really, really interested, after I’d helped to put together the materials. (That’s another thing I really like about NGO/health dept-type offices – there’s no shitwork, no lowly intern things to do. If I don’t make the phone calls to remind people about the peer educator meetings? My supervisor does. We all – all levels – worked together to collate the materials (that took awhile…) Etc).

And it just felt right.

Before this happened, I was describing it to my poet friends. It was a Friday evening, we’d gone to a poetics lecture, and then we were workshopping in a pizza place. (these are the truly wonderful moments – that – and that we care enough to do it, to hold extra workshops).

One of my friends said – “What on earth can you talk about with methadone for a whole day?!?”

I didn’t respond much more than the “Everything….”

And I was thinking “How can you talk about line breaks for two hours?!?”

That.

“How can you spend a career studying Emily Dickinson?”

That.

It’s not that I don’t respect the above. I do. I do.

But I couldn’t do it and I don’t *get * it, quite. A little bit. With a lot of explanation.

I used to think that doctor was what I did and poet was what I was. Writer, rather. Everything has become inseparable.

Much of what I write, these days, is somehow related to medicine or medical language. More explicitly than before – perhaps on purpose, perhaps reactively, and perhaps as another way to re-engage.

I haven’t, as previously planned, applied medical ways of thinking/examining patients to examining a poem. That should be next.

Looking at the graduate English course catalogues of three schools, I’ve found three or four classes I would take. Not more than that. Were it a public health catalogue, it would probably be the majority of the courses. Were it a medical school “elective” list – I would want to take almost everything listed under medicine and under psychiatry.

As it were.

Problem is, I am a poet.

*******************************

And yet.

Some days, I love being a poet – or, at least, I love poetry. And poets.

A few months ago, I first* read Cyrus Console’s The Odicy. This was before going to a reading he did with Omnidawn Press. And the first time I read it, I couldn’t stand it was over – I had to start again. I did this at the end of each of the five sections, too…no, no, no I wanted it to keep going. Breathless. Submerged. It had been a long time since I’d had that sort of experience with a book of poetry. I was expounding on how much I loved it to my classmate/friends, before the reading began, and before I knew that Cyrus Console was sitting behind me. At one of the breaks, I did have the nerve to talk to him.** I only get this way around writers. So I said – the above. I didn’t want the book to end, I didn’t want the sections to end, it was one of the best books I’d read in a long time. He said thank you, quietly, I think. It was a very quiet and seemingly awkward exchange. But, I’d said what I had to – and I had to say it. Too much to not. ***

I certainly didn’t have the nerve to ask him to sign my book, then. It’s fine. It was fine. What counts is the interaction with the writer, the reading, etc…

Later, at the reception, Cyrus Console came up to me. And he asked if he could sign my copy of his book.

He said – thank you. For what I had said. Because that would make him keep writing, another book – hearing that kind of thing. That it meant something to write something out in the world.

He asked me if he could sign it.

On the title page, he crossed out his name. And then wrote: “To Jenny, with thanks – Cyrus.”

Best inscription I have, besides the ones from mentors (different).

Even published writers – ones I admire so, so much – don’t believe in themselves and what the words can do for other people.

*I’ve read it 4 times since. Several more to go until I understand/see more and more and more…

** Cyrus is, perhaps, 5-7 years older than I am. At the most. Not intimidating at all – quite the opposite, quiet, unassuming, somewhat diffident.

*** Similarly, I once told Li-Young Lee “you’re the kind of poet who changes my breathing.” I think he understood. He seemed to, anyway. But he is quite wise.

Poets certainly aren’t known for their self-confidence. I recently read Console’s first book, Brief Under Water. Same reaction. It was over too soon; I had to start again.

It’s the love-hate of poetry. In other (non-art) disciplines, you can finish things. There are infinite things, but you can finish one. Thing. Gain an understanding of something. Learn about a disease. Policy. Community programs and theory and epidemiology and pharmacology and pathophysiology and pathways.

You can finish a book, you can finish a paper. But a poem?

(as described above)

A “finished” product is one (often) I can’t bear to look at again. If I do, I’m likely to drown or light it on fire. In my undergraduate poetry thesis, there is a poem about just that - how much the poet wants to destroy the manuscript. A year later...it was better. Okay.

Anything, looked at too much – and carefully, down to each punctuation mark, spacing, letter – loses meaning. Like a word you say too much. A poem becomes – terrible. Nothing. Can’t see the forest for the trees, to use a terrible clichéd metaphor. And the work itself – hurts. It’s recursive. It’s never done – until the above happens. I spent six hours working on one poem last weekend (and many others on others; this, however, was six straight hours). One poem of 19 lines. And it’s passable, maybe, with several red marks and slashes (not mine) as of this afternoon. The poem was initially written in September, was then completely dismantled and rewritten, and, soon, it will be again. Unless I get rid of it entirely. All the work? Well, learning, becoming a better poet, better eye, more critical, etc…

but to show for it? Lots of unused and failed files.

Our “assignment” over winter break is to write a book. And to fail. “May as well get it over with,” said our workshop teacher. Setting out – to fail. “How many failed books do you have?” “…All but three.”

And it can fail, and you might get one page, or one line, and that’s good! He says. I don’t know. Including us in that dialogue, though, included us in the discourse of published and future-published writers. Failure. Blood, blood everywhere (“writing poetry is easy; all you have to do is find a vein, and open it). Discarded paper everywhere (to be recycled).

Thus, simultaneously, public health program design, research, paper writing, article searching, curriculum creating - things that do feel satisfying. Partly in their ability to be complete, enough.

For writing.

Start again.

Freedom fries

2011-11-04T07:58:00.001+01:00

(This is a sketch of a post. The rest...later).

I used to actually hear that, fairly frequently, in 2001 and 2002. Somehow, that was a response to my being French.

It's an interesting word, "freedom."

It has a number of negative connotations for me now. "Operation Iraqi Freedom." et al. (not going into that now). It's a way to wrap things in the flag. That flag.

"Land of the free, home of the brave."

from Emma Lazarus, as engraved in the pedestal of the Statue of Liberty:

"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!"

from Tom Petty, "Free Fallin'" (incidentally, excellent Americana song, too..)

"And I'm free, free fallin' "

As one who's been in freefall, before, I preferred parachuting down (skydiving). Freefall is too fast. In sixty seconds (less? I don't remember) we descended 5000 feet or so. However the physics works out from starting at 13,500 feet and parachuting from somewhere around 6000.

It was too fast to experience, really - that would take another jump, but as - even if I jumped tomorrow, it would be 6.5 years later - might be like starting over again. Freefall. Fun? How would you remember? Too much to process, see (and I had to adjust my goggles; seemed like they were going to fall off. I do remember that).

Freedom.

I was at Riker's Island today. Famous NYC jails (and poss prison too? unclear). Tens of thousands of detainees/inmates/incarcerated...today was my second time doing any sort of prison work; I'm just starting to learn the language. I'm working with the NYC Dept of Health, and, in particular, with Harm Reduction services. Every month, we go to Riker's to teach about harm reduction, clean needles/syringe exchange on the outside, hepatitis C, and, today, overdose prevention and treatment with naloxone. It was wonderful to get back to that work.

Being in a prison is incredibly strange - the checks, the IDs, the leave-everything-including-everything, all the bars opening and closing behind us.

I had done that before. And the similarities with psychiatric wards, also (they're co-morbidities, anyway) are fascinating...

That's not the point.

On the bus to Riker's (MTA bus goes directly there, from Queens), you pass La Guardia Airport. And then thirty seconds later you're on Riker's Island.

People worry about planes landing in the water? They could just as easily, truly, land on Riker's, on any of the jail complexes. It's an unbelievably short distances. The planes were, essentially, there. Everyone's looking for the NYC skyline as they land - who sees Riker's? Notices? I never did.

What could symbolize more freedom? International airport, busy, restricted to people with some amount of money/privilege, vacation vs business vs...

airplanes. coming. going. landing. taking off.

Right over Riker's.

As to Emma Lazarus and "The New Colossus" - the Statue of Liberty and Ellis Island are well-within view of downtown Manhattan. I remember the towering displays of suitcases at Ellis Island. But then - and now. Now. "Give me your..." to whom, for whom, and for what reason? It's not Arizona in most of the country, certainly. But the sentiment...is so ...condescending. "Wretched refuse"? Wretched how and in whose eyes? "We" certainly take people with very diverse backgrounds - including very high levels of formal education, wherever they come from - and say those things don't count. At all. Redo, redo, redo. Or pretend "whatever" wasn't done at all. In medicine, the ones who get counted as doctors (after however many years of practice, retaking boards exams, and entering the Match) go where students from American med schools don't want to. For the most part.

"Give me your tired, your poor..."
Wretched. Demeaned. Demoralized. Dehumanized.

"Send these, the homeless... to me"
Because other homes aren't a home.

"I lift my lamp beside the golden door!"
And try to see inside. Gold, shut tight; if it's pure, maybe the lamp will melt some of it and allow an opening, an acquiescing, a bending.

"refuse..."
For Riker's Island, over 20,000 people, there was no evacuation plan during the hurricane. As stated, it's essentially sea level. At La Guardia.

In French, "La liberté éclairant le monde" - liberty lighting the world.
Floodlights that can be seen...well, across a large river and probably farther.
After all, electricity is an unlimited resource, not a commodity.

Let freedom ring.

~j

Colonized, not conquered, tongues

2011-10-15T23:38:00.000+01:00

In my Creole Poetics class this week, we discussed Caribbean poet and scholar Edward Kamau Braithwaite’s “Nation Language.” In essence – colonized people, who’ve had to assimilate to and be taught in the language of the colonizer – need a more natural form of expression. Part of independence, part of forging a national identity and establishing roots, was valorizing that language. Making poetry in the diction and rhythm of that language – iambic pentameter, for example, is not native to Barbados. (Is it actually natural to English? debatable).

I’ve seen this in Cameroon – French is, technically, my first language, but for the first few weeks in country, my “French” was translated into “French.” As I now call it, that’s French-French to Cameroonian-French. I was incomprehensible. I understood what was being said to me, or I thought I did. In time, I changed – I had to. It’s the inflection, the diction, the choice of words, the syntax, the prosody, the sentence length, word order, ways to get attention, non-verbal sounds to punctuate phrases…

Everything.

It’s not the same language.

I see it now as general, amorphous “French” for the basic structure – and there’s the French-French, the Cameroonian-French, the Senegalese-French, the Malagasy-French . . . they’re all different.

(And why shouldn’t they be? It’s obvious enough for Belgium and Québec).

But Africa was colonized.

The marks are there. Senegal was more closely held for longer – the French is closer to French-French in accent. Cameroon got passed over from Germany. French is different – the culture, too, is different.

And then there’s Anglophone – as PCVs, we defined at least three (basic) languages in the Anglophone (previously British-held) provinces of Northwest and Southwest. “Grammar” is the “Queen’s English,” or so they say. (Grammar – reductive; it’s language without culture or any social attachments. Pejorative? True? The way English was taught in former colonies (and is still), it’s the generic, over-arching Language. This Is. How could something so authoritative have meaning to real people, terre-à-terre?)

Anglophone. Not quite grammar, or – it is “grammar”, but we call it something else. English? No. That’s British-English. “Anglophone” is, like Cameroonian-French, related to accent, inflection, diction, syntax, vocabulary… it’s neither British nor American English nor any other Western form. We Americans were not always well-understood speaking American English.

So what did we do?

We spoke Anglophone.

(And many volunteers who lived in the NW and SW learned and spoke pidgin, as well as other local languages – as a visitor to the Anglophone regions from my own francophone province, I didn’t go further than Anglophone and a few phrases in pidgin).

It’s reflexive, now.

This is what we do.

The Vegetarian Carnivore - Rhumsiki, Cameroun

I do the same in other languages, though – it’s either a function of being bilingual (since I’ve had language, lucky lucky) or just of being…strange. Speaking English with French people who have some accent in English, some significant accent, my speech softens slightly. Slightly. I’m not going to speak with an accent I don’t have, but...it changes. Situational. If I know a person’s first or native language, it’s hard for me to speak to her in anything else.

Thus, in Cameroon – Cameroonian-French and Anglophone.

When I went to Kenya, I started to speak what I think of as Anglophone – it was English-speaking Africa, after all…

I got a few Looks.

(What does the mzungu think she’s doing…)

(Just like, when, in response to “I want to marry you” or “I love you” in Bulu, the mintangen shot back “Teke djom!” or “Ma vini wo!” (Never/I hate you).

In Kenya, they don’t speak Anglophone. The English in Kenya, yes, does have a distinctive Kenyan accent, diction, syntax, etc etc etc. But it is closer to British English, in some ways, than Anglophone sounds. Longer occupation and more in situ because there are good safari parks.

It was hard to remember to speak English at first, actually. For me – Africa meant “speak French,” for the most part.

In Equatorial Guinea (briefly), I had to remember to speak Spanish – Spanish mixed with Bulu, that is, as differentiated from the French mixed with Bulu that I was used to – same ethnic group, arbitrary border.

Arbitrary.

It makes the most sense for me to speak all my languages at once.

In Cameroon – as in many places, but this is what I know – there are 240 local languages. Country the size of California. Several of the languages are related in various groups, granted. But there’s the reason there is no African official language (as Wolof in Senegal or Malagasy in Madagascar) – there isn’t one. Not enough of one. (If Biya could decide that, on top of everything else, it would be a Beti-family language. Of which Bulu is one, actually).

One village to another could be a different language. French and English are necessary to communicate in a country with 8 Francophone provinces, 2 Anglophone provinces, a German past, and 240 other languages…

Bilingual has a strict definition in people’s minds: French and English.

I, then, am bilingual. Every Peace Corps Volunteer in country is bilingual.

And my friends who spoke 3 (least amount), 4, 5, 6 languages?

Didn’t count themselves as bilingual unless English was truly amongst those.

Every single person I know in Cameroon speaks more languages more fluently than I do. Most of them don’t count them as languages. They call them “patois” – dialect. Pejorative. Some are written, now, some have been, some are being codified by missionaries and/or linguists. In Bulu, there is Kalate Zambe – Bible, or “god book.”

Books are Serious.

Because I was often seen reading, people thought I was constantly working. Constantly. Always studying. It didn’t matter that some of the “serious” books I was always reading included books I consider equivalent to TV – passive entertainment – in a village where I couldn’t watch TV or movies.

But it’s not just that there’s not a conception of reading for pleasure (there’s not), for so many cultural reasons….*

Books are expensive. Books are expensive and sold on sidewalks. There are bookstores in Yaoundé, the capital – two, I think. Small. Most things are copies, copies of copies for university, and it’s hard to get them (corruption/competition and otherwise) and it’s expensive.

It’s not books. Even benches are shared – and paid for. Books are very expensive. Magazines, too. Anything that’s reading material, anything printed, thus gains value.

*I’m reminded of nights in my homestay in Bandjoun (perhaps written, 2005, the earliest posts here…). There was power. Technically. Low voltage. The bulb over the dining table was so dim that I rarely really knew what we were eating. For studying at night (in truth) or reading (in general) or writing letters, I needed an extra candle/kerosene lamp. This was probably (was) considered wasteful. My host sisters somehow sat, hunched, and did homework, after doing all the cooking/cleaning/taking care of the three screaming children under four. My host parents graded papers that way. But the TV and DVD player worked. In my room, with the light on, I read by flashlight.

In Mvangan, until I got a table made (long saga and looooong time in production…), there were evenings lying on the floor with the book or letter, trying to get in the right angle with the light to see enough. (A headlamp, later, helped).

That’s both the importance of reading/writing to me – and the barriers that are set up just by the physical parameters. And no one but wasteful me (or other PCVs) would light more than one candle or use more than one lamp just to be able to see well.

But I was going to talk about language.

It’s not the same language. And yet, the books are French-French. In college, I got to take a Francophone (Diaspora) literature class – actually, it was an intro to French literature, and the professor (Returned Peace Corps Volunteer from Chad), focuses on Francophone versus French. I’ve probably read more than most people in Africa have, of that canon. I can buy the books here. More easily. Writers are getting prizes in France, in the US…

Africa?

I reviewed a book of Cameroonian poetry. The poet teaches and lives in the States.

Literature – the language of a people – should make sense.

And then there’s medicine.

Words are always approximate. Always. Every art is approximate. The closest thing to anything, I think, would directly involve the body – and thus there’s singing (or any music not involving instruments) and dance.

And medicine.

We interact with this art form, shaping it and trying to understand it – I’m talking about surgery, I’m not talking about changing things through medicine, I might be talking about psychiatry, in some respects, but it’s not exactly that.

We ask people to describe and quantify things in common words.

Sharp/stabbing/dull

Aching

Where is it? Where?

And what about referred pain – how do you actually know the locus of anything, as everything is “all in your head” – interpretation of pain.

For many things, the body isn’t actually very good at that.

I worry about this with the optometrist. What if I get it wrong? What if I can’t exactly record the nuances of the images, which is really better, or just a little bit better, or not at all better?

(At my last visit, he assured me that I couldn’t mess it up – he used each image enough times, each diopter, and in contrast to other things that I should recognize more easily. This was slightly helpful – but still, I’m not completely convinced).

What about the power of suggestion? The review of systems. If I hadn’t asked about something, would the patient have thought about it or noticed it?

(For some patients, this actually does become an issue – asking the ROS becomes a litany of issues they’d never considered or might be slightly off kilter).

We define these things and assume people understand.

Pointing is helpful – that’s the body speaking more directly – and yet, with anything visceral (in basic terms, organ-related) – the body isn’t good at localizing. Take the classic case of appendicitis:

(this is textbook)

Initially, pain is dull, maybe, and periumbilical (around the belly button). Vague, diffuse.

(Is the appendix there? No. Not usually).

And then it moves to a more specific location – McBurney’s point, 2/3 on the direct line between the umbilicus and the ASIS (anterior superior iliac spine). That’s classic. And the only reason it localizes, then, is that the appendix is so inflamed that it’s actually directly touching and irritating the peritoneum (wall of the body cavity). It’s not just the intestine anymore. And all of a sudden the body has a better idea of where it is.

The body, too, isn’t the best historian.

A friend (who just started med school) told me last night that his pain had begun at 6:30 pm the previous evening. “That’s precise…” “Well, give or take half an hour. Med students are good historians, aren’t they?”

Yes, and sometimes hypochondriacs (I do think that improves with time, though).

What happens when you start to acquire the language of the body? The basics, as always, come back to pleasure and pain. And in order to communicate that to doctors (specified: doctors. Or any health professionals. Or people in a medicalized context).

Do doctors care about pleasure in the body?

Begs the question.

You could call importance of the patient feeling better as pleasure. Joy in resuming activities – or adding them, when things are truly “better.” When the patient-provider relationship has resulted in something positive and productive. There is joy in the improvement (or ceasing! gone!) of disease. (One patient called me “an angel” for helping with his cholesterol and getting him an expedient appointment with a surgeon for his hernia. Me – hardly. That’s the point of all of this, isn’t it? That’s what we learn, for? Behavior change communication, harm reduction, and then the medicines and then the surgery (order depending on the issue and its acuity).

How does the body – and how does the person – represent pain? The patient with metastatic cancer who says she’s in pain is more – terrifying, to me – than the five-year-old who is crying over a scraped knee. But?

A friend explained it this way. She was in the beginning stages of labor, with her first child. The nurse asked what her pain level was*. “Nine.” The nurse paused. Surprised. “You know…the actual birth is going to be a lot more than this.” “I know. But right now, this is just about the worst I can imagine. And now I’ve experienced this…so later, it’ll still be a nine.”

*This is a person who would probably be among the most stoic. This may have contributed to the nurse’s surprise. Also, this friend is in medicine.

Everything’s relative. The utility in measuring, quantifying, qualifying in common language is that we feel we can treat something, that we can communicate effectively with the patient.

That’s why physicians like the physical exam and lab tests, too.

But how much of the physical exam is truly objective?

And for lab tests – much closer – as is imaging, certainly – but unless there are specific points of comparison, you don’t know what the patient’s baseline might be.

(Patient. Person. Patient. Person).

Small small catch monkey
(offered to me as a present, Mvangan, Cameroun)

Poetry is about specificity of language – actually, it’s about Vortex and Image (Ezra Pound), but that’s for another day. In medicine, specificity of language is crucial; it’s how patients tell stories to physicians (and we complain! it’s not specific enough, AND it’s not in the right words!) and it’s how physicians communicate with each other.

Epocrates isn’t quite a thesaurus, but . . . working on it.

(this is already far too long).

Who wants to be a poet, anyway?

2011-10-06T19:12:00.001+01:00

The delay is that – well – since writing is so much of what I do, now, it’s neither escapist nor explanatory nor therapeutic/exploratory to write about, all the time. But it returns, now.

*other poets may disagree. That’s fine. This is my experience. I'm envious, perhaps, and/or admiring of - in awe of - those who are so dedicated to this as I am to no one thing.

The first poem I remember is from second grade.

Poem that I wrote.

I was a better poet then than for the approximately ten years after that –

because I didn’t know, yet, what poetry was. What poetry was “supposed” to be. What “sounded like” poetry.

From seven to seventeen, there was subversion, inversion, and perhaps glimpses of things that had merit! maybe! that said something! maybe! But it “sounded like ‘poetry’” – which is, really, not good at all.

Even poetry that conforms to rules – i.e., Shakespearean sonnets in strict iambic pentameter, for one – is good if it’s so natural that you don’t know for awhile that that’s what you’re reading (unless it is, obviously, Shakespeare). The rhymes, the rhythm are not forced. They’re what exists – and what happens to be in that form. And then you look and realize it’s three quatrains, ABAB, CDCD, EFEF, and a couplet – GG. Ten syllables to the line in iambs. Trying that – doing that – is hard, and often sounds heavy-handed and sing-songy with inverted structure to get the right rhyme at the end. I think everyone goes through that phase. (and maybe it becomes something amazing and there is the real poetry. Not for me, not now).

But at seven I was a poet.

To be a poet is not a choice.

Who would choose this? It’s a lonely vocation. You sit, alone (or alone in a crowded room, as we crave the (prototypical?) background noise of cafés. Street and people-watchers, listeners, we are). You spend an inordinate amount of time in a difficult headspace that most people don’t have to inhabit so often. You – if you’re really going to write – are connected as much as possible to everything, and you’re always listening, and open.

It’s dangerous.

Nselang, Cameroun - you can't capture the greens of the forest in a photograph - can't - This isn't a great photo, but that's irrelevant for this point -
and you can't capture everything with words, but we try

Why be a poet, and why not be another sort of writer? (many, many of us are, as well. These days, I’ll claim poetry-fiction-non-fiction, whether I have a “right” to or not).

“No one reads poetry.”

“People are afraid of poetry.”

“To say ‘poetry’ – to say ‘I’m a poet’ – has serious connotations. To say ‘writing’ or ‘piece’, rather than ‘poem’; to say ‘I’m a writer’ or ‘I write’ – that sounds different.” Less presumptuous? Less evocative of I’m-disconnected-from-the-world and I’m-part-of-the-tuberculosis-aesthetic, living-in-a-garret-aesthetic, surely-starving-artist who, well, teaches, because who can make a living at this, and who would do it anyway?

Among my coterie, among my new colleagues and friends and cohort, these are common discussions. Why do we do this. Who do we read. Who and what stops your breathing and heart and makes you gasp and reread from the beginning again, and again, and again.

To be a poet is not a choice. We didn’t choose this. People might choose to write fiction, in some sense (paperback? Things that sell? Even over and above that – it’s a different kind of discipline).

There is discipline to being a poet, certainly. I was reminded of this in the poem that I have, perhaps, spent approximately 18 hours on – thus far. It’s not done. It’s far from done. It’s what absorbed much of last weekend, has kept me up until 3 am a few times (that and other new pieces), brought me to a café (“my office”) with my unabridged thesaurus, reminded me that being a poet is damn hard, and is unbelievably exciting.

Why?

I could articulate it, I know it – but to whom, and who outside of poets – and those who know me and try to understand – would get it?

And why is that important.

I didn’t choose this.

One project, lately, has been rereading every poem I wrote since freshman year of college, when I first started getting serious about this poetry thing. When it went from being something I vaguely did and vaguely wanted to do to something I was really going to put energy into because it mattered. It matters.

Why on earth do that? There are the bad ones. So, so, so many bad ones. (The impulses and ideas for “bad poetry” are still there – I’m just better at self-censoring (we all learn to do this) and don’t write them down). But things are resurrectable – lines, ideas. Two of my recent poems, turned in for workshop, were resurrected – and severely edited – from pieces that are, respectively, 9 and a half and 7 years old. They’ve changed – they are something, now, maybe – but the raw material is that old. It needed time and maturity.

So that’s why. There are things there that I just didn’t understand, before.

Reading this – yes, cringe-worthy at times, but actually less than you might believe – I have so much separation from most of the pieces (not all) that they almost feel as if someone else wrote them, as if I’m reading them for the first time, with only a vague memory – is useful. One of the poems – the nine-and-a-half-year-old – has been stuck in my head for many months. Just a few lines. And that meant something. That’s why I had to find it.

Senior year of college, there was a line that was persistent, pestering all year. I tried to write poems with it. So many poems. And nothing worked. All were “bad.”

In the end, that line happened to be the title of my thesis.

That happened another time (another memorable time – but many, many more times – this was before I understood and had experienced the phenomenon frequently). A line came to me – I had no idea what it was, where it came from, or what it meant. But I knew it was “something” and that I had to write it down. I did. Turns out that it was the title of a piece I wrote three months later. Not on purpose. It was after I wrote the piece that I realized what the title was.

And thus Jack Spicer’s Martians (for the morbidly curious, it’s from the Vancouver lectures (starts in #1, but here's #3 - http://jacketmagazine.com/07/spicer-lect3main.html – or, in brief, http://www.poetryfoundation.org/harriet/2008/07/taking-dictation-from-a-martian-muse/ ). Others call them muses. Martians feels more appropriate, to me.

It’s reading these that I realize I am a poet, that there’s never been a choice, there isn’t one, and that taking time from med school for an MFA was, well, not really a choice, either. The MPH? Yes, later. But I can – and do – work on public health in the meantime (7 years, now. Much like that second poem, above). I’ll now be ‘working’ in some capacity with the Department of Public Health now. Fine.

I know many, many people who understand my love, my passions for medicine, and how integral that has become. Ditto public health.

Poetry? Harder to find them. And I have.
(Another commonality? We all hate Shel Silverstein and Jack Prelutsky. The "classic" children's "poets." Hate. Always did. This was a discussion the other night - Dr Seuss is a better poet. Certainly).

The poem from second grade:

“The moon holds a beauty within itself. That beauty is called silence.”

A more recent line*?

“The silence is palpable; I’m not.”

*completely unrelated to the project of resurrection. Interesting only in having some relationship, maybe. And in calling both "poetry" though they don't "sound like poetry." Education, too, is dangerous. Some types and some things in it. Powerful stuff. And the first doesn't have an "I", and the second has "I" as speaker - the delicate separations we make, earned or not. "I" could be the moon (really, too obvious an image for 'poetry', unless done well), or...whatever else. I just thought this was interesting. Curious. And anyone can certainly think that both/either are terrible lines.

It’s never been a choice. I don’t think anyone is a poet – not a “real” one – because they want to be. Want to hone, yes. Want to really work on and devote time to, yes. Perhaps this is reductionist, but you don't "become" a poet - you are or you aren't (apologies to some), and you can become a better poet, much. I wonder this while looking at the $#*%^ turned in as my portfolio for my first workshop - I got in on that?? There must have been something. A few lines.
And there are ways to write - read poetry. Go to readings. Be in workshops and around other poets. But the 'discipline' of poetry is different that that of fiction, I think. And others - you can choose to be a journalist. You can choose to be many things - and you can be a good writer, certainly, and you can work on that.
Realize the necessity, yes.

But no one chooses to be a poet.

I wouldn’t have.

And last week I went to the ER (the next story) to shadow for a shift (no longer covered by malpractice, I can’t do anything hands on – it’s frustrating, in a sense, because it feels like many steps back). And yet – I read EKGs, I read head CTs, I helped do differentials and diagnose, I looked up criteria for admission, I saw physical exam findings and talked to patients and thought about things – I saw a stroke code (and could anticipate the exam and what would be done), I saw an intraventricular shunt placed to relieve pressure from hydrocephalus from a hemorrhagic stroke (i.e. – yes – the neurosurgeon bored a hole into a woman’s head and put a drain in it, and things came out. A little brain matter? How not?)

All of this was rejuvenating and invigorating and exuberant and the time passed more quickly than time has in a long time. Similarly to the alone-work of a poem for late, late hours.

Reading an EKG as reading a line. Thinking through how to put things together. How to get to somewhere. And the unbelievable, incredible nature of medicine.

That too is no longer an option.

Many people want to be doctors, initially – and maybe they don’t, for various reasons, because they didn’t understand what that actually means, the pre-work, the study, and then the work. And some do and become disillusioned. Others don’t and wish they had. Others do and it’s the absolutely perfect, right choice. Is it a choice? In some senses. I chose it – at least, I thought I did. Perhaps that’s not quite how it happened.

I didn’t choose to be a poet.

But no one asked me.

~j

***Addendum: in relation to this: my poet-cohort has sent emails to our workshop teacher entitled "Poets hate Labor Day" and "Poets hate Columbus Day." Both holidays have meant missing (Monday evening) workshops - which isn't okay.

The Imposter

2011-09-13T19:52:00.003+01:00

17 August 2011

For several reasons, I wrote this approximately 3 weeks ago, but I haven't been able to post it until now. To be read in the context of mid-to-late August. I'll write soon about the up-to-present. And how I saw the writer from "Stahnding Room Only" (February) again last week.

After a job interview, my new boss suggested I check out St. John the Divine. “Have you been there?” “No .” “It’s the largest cathedral in North America.”

I walked up Amsterdam to 110th . I like cathedrals – it’s a place to commune, to be quiet. I like the stone and cold, windows and dark light. In Paris, it’s Notre Dame (however clichéd) and everywhere else. Here, it’s…

I went in, similar feeling, similar, except not nearly as cold. Quiet. Leaving, I walked up the street to discover more of my new New York. Next to the cathedral, there is a hospital. Pause. Ridiculous – no – nothing to do there – to see whom?

Pause, but there's a small pull and I walk towards the main entrance. It’s unfamiliar (but I’ve worked in 7). It’s private (never done that) and there’s a guard at the desk.

I was planning to try the Hungarian Pastry shop – almost everyone I’ve met has mentioned it, in a week and a half. So many writers have written books there, they said. Covers on the wall. Except – there is a hospital. And if the cafeteria’s anything like that at my home hospitals (ie, tables, chairs, space, half-decent coffee at times) – that’s where I could write a book, too.

I’m not dressed for it. Yes, I was at a job interview, but it’s hot, I’m wearing flip-flops – though, the rest, I have worn to work in pieces. The Cameroonian skirt. Etc.

There is a guard. He asks me “what floor?” and I answer lamely, pointing in the wrong direction, “the gift shop.” (having forgotten my initial coffee idea. It looks alien in here).

I pass people in scrubs – some in the green ones that are my favorites. The yellow cord on that woman means size small. Someone passes me in a white coat. I gravitate. They don’t know I belong.

When I returned from 2 Peace Corps years in Cameroon, I would see groups of West Africans on the street (yes, I can usually tell), in subways, hear African French spoken, see West African clothes, and feel I belonged over there. Once, I chased a woman through a train station to tell her I had a dress of the same women’s day cloth (the bright pink one).

If I dress like that, it’s a little clearer. Or on bush taxis with strangers speaking Bulu, I could surprise and make everyone laugh when I suddenly joined the conversation. Yep, ma wok. I understand. To me: “Ma nye wo!” My reply: “Ma vini wo.” (I love you!/ I hate you. Always good for a laugh). Or…the “marry-mes” (forgetting the Bulu words right now). Me: “Teke djom!” (Never!) Really, anything I said in Bulu was great for laughs. The mintangen (white woman) speaks Bulu! (some, and diminishing).

Back in the States, it was easy enough to blend with Americans (any color) except it felt false. I could look like a visitor at this hospital where I have no patients. They don’t know me. I’m posing.

In my hospitals, no white coat on, hasty ID still in the bag where the iPod earbuds have just disappeared, everyone knows I work there. We’re all obvious to each other and to everyone else. Ownership? Boredom? Concentration? Walking down the hall, checking email, entering stairwells (especially that) without once looking down? We walk faster. We are not, in general, crying (later). We carry no presents, no balloons. And especially in this county hospital (true), we dress differently (it is a level one trauma center, so those patients are undifferentiated – the patient with purposefully (expensive) distressed jeans stood out).

I walked out. I wished I was wearing scrubs, maybe. It’s close to 3 weeks since I’ve been a med student (I’m ____, one of the (a?) student doctors here) (have I forgotten my opening line?) and my stethoscope is on the wall in my apartment. Not stuffed in a bag. Swinging, swinging, swung around my neck. Nameplate facing out. It looks lonely, awkward. It’s only supposed to hang like that on a neck, my neck, and it twists. A stethoscope is never static.

From October 2008 to August 2011, the longest I ever went without seeing patients was 2 weeks.Usually one, usually 3 days. And for a year and a half, five to twelve patients a day, every day. Sometimes for 12 days stretches (or 30 hours). And after this, for the rest of my working life. Same-same.

In the tradition of William Carlos Williams (the one everyone cites to me), I am a poet. “Somewhat writer,” I say. And I only claimed that after the first check came. (First one? $6. But I kept it because in the memo section of this university-generated check is typed “Writer”).

Almost doctor (and I only claim that because, logistically, I have 6 months of classes – by which I mean mostly hospital work – left to graduate). And here I am, many, many miles from the city that’s become home and the hospitals that are home (people, places, patients. In a recent dream, the trope of someone intruding on me at home? Me, scrubs, hospital, waiting for an interminable elevator).

I’m an imposter non-med student, MFA student, and I could walk into a hospital in my scrubs and white coast (both made the packing list) – but I wouldn’t know where to go. No team and no patients. To people who run writing series, lit mags, are published-published-published, I, 7 years out from a literature class (or analysis), very under-read/educated by comparison, published only in lit mags-for-medicine, not knowing poets or literary movements or presses, am going to say I can keep up and have something to contribute? Doctor with a writing hobby? Writer with a doctor hobby? My college degree is in both, I defended a thesis in both, but MD will always precede MFA on the name badge, and I have fewer class hours in a week that I worked in a day. In a city I don’t live in, without any of my hospitals, I’m supposed to sit in cafés and – except for when I’m tutoring med and pre-med students (the aforementioned “job”), writing is not what I do between notecards and medical references. The journal, the poetry book are not what I add to what I carry. They are what’s supposed to be there, this is what I’m paying tuition to do and to learn, and no one expects me to pre-round at 5 and be prepared for rapid fire presentations and invective.

I don’t know what they want or what I can give. This school isn’t a job (paying for the privilege to work, guild system, hierarchy, etc). I call most of my hospital attending by first name anyway, but these poets aren’t doctors (and what, then, is acceptable formal address? Mr/Ms? Seriously?? They’re not all professors). People used to doubt I’d go back to finish med school after this. “I’m more than halfway,” I’d say. “I have to have something to write about.” “Besides, I can’t be a poet with med student-sized debt.” (the joke). It used to annoy me, the: oh, so you write about medicine? Well, when some weeks, months, all of my waking hours except 4 are spent at the hospital, what else might I much write about?

And now?

17 days out and I consider communing in hospitals.

This imposter – Franco-American and bilingual, bi-passported, with Cameroon considered a home, grad school nested in grad school, keys for houses in two very different cities on my key chain –

will try to learn to pass.

The title is a lie.

2011-08-29T06:41:00.005+01:00

(to follow)

There is literally nothing that did not happen today.

I spoke with a friend in Cameroun.

I found out that the research article section I wrote is, in fact, good, even with the inclusion of some writerliness.

I went to a county hospital, participated in infectious disease rounds; spoke with HIV doctors and people working in public health in Africa and people teaching about narrative medicine.

And then I went to a poetry reading with a new poet friend and we went out with one of the readers and all her writer friends after.

Dizzy.

I was in three of my major communities – Peace Corps/Cameroon/public health, medicine, and poetry.

And only in the third did I feel intimidated and like an outsider with little to say or knowledge of how to interact.

I carried a white coat to the poetry reading in my doctor bag. I wore Cameroonian clothes. I had my med student ID. Just in case. It’s next to the MFA student one. I wrote new poems on the subway. I’m better at that than reading in transit.

At the hospital, not-quite-just-a-visitor and not-quite-a-student, I asked, “should I masquerade?”

Meaning, wear white coat + ID, even bring stethoscope, to show I belonged. Walking along with the team, though, and dressed as I was, I didn’t look out of place. Comfortable, except I don’t know these hallways. Even the cafeteria was comfortable with that coffee-bad-in-a-particular-way. Going on my good things about this city list? Hospital food was cheaper; apple cost 35 cents rather than 75.

There, I know what I’m talking about. “Do you know Pharos?” in rounds, we were speaking of medical publications that incorporate literature. “I’m published in Pharos, actually.”

“Why do you still want to be a doctor, after this?” “Because it’s the best job in the world.” Nods. They know. They get it, too. There is no other reason to work so hard and not sleep.

I was remembering the antibiotics – I knew, I knew, I took notes, I thought of the antibiotics cards I needed…and I still haven’t done the poetry homework for first workshop, the explication of the long poem.

This hospital is four stops from MFA school on the same line. Convenient. In any kind of metaphor, MFA school is the last stop on this line.

Three worlds and drinks at night with the one I’m least comfortable, have the least to say and interact the least – but 3 writers* – THREE! – were mentioned whom I know, personally, including my mentor and two I met last summer. I have signed copies of the books we discussed; I’ve read all of one of them.

*Promoting poets, the three are: Olga Broumas, college mentor and leading/initial writer in Calyx, Ross Gay, over whose poetry book I actually met a friend, last year, and Bhanu Kapil, whose work is indescribable.

I should see it like medicine. I was asked to teach a class on Whitman’s Brooklyn poems – I’ve barely read Whitman, and I certainly didn’t know he was from Brooklyn. The professor asked me to teach that day as the poetry “expert.” So, just like in medicine, I pretend to know. I’ll learn. See one-do one-teach one. See one-do one-teach one.

Medicine feels appropriately fast. In my head space, I am thinking through the body. Where are the offenders, the intruders, and who could they be? How do we find the intruders, how do we get to them, and how to eradicate them, and how do we make the patient better? Better.

In rounds at the hospital, this hospital, where I’m not a student, I take notes, whether I will need them or not. I’m remembering, I’m thinking, I’m trying to keep up and realizing how much in just these few weeks has moved to the back of my brain. Maybe that’s why we work so many hours in a row.

So there is poetry homework. I did buy the book, early, and I identified the poem and counted the pages. A poem to dissect, to explicate* (one of my favorite words). Can I approach with a differential? It’s a scalpel, I say. I call this. “Approach words with a scalpel.” (line poached from my poem).

*Explaining a poem. It is like dissection – the nerves/arteries/veins/lymph channels (NAVL we say for the femoral triangle), where they are in relation to each other and how they work together and what that means. What is the brachial plexus of the poem and what-leads-to-what and how; this is also the derivation and the allusions. What nerves mix to create what other nerves, and where do they go. We don’t make up dances or mnemonics for that in poetry, though. Unless it’s formal poetry and you’re talking about meter or shapes or rhyme schemes – each dance is different. A little different. And each author’s dances are related to each other, somehow, and the thread might be the voice.

It’s false. Everything I’ve said, this title, is false. I’ve been approaching scalpels with words. My MFA applications? About how I see medicine. How medicine is like poetry.

I wrote, I explained, I sold why-should-a-doctor-be-a-poet. Why, then, should a poet be a doctor? It’s why, perhaps, they want me here. Whatever that is.

I’ve approached scalpels with words.

I brought the poet’s eye, hand to medicine. And somewhere along the line, my old explanation ceased to be true. No.

“I’m a writer. Medicine is what I do.”

“Doctor” is who I am, too. Will be. Were I staying, I’d be applying for residency right now. And it’s not a brainwashing or mind-melding or beating-into-shape transformation.

Writing, neither, is not my “hobby.” I hear that a lot.

But up until now, for the past several years, I’ve been learning about scalpels and approaching them with words.

Writer and a doctor.

Now is the time to approach words with a scalpel. To learn why that’s a good thing (assuming it is). The doctor will graduate more balanced – words with a scalpel with words.

And there’s a white coat in my doctor bag and two poetry books and notebooks, one of which has medical lecture notes – all that’s missing to make this “normal” is a stethoscope, many more than the one highlighter, and some papers. These have gone together for awhile. There is poetry inside the white coat at times. Maybe I should wear it to write. Maybe I should wear it to teach poetry, wear it to readings, and be subversive – there, it won’t represent the hierarchy it does in the hospital. In the hospital where I don’t like to wear it for reasons other than practical pockets. It represents who I am. Maybe the stethoscope would be easier to carry.

On the subway on the way to my first day on poet-campus, I considered bringing JAMA to read. For med school, I often had poetry with me. Close to always. Novels. I brought a poetry book(s) for boards – totems of good luck, things of balance. To my first workshop in college, I brought what was, at the time, my favorite book of poetry. You didn’t know until you arrived at the door if you had made it in. We had turned in the pieces – applications – the week before. I didn’t expect to get in. If I didn’t, the reasoning went, I would still and always have poetry.

And then I got in.

The first poem read in that first workshop – it’s Li-Young Lee’s “Words for Worry” – became my touchstone, after that. I started a reading I did with that one. I’ve started workshops I’ve run with that one. Any poetry class I teach should begin with that poem. (http://www.youtube.com/watch?v=ILPbJHqEXu8)

So JAMA on the way to poetry school for balance? Maybe it should have been. Instead, the compromise, I read a book of ‘psychological poems’ – by providers and patients.

That’s where I belong. And today I wrote in the hospital.

I’m not the writer who graduated with dual degrees and dual theses in college. I’m not the writer who returned from Peace Corps. I’m the writer whose signature has not degenerated, per se, but is often accompanied with an identifying code and a pager number. I’m the writer who uses abbreviations and bullet points in the hopes that maybe notes will be easier for others to read. And shorter for her to write. There are so many…

I’m the writer who could have been, would be, a doctor in less than a year. Who’s still trying to work on having thorough differentials with a consistent approach. A flow to the physical exam. To work with patients. To presentations. Conciseness. Meaning. What is said and what isn’t said.

That’s what poetry brought to medicine.

Now medicine brings to poetry not-just-subject-matter. I don’t know what else that will mean, yet.

Use it.

Use everything.

The Mental Status Exam and obsolete ethernet cables

2011-08-21T21:59:00.000+01:00

I’ve written the neuro exam, the respiratory exam, the cardiac exam? (not yet) – what else. Pelvic exam will certainly deserve something. Anything that intimate. Eye exam (except I’m not good at it/we don’t really learn a good one, in med school). Musculoskeletal could be interesting.

Dermatologic, again, we don’t really learn, but that sort of scrutiny to the outside might be the most similar to psychiatry’s scrutiny of outside-to-inside-to-outside.

It’s applicable to anything. In psychiatry, actually, I did a presentation on the mental status exam and interpreting poetry – poetry I blurred on the projector screen so that you couldn’t read the words.

Mental status includes action, includes movement and speech and anything that indicates internal state in externalization.

I spend a lot of time, lately, searching for wi-fi.

Crossing into Chad

We haven’t installed it at home yet (new apartment, new city, new life as a writer-med student rather than med student-writer), and so we’re stealing – pirating – where we can. There’s one network that’s usually close enough for us to get onto (have they realized? How much slower has it become for the mysterious Them?)

It’s available at different points in different parts of the house. If that makes any sense – but there is a distance from the invisible (waves I don’t understand) that makes it easier and harder – and the distance is about 20 feet. There is, most of the time, a cloak or shield around my room. I don’t have it. And rather than take that as a sign that I should be doing other things, I should be reading, or I should be writing other-than-emails.

Instead, I search. I go look for it. I move around.

I’ve been back too long.

My frame of reference for frustration in Cameroon:

The summer prior to leaving, I was frustrated when our wireless internet wasn’t working and I had to go downstairs to plug in my computer.

A few months later I didn’t care if there was power, I’d rather it stayed off than dimming the bulbs (yes, there, it can be cut by what seems like half) and flashing in and out.

I’ve been back too long.

(I’ve said this, I know). But there is cell service in the village, now. In Mvangan. I’ve gotten calls in the middle of the hospital from friends in village – things I can’t explain about how I can’t talk at work, I’m with a patient, I’m in the hallway, and I can run into the stairwell but I can’t stay for too long and I can’t really shout and if I’m heading into the elevator I’ll lose connection. Or have to cut it off.

I wonder how frustrated they get with me. And because I have to Skype I have to count the hours, be at home, and remember. And my excuse now for not answering the phone calls upon phone calls (it’s biping, for the most part – call and hang up so the other person sees the number and calls you back).

Because there isn’t always internet.

In Cameroon, they can call me. For me to call – money less of an issue on this side – there are many, many other factors.

It’s the logistics here that are more complicated, and that’s what I have the most difficulty with. Logistics. Dealing with such. And having intermittent internet. Being in a large city in the United States, naturally, it’s easy enough to wander to a nearby café with free internet. Sit for hours with a table and a mug in the style (is it really first from Friends?) And even from there, it wouldn’t be couth to have a loud (necessarily, it’s both Skype and a phone call across sometimes-hesitant network to Africa).

I’m pirating and it’s more difficult to communicate. Or that’s an excuse.

In psychiatry, everything is relevant.

(Even this)

Cacao drying, Mvangan

One of the interesting – and difficult – things to learn, in the beginning, was that in an hour you can speak with two patients who are very anxious. One is afraid of a recurrent heart attack, a recurrent theft, an attack, a nightmare.

The other can’t access wireless internet and feels disconnected from the entire world* (yes, without ‘smart’ phone or 2/3/4 G).

*Not actually the case. Though, anyone who knows me does know that I don’t have an internet-capable phone.*

Another (perhaps relevant) point is that, when too tied to internet/devices and searching for internet/devices, you forget to pay attention. Attention to detail. To listen to everything around you – we block things out with headphones and ear buds (how much more intimately invasive can you get than actually blocking the ear canal directly?) Loud noises that drown out less loud ones. Right now, as I write, I’m periodically checking to see if I can access Wi-fi. If I could, would I be periodically checking email? Likely.

I had learned at one point to turn off the internet capability of the computer in order to really write. Editing poetry is generally long-hand, on paper, with red pens and a paper thesaurus. That helps with the concentration. And typing that is stream of thought, something moving forward, at any rate, so I’m less likely to multi-task in the middle. (And this, compared to any sort of essay or assignment, is stream-of-consciousness and directed thought. And yet. I’m still searching for internet. I’ve moved to the part of the apartment where I’m more likely to find it…are they onto us? Are we cut off???)

The mental status exam, like writing poetry, is about using every sense.

Appearance.

The patient might say he doesn’t drink, ever. Or hasn’t had a drink in two weeks. Your sense of smell gives you a different answer. Write it down .

We classify each other into subtypes – the ones most discussed in my life, currently, being hipster and hippie. High school was goth. Emo. Etc. These change, generationally. And they don’t at all. Incredible how people, even, are tropes. Would that be a shortcut to describing appearance? And how do you describe so that someone can listen to your presentation, someone can pick up your note and see the patient, exactly? A psychiatrist, any doctor, should be a writer. Is.

Behavior.

Who’s actually calm, these days? Behavior is being constantly connected. Behavior is what’s on your facebook status, gchat status (previously AIM – someone recently said I was betraying my age when I admitted to having an ICQ account, long ago). Behavior is having to tell people where you are, when you are, how to find you, your GPS coordinates, what you’re reading, where you’ve been, and who you know. I remember the Kevin Bacon game (preceding or co-existing with the advent of IMDB?) We do it to each other now, and not celebrities.

Behavior is voyeuristic. (Photos of people you haven’t spoken to in a decade? What, really, is the curiosity, and why is that what becomes part of the procrastination routine? (admitted)). Finding out how friends are connected to friends of yours, from other parts of your life – connections necessary to know for curiosity? This is how the world is real. There are few people who do not, to some degree, know each other. Whatever knowledge is, now. Behavior is having to be online to work and thus being online for everything else. What’s “productive” and what’s not.

And because I am in a coffee shop – and I spent at least 15 minutes trying to troubleshoot why the internet was, initially, not working, though I mostly don’t need it – and because this is procrastination from working on a research article – and because this sort of rambling, this sort of unedited diatribe, is common in the self-promoting, self-actualizing world of blogging and online conversations without punctuation other than key returns becomes unbearably long – I will continue the mental status exam later.

Attention to detail. Attention to length. Attention to the icon on the bottom of the screen that, moused over, declares both local and internet connection. The shiny blue circle over the superimposed monitors, on my computer, looks like a little world of oceans.

The Procedure

2011-08-16T15:47:00.003+01:00

(This was written several weeks ago – refers to all month of July)

Today I used sound waves and a plastic transducer to take moving photos of a fetus-squiggle. I was outside, it was inside, and now it doesn’t take long for me to find the uterus, to see the black-filled-collapsible bladder on top of the double-stripe collapsible uterus that now, in pregnancy, isn’t so collapsible (potential space). The black-fill is water, and there’s a tiny yolk sac (depending) and there’s a little squiggle (this early). And it turns and turns and turns on a stalk, and I have to move, patient, to capture it. Length-wise. Freeze. I measure. My machine converts that to weeks.

And I print the photo, attach it to the woman’s chart on which I’ve written LMP/Gs and Ps/prior c-section or surgery. Bleeding or pain? Prior ultrasound?

I’ve filled in provider (the attending), the clinic, the date, and the patient’s name, DOB, medical record number are stamped at the top of the carbon-copy page. White copy on top.

I write in the length I found (if it’s first trimester-early, it’s crown-rump length - descriptive, no?) and I write it in mm and I write the gestational age.

I mark: + IUP. + FCM

Single, intra-uterine pregnancy

Fetal cardiac motion

Under “reason for exam” I write “dating – undesired pregnancy.”

Every day for the past month I have been working in an abortion clinic.

And three days a week for the past 4 weeks I have done abortions – yes, I, at least once on each of those days. And at times more (depending on patients – can the student doctor do it? Yes/no. Would I let me, if I were the patient? Yes/no).

On the other two days, I’ve been helping to prepare for other abortions.

These are TABs or VIPs – Termination-abortion (as opposed to SAB, Spontaneous-abortion, commonly known as miscarriage).

VIP. Voluntary Interruption of Pregnancy.

This is not a treatise on abortion. This is not political. This, simply, is.

***

I’ve been working in an abortion clinic – it’s part of my education. It’s my fourth year, now, so I chose this. I chose to work here. A clinic in a large-liberal city in the United States. Where we are, at this clinic, we don’t have to deal with protesters or laws forcing doctors to do things doctors shouldn’t have to do or say. Legalities interfering in even the conversation of the doctor-patient relationship.

There are legalities in every part of medicine. We learn medico-legal speak. We learn what to write, what not to write. How to cover yourself and everyone else.

And for billing purposes, I write “undesired pregnancy.” That is the reason for the ultrasound.

And I do ultrasounds.

***

It doesn’t matter what the stories are; I don’t need to tell them.

My patients have been mothers of 3, high school students, animal trainers, women with master’s degrees (spoke 5 languages) now "without a home; if I have one more child my family is going to ...." Another, talking on the phone to get furniture delivered and 4 kids picked up from school… taking a day off from school + 2 jobs.

Twenty, three kids, here on a bus alone (can’t tell anyone at home), wandering around all night..and that’s why she showed up so early, and why I didn’t want to let her into the clinic, yet, when I was the only one there (protocols? Liability? Who knows. Or my laziness and wanting to finish breakfast, studying, and work for the day before anyone came in whom I had to talk to).

then the other one whose entire family lives on the same street

or the one with a two year old and a six month old – she’s 18.

or the one whose mother is there to hold her hand

or the one whose partner is pacing, anxious, in the outside waiting room

or the one whose social work/case manager is the one in the clinic, in the ultrasound, in the procedure, holding her hand

it was a different one who came from the psychiatry floor

it was a different one and a different one and another one who didn’t know she was pregnant

it was another one who had had to cancel three appointments – mother-in-law sick, died, funeral, then she was sick, then something else happened… but today, she had a day off, and she could do it.

(same for another, who luckily didn’t have to miss one of her summer school class days).

This is what keeps my day and my job alive, vibrant, constant, and me invested in what I’m doing with fresh (tired, tired, tired, red) eyes and hands, again.

Otherwise, it doesn’t matter.

Some are there for fetal anomalies (abnormalities? wide, wide range), chromosomal abnormalities (from amniocentesis; some, we know exactly what they mean – Down’s syndrome, etc. Others, it’s not clear, exactly, just clear it would be bad. Bad). Fetal demise (died inside. Didn’t come out. Could be an incomplete miscarriage, could be…whatever. Something happened. And something inside is dead and has to come out). And then there is every other imaginable reason.

But it doesn’t matter, does it.

***

As a future physician who will specialize in HIV/infectious disease, I shouldn't feel differently about my patients with AIDS-by-blood-transfusion or AIDS-by-heroin-shooting-up. (But are the babies different? Yes...) Health care worker? (yes, I identify more here). Unprotected sex, bad luck, the traditional birth attendant in Cameroon, the wife of the husband who was with the teenager and all those other ones...man in the same situation. Teenager (young). Before HIV was known about and how to protect from it. After.

The medical treatment is the same. The clinical treatment, patient in the clinic, my patient in front of me, should be the same in that moment. I'd like to hope that one-to-one, ceteris paribus, it will all be the same.

But it doesn't matter, does it. The how or the who.

If I feel differently about the ones with anomalies or chromosomal abnormalities

If I feel differently about the fetuses that were absolutely desired pregnancies but, for some reason, the pregnancy can’t be continued – health, health, dying, fetus dead, health .

But no one’s happy to be here.

No.

The staff are happy to be in this amazing clinic, to be working together, doing this work, helping – counseling for psychosocial, support where there might not be any other in this woman’s life. Doing something small. Having a positive impact. And in this clinic, at least, family planning and contraceptive options are a big, big part of the counseling. Looking toward the future. No one actually wants to do this again - the providers don't want to see the same patients again. The patients don't want to be here again.

No one is happy to be having or doing an abortion. That's not the word.

Nothing is easy about this. In the beginning, it felt different – believing in, supporting abortion rights – and being the one who performs it. Is it? If I weren't in medicine and had the same socioeconomicpoliticalhealthcare views, I wouldn't be on the side with the hands-in-gloves, the mask on, concentrating on the procedure.

But I am in medicine, I want to be in medicine, and that's part of the views, anyway. Getting to enact - getting to be part of extending health care, of making that a more positive experience for people who might not have those in a power structure. Respect. Just...being there. Like Peace Corps. Being there with whatever skills you have, working to learn as much as possible, always learning, and working because you care so much about it and about what you're doing. Lucky to get to do that. Lucky to be there, on this side. And that's all.

***

Before I started medical school, there was one procedure I was looking forward to learning:

This one.

I didn’t want to be a surgeon; I wasn’t looking forward to learning about appendectomies or heart transplants or venous grafts. I had no conception, yet, of so many of the things I would come to love in medicine. I didn’t know.

This, though – I knew. It had nothing to do with the procedure itself. This is, again, the privilege of medicine to me – and the responsibility, or what I feel it as. I’ve worked in places where abortion is illegal (though I haven’t worked in any of those places in the US, where everything is an unbelievable barrier). I’ve seen the sequelae, actually, a few times. And I’ve read about it (who hasn’t?), even back to my John Irving days and The Cider House Rules (book. better than movie). I wanted to be able to provide safe abortions. Safe. I wanted to learn how to do that, not just a safe procedure but a safe space to come for it. I want to fill in the gaps, in medicine. The things where there aren’t enough people (just need to be filled) or any at all.

Here’s a gap, to me. It’s a place I can fit.

Nothing is easy about this, and I don’t think it ever will be.

Nothing is easy about this. I'm learning. I'm going to keep learning. The skills will build. It won't be easy.

The Luckiest

2011-08-04T06:29:00.001+01:00

It’s said in many ways.

Absence makes the heart grow fonder.

Nostalgia in looking back.

Selective memory.

And, per Ben Folds, “The Luckiest.”

This usually refers to, I think, people/place/thing. Certainly people. Certainly place. Time period. Self at a different stage of life.

It’s not usually used in reference to career.

It’s now been three days since I was an active medical student.

And I miss it. A significant lot.

I can’t wait to be a doctor.

Kribi, Cameroun

Before I started med school, I couldn’t believe how lucky I was to get to go to medical school. I’ve had a lot of privilege in my life. This is one of the greatest, most amazing, most incredulous ones.

What I’ve done, what I’m doing, what I will be doing.

I was let into this hallowed profession – in some places, hallowed, darkened halls – in which I get to learn all about the body. Get to. And I get to interact with people in the most intimate way, at their most vulnerable – they trust me, let me in. I have to earn that trust.

Starting, and before starting, I didn’t understand that sacred trust. It’s something I continue to learn, every day. And I am amazed.

After a day with patients, last week – any day – I left the hospital exhilarated. Exhausted. Beaten down, burnt out at times. But exhilarated.

I will have no days this amazing as a writer. Or as anything else.

I am unbelievably, incredibly lucky. I get to do this. They let me in.

When I graduate from medical school, I will have been thinking about becoming a doctor for about 17 years.

I am the luckiest.

When I hear about people studying for the MCAT, my first question – reaction – is why. It’s partly that I’m still not sure if I would do this again; there are other things I could have been very happy doing, and I wouldn’t have known, exactly, what becoming a physician means. Why. This is too damn hard if you don’t love it. Too hard. Not worth it. Become a lawyer, go into business, science, anything, anything, anything that is intellectually challenging/prestigious/hard/will make you money. Whatever the motivation is. This is too much work if you don’t love what you’re doing.

Perhaps I’m already nostalgic, but that’s why it’s important to write this now – so I remember, have it to read again, on the inevitable terrible days and nights.

I get to be a physician. I get to have patients.

When doing procedures that are uncomfortable/ painful. . . I give patients license to do whatever they want. Whatever helps, I say. Swearing. Call me names, I say – it’s nothing I haven’t heard before. And it won’t hurt my feelings - promise. It’s definitely not personal. You can talk on the phone. Whatever. . . If I’m holding a patient’s hand during a procedure that someone else is performing, I joke about breaking my hand. Go ahead, I say.

The unbelievable, unbelievable, incredible privilege.

It began with cadavers.

No, before that. It began with getting in. Before that. The opportunity to do pre-med at a ‘very good’ university, with a lot of support, and enough liberty to really have time to focus on classes. Which goes back to high school, etc.

I was in the school bookstore today and I almost started tearing up, looking at the stethoscopes. Mine is coming with me to writing school. It’s part of me, at this point – it’s an extension of my ears, another way to augment my senses. And it hangs so naturally around my neck that I once picked up someone else’s stethoscope – same color – thinking it was mine, and didn’t notice I was wearing two until someone pointed it out.

I get to have a stethoscope. Mine. I get to listen to the inside of the body. And with this training, I learn to interpret what I hear. Sounds and silences. The natural unwinding of this caduceus. At one point, I thought I’d lost it – left it in a clinic, somewhere. (I know people who have lost them/had them stolen). And it wasn’t just the frustration/annoyance of having to spend money on another one.

It was the thought of losing mine. I can keep this one for the rest of my career. I’ve gotten to know it. In mine, there are still a few grains of sand around the bell from the time I put it in a bag I’d just taken to the beach…

If I don’t use it, as a writer, it’ll hang on the wall.

The early med students walk around in clean white coats (I remember being told that was how we were recognizable), and the stethoscopes look a little awkward. The scrubs are almost a status thing, at that point – a little bit in awe of getting to wear them. (Getting to). And now… well, nothing used in that context stays white, and bleach barely works. The stethoscope that I used to wind carefully into a little bag, the one my sphygmomanometer (blood pressure cuff) came in – now goes around my neck, winds into a pocket, gets dropped into my bag. It isn’t fragile. And it’s mine.

I get to be a doctor.

I can’t imagine any job as incredible as this one.

This morning, talking about this with a med school friend –I, starry-eyed, was waxing poetic. I know it. And I’m trying to not forget the hours of exhaustion, “scut” (busy + mundane + worse at times) work, being grilled on the spot and judged on absolutely everything you do in a day, subjectively. And being graded just on that. And test scores. I got into this business for my patients. I want to be a good doctor for my patients. That’s the point and it comes back to that, it should always come down to that.

No matter what else is going on in the day – getting yelled at by an attending for something out of your control that you had no idea about – you get to be alone in a room with a patient. I do. And there are the patients who scream and throw things (more often, on psychiatry). There are the patients whose affects are so disturbing that you really hope the drug test comes back positive, to give you an explanation…There are the patients perseverating on things you really don’t need to know about and you have limited time and the story isn’t making sense and they’re ranting about things in the clinic or the health care system or life in general that are out of your control but they’re somehow being put on you. . .

There’s that.

There isn’t anything that doesn’t happen.

There isn’t a person, or a “type” of person, who doesn’t get sick and need to go to the doctor at some point. (Or they show up in the county hospital ER, or they need primary care but are marginally housed. . .) Or needs primary care/preventative medicine, which is generally not covered at all.

In the room with a patient, I am focused on that patient, and – the point is what the point is. I want to be a good doctor for my patients. And that’s most of what I have to think about, in those moments. That’s what I’m doing.

And I do it every day. Now, it could be a dozen times in a day. Different people, different stories, different ways lives are affected by the exact same pathophysiologic disease. But I have to do something different. The treatment might be the same, the procedure might be the same, but the way in which I approach it, talk about it, take time explaining (or not, as patient preference dictates) changes. The way I sit. The way I talk. What I talk about. Tone, volume, rhythm, posture, eye contact/facial expression – it’s not an act, it’s a mirror, and it’s finding how to be what your patient needs in that moment. Learning how to do that. You’re not changing yourself – you’re accessing all of yourself in different ways. You use the patient’s language and metaphors.

And then there is the science, some of which is supposed to become second nature. Pattern recognition and understanding the underlying conditions, the physiology, what is going on in this body at this time.

I get to do all of this.

I am trusted by the physicians around me – my colleagues – and by my patients. I get to go in, alone, and do all of this. And it’s the trust on both sides that helps me need to do it right, or as “right” as I can with the training I have.

There are the times I’m frustrated with the thing (or the patient). The vein is rolling or they have no veins left… the cervix is wayyy anterior and it’s hard to find/access. The tonsils are large and obstructing the intubation. The heart sounds are muffled. The patient will not get the concept of taking a deep breath (“in through your mouth, out through your mouth). And I still have difficulty (a lot) finding the optic disk…

For now, I get to take time as a writer – a writer who misses medicine and patients and remains involved, in ways –

But I still can’t imagine a job as good as this one (perspective).

There are days I left my internal medicine clinic almost skipping across the parking lot. My patient’s blood pressure was better. Another one’s insomnia was improving. Another was seriously keeping track of his blood sugars. Another brought his three-year-old in to meet me (not all the same day).

My job. My future job, my future, and the present/future job of so many wonderful people I know. We – no, they – no, we – are going to be incredible doctors for these patients, because that’s the “why” in this privileged position.

Lucky, lucky patients?

Luckiest – us.

Kribi, Cameroun

Licensed to

2011-08-01T00:16:00.001+01:00

In James Bond terms, it’s a license to kill.

In philosophical terms, it’s a license to heal or to help live.

In pragmatic terms, it’s a DEA number and a way to bill and get reimbursed by insurance.

In French, license means bachelor's degree, and permis means license. Unspoken, assumed permission. Allowed.

A medical license – just a general one – requires five full days of testing, over 3-4 years.

A lot of time is spent studying – during school, after hours from the hospital. A lot of money goes into each part of the exam, from the question banks to the tests themselves, with the requisite nothing-but-the-ID-check-in and checks inside of your sleeves .

Eventually, 5 years after starting medical school, many more years after starting the process of getting into and moving toward medical school, you have a license.

On the most basic level, this allows you to prescribe – that’s helpful for your patients, your attending (who no longer have to cosign your scripts), and potentially for your friends and other loved ones. All it takes is your name and license number – the person you’re prescribing for’s name, birthday, and allergy-to-medications status, and any pharmacy will transcribe it over the phone .

But a medical license – and the steps to obtaining one – implies more than this sort of power (and responsibility).

Doctors can pronounce death – we learn to know when someone is dead, or alive, and to say it officially. Saying it makes it true.

Doctors can teach other doctors. There’s no teaching certificate required, here, but the way medical students, in the clinical years, and residents and fellows learn is by teaching each other. On down the food chain. The main source of information, actually, is the teaching on the wards. There’s no training in that.

Doctors can run businesses – what else do you call a medical practice? No business acumen or training required (technically, not optimally).

Doctors can work in public health without an MPH.

Doctors can get a loan for a house – even med students can, sometimes – while 100s of thousands in debt. “Future earnings potential” they call it, not taking into account whether your career choice within doctor-dom actually has much of that.

Doctors can run labs without having PhDs.

Doctors are more likely to get published as op-eds or letters to the editor – “MD” looks pretty official and officious, tagged onto whatever-name.

And doctors can tell patients to focus on self-care, sleep, the importance of healthy eating and exercise. Well, we do get exercise on a service that runs up and down the floors of the hospital. Even on one floor, you’re constantly dashing between rooms.

I don’t have a medical license. I have ½ or 2/3, depending on how you count it.

And I hurt people on a daily basis.

With license.

I hurt people, by which I mean I cause pain.”Discomfort.”

I don’t lie to patients. “Will it hurt?”

“Well, it’s not fun. It shouldn’t hurt, but it’s not comfortable. It’s different for everyone – you know, I had a patient the other week who was talking on the phone the whole time.” (Now I can count that as two . And I’m not even counting the texter).

I don’t lie to patients. The one who, somewhat suspiciously, asked “how old are you?” I told her. She’s three years older. And she decided to trust me – I can say I’ve done this (dozens) of times before, that I’ve only been in this clinic a few weeks, but before that, I was working other places (…in other areas, not doing this particular job, but I can hand-wave a little about that).

“How much longer do you have in school?”

In truth? Six months of coursework.

I like procedures. I like working with my hands, having those physical skills. And on this rotation, I did just a few procedures but many, many times. You can get good that way – or, closer to good. Pretty good. To the point that, at least, I can carry on a conversation the entire time, smoothly, while doing what I need to do.

One Filipina patient – her entire family lives on the same street (in the US). Everytime someone leaves, they buy up another house.

Another patient is a horse trainer and travels around to county fairs.

Another works as a security guard.

Another is majoring in environmental studies.

Another’s kids are at Disneyland.

The list continues. And this is what we talk about.

For some, it doesn’t help so much – but others are so distracted that they have no idea what I’m doing, and they’re surprised when I tell them I’m done.

We’re done. “Great job!” I say.

I say.

I tell them about books I’ve read, if they bring that up. If it’s a commonality, what I majored in, in college. If I lived where they do now, know the area. If my friend is moving there. That one of my patients lives on the same street as her entire family. For a Procedure, there’s a whole other set of shtick. “I swear, I think I spend half my day fighting with this lamp…” (it was actually somewhat true, but it made patients laugh). “Hopefully, this will be the longest part!” I say similar things about computers. Math, etc. The light self-deprecating humor works pretty well.

(My doctor self is really, really good at small talk).

“Do you like your job? Do you like doing this?”

“Yes, I do. But the part I don’t like is when it causes people pain.”

Person to person

2011-07-23T08:31:00.002+01:00

I got a patient’s blood on me the other day.

(not unusual)

A patient’s blood splashed in my face the other day.

(unusual)

A patient’s blood spattered over my face, little drops over my neck, cheeks, forehead, and one on the inside of my lip. That I felt – one. None in my eyes.

A patient’s blood spattered on me and her eyes were closed and she was concentrating so hard on her breathing that she didn’t notice I stopped, stopped the procedure. I stopped for a minute, maybe two, at most. More like 90 seconds.

Paused.

I stopped touching her when her blood spattered over my face.

There was a second year medical student in the room – she saw. I motioned her over to me. She grabbed a paper towel and started dabbing at my face, my neck. I gestured, half whispering, half mouthing the words without moving my lip – here. My mouth. Finally, she slipped the paper towel between my lips and the one blood spot, the one, might have been wiped off and gone. “Go check in the bathroom later,” she said. I was almost finished, so I finished the procedure, had the patient sit up and made sure she was okay, then I left the room. Walked, walked to the bathroom, rinsed my mouth, saw a few other spatters. Tiny, tiny red spots. I might not have noticed right away if I hadn’t known – someone who wasn’t right next to me might not have noticed. The debate then, was whether to tell anyone.

It wasn’t a needlestick.

And blood to skin…yes, mucous membrane, that one spot on my lip, but it’s not like I was bleeding, too, and had a cut there. None to my eyes. The risks of transmission of anything…

thinking, thinking, thinking. Nothing. Nothing that wasn’t curable and easy. And probably nothing.

I did. Tell. I told the charge nurse, she told me to call needlestick (“exposure”, it was. I had an exposure. I was exposed to a patient…). After a series of call-backs, call-back-laters, and why-are-you-calling-this-number-and-not-that-other-ones, I described what had happened.

I’m a med student and I’m interested in infectious diseases. I’ve studied/worked in HIV for almost 7 years. I know the risks, I know them, but I wanted to check I wasn’t being cavalier.

The woman on the line said the only thing she could have worried about being transmitted would be heptatitis B – but I’m not only vaccinated but immune, as proven for school. Anything else… HIV, hepatitis C being the major worries – was next to impossible. Next to, since nothing is.

We discussed testing the patient – she was coming back the next day, anyway, and we had no labs for her.

If it won’t change your clinical management, don’t do it.

We learn that. It’s rational.

Were she positive, would I go on PEP? (post-exposure prophylaxis for HIV, a month worth of antiretrovirals, making you retchingly, wretchedly tired and sick). No.

For Hep C, there’s nothing to be done anyway.

And anything else – well. Both close to zero possibility and curable.

(End Infection control and disease transmission lesson for the day) .

Universal precautions? Not applied universally. No one wears a mask for this.

We love to use the word “discomfort.” “This shouldn’t hurt, but it might be a little uncomfortable.” “Pressure… lots of pressure.” “Is that pain or pressure?”

(Discomfort: acutely feeling each drop, real (real) and maybe imagined, each spatter-point. Hyper-aware. Discomfort: the mask over my face, eyes, that alien-like barrier from the patient, frustrated with breathing, sometimes, and not fogging up the eyes).

What I used to consider a sort of torture instrument (tenaculum), I’ve used to manipulate with ease – and as much force as I can muster. It’s a clamp you put on the cervix to straighten out the uterus, essentially. In some techniques, you inject lidocaine first; in others, you don’t. Is the tenaculum-discomfort worse than the lidocaine injection-discomfort – should you just get it over with? With these procedures, it’s injection first, tenaculum second, and then two more injections for the paracervical block.

The tenaculum is there to help straighten out the uterus by pulling on the cervix, which makes it easier/safer to manipulate anything in there, instruments, etc. And if the patient isn’t flinching, I’m pulling. It’s my counter-traction. And I’m pulling hard.

If the patient isn’t flinching or saying anything to me or tensing her legs – she’s not feeling it. True? Yes, or at least, I’m not causing any additional discomfort. There are varying theories on this – do the block first and tenaculum second? Or just the tenaculum? Ie, pain of injection, anxiety of longer procedure, versus just pain of tenaculum and over more quickly?

The patient, the patient’s blood, the blood on me.

For this procedure (consider: tenaculum. This was a pelvic procedure, involving the cervix. It was frank blood, fresh bleeding, from something that I had caused – normal, normal, when any instruments touch it. It’s friable (delicate, in brief).

In Spanish, “cervix” is boca de la matriz. Mouth of the (mater, mother). In English, the opening of the cervix is the os. Latin for “mouth.” We could call it “mouth of the womb.”

Bright red bleeding per os, this was. Fresh from vessels I had micro-lacerated, in space, to me.

No one wears a mask for this. But there was blood pooling in the vault, in the fornices…

(in the next, or the next-next, I will describe what I was doing, why I was doing it, and what I’ve been doing this month. For now, the patient, and her blood).

On my ob/gyn rotation, third year, a patient’s blood spattered at me – but I was wearing glasses. I only knew later, taking them off, seeing the dried flecks on the glass. It was unusual for me to wear them. It was the first time there had been blood.

Another time (there are many times), a patient’s blood dripped onto my skirt. I was wearing red that day, luckily – and I don’t say this just for staining purposes, but because that way the patient didn’t do. I didn’t want her to – I never do with this. There’s no reason for them to feel badly about it. They apologize enough for having bodies and for reacting to things within and outside their bodies.

No apologies for what those bodies might do, might interact with me. I don’t tell them. Unless it’s a question of real disease transmission – a needle stick or way I really could have contracted something – they don’t need to. There’s no purpose – there’s no therapeutic purpose in them knowing. As long as they don’t see, I don’t say.

Patients apologize for the state of their bodies, for what they look like while sick (or well), for what they're wearing, for what they say in pain – in-between bouts of complaining (we say everything they say is complaining, and everything they say “no” to is denying) and yelling and sleeping and getting pain meds and getting off of pain meds and feeling better. I’ve had apologies after pain meds wear on, after patients feel they’ve been listened to, the next day, in clinic a few weeks later…

The patients who mutter under their breath, apologizing for the language they feel slips out uncontrollably while I’m doing some procedure that is quite uncomfortable – no apologies, I say, say or yell whatever you want. Call me whatever you want, I promise I’ve heard it before – and I won’t be offended. (True and true).

They apologize enough for having bodies.

We are holding you here

2011-07-03T00:47:00.003+01:00

Danger to self, Danger to others, Grave disability

For the past month, my patients have either been dying or seriously troubled. Or both.

These might be different sorts of dying.

This may be an introduction for stories to follow. There were more patient moments of transcendence, on palliative care. That’s next – what it means to be able to imagine a life for someone when you’ve never really met them before almost-death. There are the hours and hours and hours of stories, now. The Mental Status Exam – there’s another piece. Will be. But for now, by way of segue, and because the writing for the evening is meant to be five closely hand-written pages on my patient’s background, the factors that have contributed to her current situation, and an assessment and plan of what, in the hospital, we can do.

Cameroun, primate reserve/rehab near Yaounde

Now, I’m on psychiatry at the county hospital. This is exactly the sort of hospital where I want to work – underinsured, uninsured, every problem is more complex than medicine and medications. It’s not about thinking you’re saving anyone, at all – it’s math. There aren’t enough doctors working with these patients. Patients with more insurance, patients with more money, patients with fancy papers and jobs and luck at some level – they have doctors. Math. Simple.

So this is where I’ll be. I’m learning, everyday, what it means to be a doctor. What it will mean. And there are the practical issues like having to clear the pages from my pager, sometimes several times in a day. (Disbelief, the first day that happened. That’s what happens to residents) . Being first call for a patient – this is what that means. Any issues, I get called. By everyone.

It’s about teams – trite, maybe, but true. At the university, tertiary care hospital where I was for palliative care and pediatrics – teams might be like the Congestive Heart Failure Team, the Liver Transplant Team, the Restrictive Lung Diseases team. I had no idea how deeply you could specialize. Patients may have multiple failing organs plus a rare rheumatologic disease and a mitochondrial disease and something neurologic going on. Presenting with an endocrine problem. (For one of my patients in pediatrics, the team coordination I had to do literally consisted of pediatrics, child neurology, child endocrinology, molecular genetics, and then psychiatry) . Not uncommon.

Here? One team consists of ENT (ear-nose-throat) surgeons + psychiatry + social work + nutrition + pain management + social work + nursing. + psych-consult nursing (separate from the psychiatric consult service I’m on, for some reason) . The patient needed surgery, complicated surgery, for the second time. And soon the fifth and sixth and seventh. There’s the CT, the MRI, the X-ray, the lab value version of what happened to him. And there’s the homelessness, alcohol, other drugs, history of child abuse (to the patient), family estrangement, language and cultural issues and differences, a country that isn’t recognized as a country, everywhere, and doesn’t want him back. . .

That’s a team. The surgery note, every day, says “appreciate psych input.” And I end up calling the resident every day, for some issue/discussion about Our Patient.

Our Patient.

This is what I say when I call outpatient providers: “calling about our mutual patient. . .”

The people in the hospital I’ve developed working relationships with in my short time here? (aka, those who recognize my pager number. And voice) . That surgeon. An emergency department social worker. A psychiatric social worker. The charge nurse on the geriatric floor. The residents for my patients (more obvious) . A patient’s therapist. A patient’s psychiatrist. A patient’s social worker. Patient families.

A friend once asked me if doctors think about their patients, outside of the office.

I’m in the hospital. I see the patient at her most acute. My patients, right now, are there for suicide attempts, suicidality, drug overdoses (intentional or not?), altered mental status from alcohol or drugs, assault related to homelessness, dementia related to HIV, dementia not helped by alcohol, everything related to social situation, to past factors, to family history, to childhood, to marginal housing and relationships and proximity to their birthdays. . . everything.

I’m in the hospital, and with permission, I call the out-patient providers.

Every single one has been glad I called – many, relieved in a sense, to know their patient is being taken care of, and that it’s by someone who cares enough to call them to let them know about it. And to get more history. We call that collateral.

I call many times. Maybe we need more information, we need clarification – I’m seeing the patient at her most acute. They may have known her for years. And I promise to call back with our plans. We coordinate.

That’s not billed time. It’s after hours, between patients, during lunch. From home.

I don’t think medicare or insurance companies count that.

And these aren’t short conversations. There are the half hour conversations (almost an hour, with one patient’s husband) . And then we call each other back. And back. I give updates. They ask me.

Nothing is static here.

And the license I have, the incredible, humbling license to call my patients’ medical and psychiatric care providers, to learn more about their relationships with these providers, to know my patient a little bit better pre-hospital and to figure out what I might be able to do. Maybe.

Many of my patients are on holds. The first one is 72 hours - held. In the hospital. Danger to self, danger to others, or grave disability – inability to find food, shelter, clothing, medical care (essentially. And homelessness doesn’t count – technically, if they know about and can access shelters) . There have been holds for danger to self – the ones with suicidal intent/overdose – and for grave disability – the ones with dementia. Yesterday was the first time I saw what happened when a patient on a hold tried to leave – security came. She was restrained – soft restraints. Is it safer for her? Arguably, right now. Maybe. Can we do something for her? Maybe. The problem larger than the current overdose, though (which she says she’ll repeat – and better) is the living situation. Money, drugs, and how to get that money. Other people on the street. Everything that’s happened up until now and before and after. And this patient spends hours at the library, online, reading about the pharmacology of various drugs. The particular enzymes.

Then there are the 14 day holds. And the hearings – the patient presents his case to the judge. Accepted – patient free to leave. Denied – patient stays until we say go, within fourteen days. Law, medicine, minds.

The new interns have started. These are the people who are a year ahead of me in school – weeks ago, they were medical students (as I’d always known them) . Now, the IDs say “, MD” and the ones in psychiatry have license (with supervision?) to hold people in the hospital. Danger to self, danger to others, grave disability.

Grave disability. Inability to provide food, shelter, for oneself. But “homeless” doesn’t count, as long as you have enough wits/facilities to find shelters, to find food kitchens, to know where freer things are.

Four years of school and we get to pronounce death (time of. . .and the certificate that must be signed). We get to pronounce life (time of. . . and the certificate that must be signed) .

And we get to decide who can’t take care of themselves or their own lives, right now.

"Death" is easy to pronounce. "Danger." "Grave."

Cameroun, primate preserve/rehab near Yaounde

Learning language

2011-06-27T06:55:00.001+01:00

The following is slightly modified from a recent graduate admissions essay. (The first paragraph, alone, was posted in December). It may be a cop-out to post something I've already written - and, quite differently from everything else I write here - this one is highly edited and revised. With help.

This, however, is the manifest - and I wanted to explain what the connections are, for me, between the disparate interests. It's like writing poetry - once I've written a poem about something, describing that (event, feeling, person) in other words and sentences falls short. It isn't exactly, not quite, what I mean. Hence the quoting-of-self that happens. Inevitably. This, I imagine, must happen to all writers. So, rather than expound upon what's already been written:

***

It starts when I enter the room. How many words can my patient speak without needing

air? Is she leaning forward to breathe? Are her fingers clubbed? My stethoscope hangs without weight. My hand is on her shoulder now. My eyes close. “Breathe,” I say. “Relax.” And I am listening to the inside of her body. It’s telling me things my patient knows but lacks vocabulary to describe. It is my privilege to explicate this poem.
I was born speaking two languages, and, as a bilingual child, French and English were imprinted in entwined synapses. I do not always know which language I am speaking. If I read a book in English that takes place in France, I “remember” the dialogue in French. I transpose. In this way, I have learned that translations are only approximations. I connect most with those who speak both my languages because that allows me to use the most precise word possible.

I speak two languages. From my early years in school, I was drawn to science because of its inherent beauty and creativity. I decided to pursue biology the first time I looked into a dish of pond water under a microscope and discovered an entire invisible world. I spent late hours in the lab, peering at 400x magnifications of cells I had stained green for mitochondria and red for nuclei in a 12-hour painstaking process. I would forget to count and simply stare.

Cacao field, Mvangan

As I explored poetry and science in parallel, organic chemistry flattened molecules into boxy lattices. I couldn’t see their relationship to even the scientific study of life. At the same time, I wrote a paper on Sharon Olds’s “I Go Back to May 1937.” First look, second look, I loved the poem. As I delved deeper, I discovered the structure – the tendons, ligaments, and fascia – subtle scaffold for this exquisite organism.

I see the body as a poem to learn, but early medical training spends years on anatomy, physiology, and pathology. It’s like learning to read and write poetry by counting epics in syllables. Every two beats must be an iamb. But the iamb echoes the meter of the healthy, human heart. Exactly.

The poet is better at listening. The doctor is better at discerning what to listen for. Dr. Rafael Campo’s Desire to Heal circumscribed the locus where I want to exist: narratives of illness, stories of medicine, exploring the palimpsest of the body. Diseases are stories that have been written over and over through history, and yet they continue to engage us in the same basic plot. I had the opportunity to work with Dr. Campo both as a writing workshop teacher and in his medical practice. My first steps in clinical medicine were alongside a poet. I started learning the practice of medicine by listening and asking for stories.

Batoke, near Limbe, Cameroun

I find the narratives of medicine everywhere. In AIDS in Anthropological Perspectives, a college course, I read the history of AIDS from the first descriptions of a strange epidemic in San Francisco and New York to the scientific papers, anthropological dissertations, national statistics, and the poetry and fiction by those infected and affected by the virus. Here altogether was public health, literature, medicine, global health, and an opportunity to work with underserved populations. In college, I volunteered in AIDS outreach and activism. In Cameroon, as a Peace Corps Volunteer, I directed a rural health district’s HIV programs, trained HIV counselors and counseled patients, worked with high school students, and wrote curriculum. In Kenya, I did public health research on HIV. As a medical student, I work in HIV clinics. I am reading the literature as I learn to write it. Every connotation and different cultural metaphor is critical to my understanding. And this is just one disease.

HIV poster in Migori District, Kenya

When I was a community health volunteer in Francophone Cameroon, no one understood me for a few weeks. I was technically speaking the same language as they were, but African French is a more oral language than French-French, with different and mutable vocabulary. The natural storytellers I worked alongside and who became my close friends were raised in a poetic culture of call-and-response. To be an effective volunteer in my village and in the larger health district, I had to re-learn to speak my first language. Words, though, weren’t enough. In Cameroon, people also communicate with clicks from the back of the throat. These clicks mean assent, empathy, “I am listening,” “I am here with you.” They express more in a single sound than can any combination of words. Every language requires the tongue, larynx, and jaws to move in varying configurations while air expelled from the lungs charts a slightly different course. It was difficult, as an adult, to learn to shape a sound I had never made before and could not write down. I spent many hours practicing in order to be able to say what I was learning to hear. Back in the United States, I find that I want to use the clicks just like I want to use French while speaking English. Having to communicate without access to my full range of languages is challenging and, at times, feels stilted and stifling.

in Madagascar (sign in Malagasy)

I have spent three years formally learning to read poems of the body. I turn now to MFA programs to learn to write them. I want to be equally a physician and a writer, so before I continue a clinical education that will not allow deviation from a strict path for many years, I feel it is time to explore poetry as rigorously as I have medicine. Scientists are just beginning to study human history through mitochondrial DNA. Living in contemporary poetry, I want to study literature’s attachment to the earth.

In my career, I plan to work as a physician in global public health, and as a writer. I will continue to explore experiences of the body across cultures and demographics, working with underserved and under-heard people. The poets writing about AIDS in the 1980s had no small part in raising awareness of the epidemic. Writers lent humanity and narrative to disease, working in concert with and giving imperative to the medical fight for progress. Theirs was a revolutionary act, in showing that even the ill body, ravaged with disease, could be worth loving – and thus – human.

Getting it right

2011-06-22T08:19:00.002+01:00

*(I’m studying for boards (at writing) /just took boards (at posting) = Step2 CK)*

I hate the questions I get right – cancer, terrible diseases, medications, hard side effects to deal with, long-term complications – that I know, for sure, because of anecdotes

Anecdotes.

I know how you died.

I know how you might die, I know why your life is and will be difficult.

There are the simple ones – the amoxicillin prescriptions we wrote for kids with ear infections, the reassurance, reassurance, reassurance of parents.

The patients who came in with the side effects to medications that I’d read about – EUREKA! moments – your cough, the nagging cough, and you started lisinopril at the same time.

I know the answer to the puzzle.

I win.

Un des lions indomptables, Ebolowa

There are the diagnoses I’ve made because they were so “classic.”

(The people on the subway I’ve wanted to/have diagnosed at glances because I can’t help it. That part of the brain doesn’t always turn off.)

When a friend’s telling you a story and the diagnosis isn’t the point of the story but all I can think is – the diagnosis – the one he was given, the one that makes everything so hard – isn’t right. (in the end, it turns out, I am right. Turning point. I solved it)

I hate when it’s the ones who are dying. I get it right.

But then – that’s the point, isn’t it.

We're supposed to know the common things, classic presentations - the "bread-and-butter" cases. We're supposed to know the rare things - the "zebras.*"
We all know the same diseases. But these are how I remember mine, the pictures conjured. Everyone has their own.

*when you hear hoofbeats, think...

Some patients have been so happy to be part of my education

There was the mother of one of my patients –

Maria, my patient, was pregnant with twins. I was there for the delivery – and I delivered the placentas, but I didn’t get to do the birth because it was complicated, one was breech and one was vertex (normal). Anyway. Maria’s mother was so excited that this was my first delivery, that I would always remember them for that, and that they got to be such a special part of my life.

First? No. Delivery? Well, placenta, and I did lots of those. Not very exciting.

Remember them? Yes. I remember Maria, her friend, her mother, her grandmother, the twins…her in labor, her coming in twice prior to being in labor, the preeclampsia, her friend’s cell phone ring.

I remember. And that was a year ago.

I don’t remember because of this, though maybe partially – Maria had preeclampsia. She was the first patient I took care of, personally, who had preeclampsia. So when I think about that process, I think of her, and then I think of Shonda, my family medicine patient who had had preeclampsia and was still dealing with it, weeks after giving birth. I remember her daughter’s name, and how her uncle died and she still came in for the appointment with me but she was late…And because of her, I remember the medications you give for preeclampsia.

Belize City, Belize

And then I think of Melinda, who had debilitating OCD and was losing her house and I called to remind her about the appointment and she was crying to me on the phone… and that’s how I remember that condition. Then I remember the night I met Melinda, in the ER, when she was in for evaluation of DVT versus cellulitis. I remember the work-up we did, and the differential then and later, when she was in my primary care clinic. I remember – family history – her son had a blood clot (genetic bleeding disorder?) – but mostly I remember that he died when he was 15 and she was saddest to have her house foreclosed on because it was where he had lived, with her.

And that’s how I remember the tests we run for problems with clotting, too.

What drugs people like for what.

I remember how serious pseudotumor cerebri is from Cristina, how her symptoms were, how they affected her life, what the treatments were – and in order. What she looked like – some classic features, too, in how they describe the cases, and that she preferred dialudid for pain so they called her drug-seeking.

Make me a better doctor? Could argue indirectly that I’ll get into a “better” residency with “better” scores – though, other than the quality of teaching (important), access to multiple hospitals, including tertiary care (important for breadth of learning) - prestige won’t make me learn. My teachers will – the other residents, the fellows, the attending, with me teaching med students and later interns/residents as I move up.

But this is about pattern-recognition (so is medicine) – the African-American male (or boy) or African-American woman in her 30s or white woman in her 20s or Asian man in his 50s or obese young woman – for the test, anyway, they’re consistent, insistent, and repetitive with epithets. Those will, in general, mean very particular things.

This is about getting things right (isn’t medicine?) Medicine, though, isn’t multiple choice.

How I’ll always remember what Crohn’s does to a person. Seven years on a college police force and how many days he had to take off from work. He hoped this surgery would work for a longer period of time. As I was about to leave the room – history, history, physical, and me listening in to the gastroenterologists as they explained the condition and what would happen from the operation to him – he stopped me. “So, what does laparoscopic surgery mean?”

Somehow we’d missed that point. Words that become commonplace. So the CO₂ insufflation, the little camera and TV screens and tools through small ports – something I’d seen enough to describe. And I remember what they did with the tiny instruments operated by larger hands, and why.

Serena, twenty-five, aching joints, weight loss, fluid around her lungs, fluid around her heat. Getting married because of a diagnosis of lupus – and all the symptoms of lupus – she had most of them. She had all the lab values too – those get tested a lot.

Tikal, Guatemala

Myxedema – what happens when hypothyroidism goes to your head. That was the Portuguese-speaking patient, Julia, who hallucinated numbers she drew into her hand. Everyone thought it must be difficult to communicate with her, with the language difference – that and her tongue, so big from the matrix deposits from Hashimoto’s hypothyroidism, not quite fitting in her mouth. She and I discovered we could communicate in Spanish. I wonder who had tried that.

At any rate, the changes in personality, per family, her forgetting things, and her dreams and dreams and dreams of numbers that she drew on her hand and on the back of my patient list – I wasn’t carrying any other paper.

CHF* exacerbation vs pneumonia, or COPD* exacerbation: that was one of my first ER patients, and it’s a common distinction to make. I got it wrong in him (the resident got it) . And that’s how I remember. The disease and how to distinguish. Mostly I picture him where I met him, on that gurney in the ER hallway (busy day, that was Yellow Hall bed J, or something), long hair sweaty around his face, uncomfortable, leaning forward, trying to breathe better, pausing between every few words. That and how he couldn’t afford his medications anymore because he got a job that didn’t pay enough to cover them but mean he had more than zero.

*Congestive heart failure. Chronic obstructive pulmonary disease: emphysema, chronic bronchitis

A classic hand fracture and how I effectively used a hand musculoskeletal, cardiovascular, and neurologic exam. The snuffbox fracture and how I was more worried that the patient would reinjure it because basketball playoffs were the next week (this, to me, wasmore of a reason to cast it, poor kid) . If we didn’t? He could lose blood supply to that part of his hand and end up with a permanent injury, nerve damage, etc. . .Good kid. It was right after his birthday, too. He understood. I remember the treatment – the spica thumb cast – because everytime I called radiology they were either not in the office yet (too early for them) or about to go to lunch (I win!), they’d read the X-ray over the phone with me, and then I had to call the orthopedists to make an appointment. Again. Or call the patient and tell him to go to urgent care. Again.

The angry little girl? Her condition comes with very rare infections. I remember the bugs and I remember the drugs we used, they showed up in my repetitive progress notes every day. I know the treatment regimens from talking with her and her mother. She showed up on boards.

There was the kid with the rare immunodeficiency and brain abscesses, on IV antibiotics at home (devoted, attention-to-detail mother) . He came in for appendicitis that we knew he didn’t have, but anyway, he’d had these abscesses in his brain and his lungs. And he didn’t have appendicitis. But I met him and I met the family and I read the chart. That kid showed up a lot in boards practice questions – the disease he has, at any rate.

How to remember genetic inheritance of diseases encountered. Who in the family has it? I pin diseases to people, in my tenuous neuronal connections. One disease is a friend-and-her-family-tree. I’ve read about it. It’s interesting. It can have a lot of features that she (thankfully) does not have. But I care because of her. And she’s how I remember it.

I’ve seen a lot of patients this year.

Side effect? getting questions right on a nine hour multiple-choice test.

Effect? Learning how to take care of the real ones.

Living changes everything

2011-05-29T18:51:00.005+01:00

My patient invited me to his funeral.

Indirectly.

He asked for my phone number so that his daughter can call me when he dies (he’s dying). He asked for my phone number so that his daughter can call me when her daughter, his granddaughter is born – she’s due in August. He might be around. He might not be around. My patient said that maybe I can see photos of his granddaughter, maybe I can see her grow.

He won’t see that.

My patient invited me to his funeral. It felt sacred but not strange. This many months, years into med school, I’ve learned what boundaries are right for me. I’ve learned that my patients – most of my patients, the ones I truly have relationships with – will not cross those boundaries. So I wrote down my phone number and my email. And maybe his daughter will contact me.

I’m on the palliative care service, now. One week gone with one week left. I’ve been here before, with dying patients – even before I was on this side of the medical line. Cameroon. Kenya. I’ve seen babies die.

And this year, I’ve had patients die in other hospitals, on other services (this year of medicine – everything I’ve written – actually takes place in 7 different hospitals, thus far). None of my patients who died, previously, were seen by palliative care. They may have died after everyone involved had decided to stop working on curative treatments. Possibly curative treatments or impossibly curative treatments.

It’s hard to not feel like the angel of death, sometimes. I’m learning how to talk to patients about death. They know, I know (doesn’t make it easier for me to say it). I’m not announcing the news – though I’ve been a part of announcing cancer diagnoses, in the past. Fear of death but not death – not yet. It may be new news, it may be old news, it may be something they’ve known instinctively for a long time, they haven’t wanted to know or realize, or they’re no longer able to communicate directly and it’s the families that are communicated, being communicated with, making decisions.

Coming in on a consult, the first visit with palliative care, explaining what the service does is tricky. It’s not about death, not exactly. It’s about supporting patients’ goals of care, what they want from the hospitalization, how to treat their symptoms, and what they need now – physically, psychologically. It could be near death, it could be farther death, it could be a new, chronic, serious diagnosis – likely one that will result in degenerative disease or a somewhat hastened death. It’s patients who are very, very sick and potentially going to be cured. Potentially. Being on chemotherapy, ventilation – the proverbial “machines”, the “lines and tubes”, the “machines keeping you alive” – not contraindications.

Not usual.

Unusual.

For patients who’ve recently been told they’re dying, which may be in the form of “not eligible for further chemotherapy” (the “nothing else we can do” – which isn’t nothing, but isn’t a cure) – it’s hard not to feel like the angel of death. That, I’m not used to.

One patient’s family told me that they were frustrated and that they knew the oncologist (cancer specialist) was frustrated, as well. He had nothing else to offer – so he called the team that isn’t ever going to talk about a cure. Doctors don’t like the feeling of “nothing else” – particularly oncologists, I think, though/since it may happen to them more than to some others. But stopping trying-to-cure treatments is part of “do no harm.” That’s the best known part of the Hippocratic (now Lasagna) Oath – but it includes, also, “do good.” Balance of action/inaction. And “do no harm” may include, at times, not giving medications, not doing surgery, not doing, exactly, what a patient’s family may ask for (with an ethics consult).If harms vastly outweigh the benefits. If, as a surgeon, you know that the patient is vastly more likely to die on your table than to live and helped – you shouldn’t do the surgery. If you know that further rounds of chemo are going to be just poison and not medicine – you shouldn’t do it.

Good medicine isn’t always about giving or practicing or employing modalities.

I don’t have so much medicine. Not yet. I have some, I can contribute, and I can care for patients. What I have the most of is time. It’s fourth year now – there is less time than in third year. And/or, I’m supposed to be more efficient. Less scared, less intimidated. This past week, I’ve had four patients. (Third year, I never had that many). Granted, on this service, they take less time – medically. And some want or need more than others. Take Mr. P, the patient who invited me to his funeral. I met him on my first day. For various reasons, he has no particular place to go, no money, and no chance of taking care of himself, anymore. He does have a supportive daughter, who is close to him. And his daughter is pregnant. Communicating through a translator (he’s Vietnamese), we talked – at first, this seemed stilted. The fellow on the service told me she didn’t think he was depressed (in patients with “terminal” diagnoses, weeks-to-months-to-years, this still surprises me). He’s not hopeless, she said. He does want to be around for his granddaughter’s birth – even though he doesn’t think it’s going to happen. Meeting with his daughter, later, she said she’d asked him to write a letter to her future daughter – and he hadn’t wanted to. There, there something I might be able to do. So I mentioned it. And again. The chaplain mentioned it. And again. I went in and mentioned it, again. He said he wasn’t sure what to write, but he’d think about it, and then four visitors walked in, so I left.

When I returned, the following morning, he was sitting up in bed, wearing glasses, writing in a red-bound notebook. He had already covered many pages.

In the afternoon, through the translator phone, we transcribed it in English. He read it into the phone. The translator translated to me – and I wrote as quickly as I could (Mr P used a very good speed, pausing to give me enough time for phrases) .The translator, as she spoke, was crying. She’s a medical translator – used to translating exactly and impersonally. This was different. I was writing too fast to feel as much – wishing I still remembered short-hand, from the brief class in 5^th grade, and making up my own as I went along, planning to type soon so I wouldn’t forget the semi-legible words. I didn’t tear up until I was typing, later, and I read the phrases in order. “My dearest granddaughter,” he began, telling me he wrote that because he didn’t know her name. But the letter was full of love for her – this future-dwelling letter girl. And full of love for her mother, his daughter.

Scribe, not narrator.

(one thing I’ve learned – what sounds like a lot of words to me, in Cantonese – isn’t. Maybe I’d feel that way about a lot of languages I don’t understand a word of (no, I have approximately one now) – but I always think there are more words than there are) .

He told me he’s going to keep writing every day.

Unbelievable, incredible, sacred privilege. I was entrusted with this. And it’s a job anyone could do – all I did, technically, was write down what the translator said. But I was there because it’s a hospital and he’s “my” patient and this is what he needed, what he wanted for his health and comfort and the health and comfort of those he cares about most. “Legacy work” they call it, “the dignity of dying.”

I have barely-can-vote patients who are dying. I have have-been-living-with-disease-for-decades patients who are dying. I have patients who don’t want to “live like this” – they can say – or they expressed it earlier and it’s up to their families to say.

It isn’t, necessarily, a glass-half-full thing.

If medicine is about life – and it is – than we’re not helping patients die (even euthanasia, arguably, could be related to quality of life. But that’s an entirely different topic) .

We’re helping patients live – how they want to live – with the time they have that we’re terrible at predicting (doctors notoriously over-estimate how long patients may have. Patients may not want to read this – and if they do, they can say it’s not their doctor. That’s fine) .

The point is and always was about the patients. Do no harm, do good, to… and for…

And when the scientific knowledge has reached its limit – do good is what we can do, anyway, and do no harm is not doing what we can’t do or can do but that the patient doesn’t want.

(In my French etymological dictionary – the entry for medicine starts with “Art that has for its objective protecting health and healing illnesses.” Art. Certainly isn’t a science).

...

"Writing allows you that. Approach

words with a scalpel.

You reopen scars without new

wounds, or lengthening.

The firm white line –

a rope that binds you, if

not to this life,

to the living."

Not everything in pathology is dead

2011-05-23T07:18:00.001+01:00

That is, perhaps, what I’ve learned in two weeks. I haven’t been in what’s popularly thought of as pathology – no dead bodies, no tissue specimens. Vials and vials and vials of things, petri dishes grown from people, blood and bone marrow biopsies.

Parts of people, taken out, to see if they are still alive.

(or, parts of people, taken out, to analyze and see exactly what’s in them and what they’re doing) .

It still feels like an inexact science, in some ways. Microbiology is detective work – but this isn’t what they show on House or CSI; it takes days and days to grow. (Then, clinically, what’s the point? In the immediate. . . there isn’t one. Patient is sick, patient looks “toxic”, you treat as if she’s bacteremic.* (Has bacteremia) . Septic. (Has sepsis) .

Rat glioma, nuclei

*Bacteremic means bacteria within the blood stream, meaning they’ve escaped the confines of wherever the initial infection was. Bacteria aren’t supposed to be there, nor fungi. Viruses can be – but this should be more antibodies to than antigens from. Once bacteria escape – and this includes the good, normal kind who are supposed to live in the intestine – they wreak havoc. This becomes sepsis. (Interesting word relationship/derivation to “septic tank.” In medicine, sepsis means shock. It’s a terrifying emergency.)

Then, septic. The body can attack infections where they are. But if the infection is in the blood, it is, by definition, swiftly moving everywhere. What to attack? Itself. The immune response is upregulated and storming through the blood vessels. The blood vessels, in response, are dilating like mad – and things are leaking out – and blood is rushing quickly, quickly, quickly, but there’s not enough pressure and it’s not actually working – and the body is attacking itself because the toxins are spreading, spreading . It’s the one kind of shock where the patient is warm, flushed (with other types, pale and cold) . The blood is moving everywhere but nothing is working.

So the clinical lab scientist in her jeans and sequined head band, mechanically incubating bottles with blood and other bodily fluids (anything that might grow something, whatever might be the initial source of the infection) – is looking for sepsis. A light goes off on the machine if something grows (so much is automated) . But then that gets plated onto various types of agar, separated, separated, then checked by gram stain and color of growth and look of colonies (shiny? mucoid? smell like fruit?) to figure out what the actual organism is and how to treat it.

Meanwhile, the medicine team is throwing every sort of antibacterial, antifungal, antiviral at the patient; anything, anything that might be suspect. When the organism comes back – after days – they can narrow the treatment (and this part is important, too) .

The question becomes, then, how does the patient look.

The pathologists don’t know. I appreciate it when they ask. Pathology rounds – the micro kind, anyway – consisted of petri dishes. Walking around to different stations, looking at them under the microscope – what’s growing, how do we know. Is this actually making the patient sick. And that’s why the ID (Infectious Disease) team is there, to answer. They know the patients.

There are things like the infection control meeting – patient with suspected bacterial meningitis (emergency, fatal w/in 3 days, often. Highly, highly infectious/transmissible. And, like plague, easily treatable with antibiotics. ) . The issue was that the six firefighters who had taken her into the hospital, stuporous, on the ground, hadn’t worn masks. So were they exposed? Then their families? . . . and everyone else in possible contact.

It’s problematic (maybe) that I want to go into ID – to be a “global fund doctor” – HIV, malaria, TB, on to yellow fever, dengue, dysentery all causes, filarial, schisto. . . etc. But I don’t want to be stuck in the lab with the petri dishes at any point.

Rat glioma, nuclei (blue) and mitochondria (red)

Digression.

Pathology gives the answers. We trust them. Particularly for oncology, they’re the ones who say “cancer” or “not cancer”, and, if cancer, what kind, which dictates what treatment. How bad is the cancer. How far does it spread. Much of this is directly based on what the cells look like – and, yes, there are some biochemical markers and non-subjective measures of this, now.

Take prostate cancer, though – the grade of cancer, related to prognosis given, is 100% based on what the cells from the biopsy look like – that plus how far it’s spread, where else it might be in the body. Radiology, pathology, and surgery will tell you that.

And medicine is left with the patient, and with treating the patient.

“It’s a good lifestyle,” they say. Pathology’s not officially part of the ROA(U)D to happiness – radiology, ophthalmology, anesthesia, (urology), dermatology. The specialties that are very, very lucrative, particularly compared to work both in residency and in practice. (For urology, this is generally true in practice, but residency is similar to a general surgery residency) . And there are people who pick a specialty based on those letters. ER counts sometimes as “good lifestyle” because it’s shift work, you don’t have work to do at home or follow-ups on patients, and you can cluster your shifts and then have other weeks to do other things that are important to you. (It doesn’t match the lucrative or less work parts, though) . Pathology – can be very lucrative (one resident remarked to me that his goal was “to make as much money as possible for as little work as possible.” I had nothing to say to that. I only wondered what he’d actually said in his interviews) . Psychiatry is sometimes grouped with these. “Lifestyle,” people tell me, “lifestyle,” as if that has anything to do with anything, for me, in choosing what to do. (Medicine, out-patient medicine, county hospital or international NGO, + public health, is essentially the opposite of all of the “positive” things above. Except that I love what I’m doing. That’s the lifestyle bit) . With other interests (writing, public health work. . .) it would certainly be convenient to like a field with more straightforward hours that allowed more room for that – emergency medicine, for instance.

There was a night I realized that, without a doubt, I’m not a ER doctor^* (besides the medicine bits, ER doctors are probably the coolest specialty, and most of them own kayaks and/or go rock climbing a lot) .

* We speak of this in terms of personalities, too. “Finding your people.” “Who are your people.” Mine happen to be internal medicine HIV docs, or medicine working in public health/county settings.

Rhumsiki, Cameroun

Tomorrow, I start on the palliative care service. It’s mostly (as I understand) for patients who have chosen to not pursue further aggressive medical care. There are chaplains (specific and non-religious in bent; whatever the patient wants), medical doctors (pain of all sorts), social workers (perhaps) – we’ll see. It’s not something I could do as a specialty. I have to balance death – and many of them do; not many could do this all day, every day. Pathology has weighed in and no longer matters. Or that’s what mattered in the first place. Or they’re the ones who made the patient (person. person) decide to continue* with treatment – or not.

*I wrote “fighting” and erased it. I try, conscientiously, to avoid words that are negative metaphors in medicine. Medicine as war. Disease as enemy. Is the word “survivor” empowering? Does it necessitate the winning of a war? Is a victim someone who was weaker, or didn’t fight back enough, or let the guys on the street with guns take his wallet because, in the end, it wasn’t worth what the consequences might be otherwise? The chance? That means, also… women who (here and in other countries) get blamed, explicitly or implicitly, in part, for attacks. Can they be compared to smokers, then, who get lung cancer? (and heart disease, etc). IV drug users for hepatitis C, alcoholics for liver failure? (These are ethical issues that come up in transplant committees. We had a discussion about this in class, a few years ago. There were many differing opinions). Former alcoholic who needs a liver versus person with a genetic disease that destroyed their liver. Perpetrator versus victim. Same thing for HIV transmitted from mothers and blood transfusions, versus sex and drugs. Victim. Perpetrator. Same disease. I don’t think the metaphor is fair to either side.

Susan Sontag’s Illness as Metaphor, and the updated AIDS and its Metaphors. Every generation, the culpable disease changes. It was tuberculosis. And then cancer – people were thought to be at fault for that, somehow. It was shameful. And now AIDS is becoming somewhat more normalized – or maybe that’s my socialist working-in-county-hospital-in-liberal-city perspective. What next, then. Meanwhile, for the next two weeks, we are told to – not – think as much about death and how that will be, or about delaying it, but about what the rest of the life should look like. To that end, and to learning it.

Sustainable - Ecstatic.

2011-05-11T00:19:00.003+01:00

Everyone talks about 'sustainability.' 'Sustainable development.' (which, by definiton, should be sustainable - otherwise - it's patchwork construction and shantytowns, metaphorical or literal). The environment.

Etc, etc, etc. It's as much of a generalized buzzword as "global health" is becoming in medicine.

If there's one thing I learned in Cameroon, it's that I can't take on things much larger than a village. A small part of a health district, perhaps. A health district (rural). A larger health district (someday). Part of a small NGO (someday). One project, perhaps two. Other things are less sustainable.

In medical school, the largest thing possible was a small, student-run clinic in a homeless shelter, operating for a few hours two nights a week and a morning every other weekend. That, in itself, was enormous. And there were several of us. (Alone? Possible? One person is not sustainable).

The Mall, Washington, DC, February 2003

In college, I was actively anti-war (can't even be apolitical in writing). (and I've learned that the strict position of 'anti' isn't useful anyway.) Peace marches, protests, demonstrations, a dizzying 'march on Washington' (to be done once in a life, at least, if politically inclined) gave a sense of community and something greater when the state of the world was terrifying. In this state, there are rallies at the state house for single payer healthcare. I haven't gone. It’s the global and local thing. Someday, maybe, WHO-type work. Someday, definitively, public health education/behavior change communication and program design. Local to larger to local.

If I hadn't gotten into medical school the first time, I would not have applied again. It would have been, I think, a year of something then two years of MPH. There are so many paths to the same thing – these are not Frost’s diverging roads.

Hopital de District de Mvangan

I digress.

Different ways to get at the same thing.

Sustainability, ecstatic. Things I worked on – sustainable/sustaining. Me – ecstatic.

When I – when we – took over the homeless clinic, almost two years ago, it was not, in my viewpoint, functional. My basic stance was either we turn this into a real clinic or we shut it down. The clinic operates within the largest homeless shelter in this city. (But this is not a story about the clinic). It was tied to the Department of Public Health (DPH) – sortof. We took supplies from their supply closet (ah, the delectable power of having that key on my key chains… the thrill of wandering and finding new things for the clinic, new ideas for how to expand and what we could do with them. This is a story about that). We had the same patients in the same clinic space as two health care providers from the DPH. We had files, sortof. They had files. We gave them copies of our notes, the billing parts that were not ever filled out correctly. The “billing sheets” went to the DPH for their statistics, which help determine state funding. And every year, the clinic leadership turned over to a new group of medical students. Medical school is short and fast. Four months into starting first year, three months – or less – into starting clinical volunteering, students have to decide if and who is going to lead next.

African Development Bank's unbelievably costly hospital, Amvom, which has nothing but expensive walls and nothing to sustain it

This is not sustainable unless there is a standardization of clinical practice.

This is not sustainable unless this clinic is a direct part of the DPH.

This is not sustainable if there is no public health group incorporated as part of clinic leadership, running monitoring and evaluation.

This is not sustainable if there is no cohesive clinic structure, cohesive and streamlined clinical practice, standard of care and operating protocol – because – the clinic coordinator is not the same, every night (though, in the end, it rotated between about 4 people, every week, who were there at one or both of the clinic nights).

Without the above, this is not a clinic.

This is not a story about what I did, or about what we did – it’s a story about how we made something function.

At the end of a year, less, the clinic was a clinic. Maybe a shaky one – we weren’t sure. It was part of the DPH. We were continuing all the relationships we had cultivated. The way to create sustainability, or the illusion of a functioning structure, is to present it as if it has always been that way, and that this is just the further iteration of institutional memory. So we conned them – the new group of students – into thinking this was a longstanding procedure, a longstanding part of the DPH, that their job was to continue and continue to improve. We wanted it to be an illusion – or was it, or did it need to be? – that these were time-honored and strong foundations, that they weren’t brand new. We inculcated our new recruits with new procedures.

Prior clinic in Amvom, which functioned for a long time

How?

A checklist.

I just finished reading Atul Gawande’s The Checklist Manifesto. And I just returned to clinic for the first time in a little over a year. It’s functioning exactly as we hoped –moreso. The same structures are in place, the relationships are stronger, and the foundation we left was firm enough to be built and improved upon. Many things we’d wanted to do, but had not had the time to do – have been are being done. And then I realized how we’d done it.

It’s called the Coordinator Checklist. It hasn’t changed; basic procedures really haven’t changed or obviated the need for change (the contact info is the same for the same four of us who were running it then, actually). We went through and tried to create a standard operating protocol; the things that needed to get done and how we did them. According to Gawande (and in truth), it’s too long, too complicated, with too many full sentences. It can serve more for troubleshooting, then, and the most motivated ones, early on, do read it. It references an entire binder of SOPs.

I went back to clinic last week. I was nervous and excited – how was it functioning, now, (and how much better would it be/how little had I worked), would I remember what and how to do things.

Clinic is there.

Clinic is better.

They’re more a part of the DPH. They’ve kept the same positions/core group structure that we created (ie, made up) and have built on it.

They’ve created more SOPs than we did – things we’d dreamed of, somewhat, and not had time to do. Better structure for patient education handouts – and using them more. Domestic violence screening practices. Etc.

And the coordinator for the night told me how the best thing we can do for patients is get them into primary care through the city programs.

He told me.

I started that. (Having a large/main focus of our clinic as getting our patients into primary care and training everyone else to know how to do it. And to track what we were doing.).

Things that feel tenuous when you “make them up”, when it was built on an idea and a few students in a windowless small group room … aren’t tenuous. What is real, then? (Anything).

This is not an NGO, this is not something that’s going to transform health or homeless health or a shelter. It’s not going to revolutionize anything. But it’s something. It is something. All it needs to be maintained are interested, motivated students (no short supply in any conceivable future). It’s incredibly lucky that we can count on that. We rely on free labor from people who are doing this because they’re passionate about it – and who, realistically, don’t forget that all this goes into residency applications (and for the pre-meds, into med school applications).

Closer to two years ago than I’d like to think about, I was on a bus from Yaoundé to Ebolowa, and we’d just arrived. The woman next to me asked me where I was going, and I told her I was going to Mvangan, that I had lived there for a few years as a Peace Corps Volunteer (did I even say PCV? Maybe I said American. Maybe none of the above). “Ah!” she exclaimed. “I know Peace Corps Volunteers in Mvangan and Ebolowa, they taught me about nutrition, it was a project with growing soy.”

She told me about the soy nutrition project, the teaching, the health and agriculture and business components.

I started that.

And now it’s infinitely better, and more, and makes more sense, and has done more than I would ever have imagined/could have done myself. I am unbelievably, incredibly lucky to have been able to (already) see not one but two of my most beloved projects grow and become sustainable. Take on a life of their own beyond me. Were these children, they’d be walking, and maybe talking, a little.

Fields in front of Hopital de District de Mvangan

Writing about the bits of public health that really excite me, the things that create programs that can sustain themselves (involving motivated people, obviously) – would not be, may not be so exciting. Monitoring and evaluation. Quality improvement. KAP studies (knowledge, attitudes, and perceptions). PACA – the Peace Corps one (Participatory Analysis for Community Action. or similar. I still use that). Behavior change communication.

Where There Is No Doctor. Helping Health Workers Learn. (Hesperian foundation). I still use those. Patient care, though, is only sustainable in out-patient, longitudinal practice – if that. Building they physician-patient relationship, working on stages of change. Etc.

With writing, I suppose this would include being quoted or included in someone’s personal anthology. Publishing has other attributes, unless the point is advocacy. Or something. But even that has a self-promotional aspect.

There are writers whose words are always in my head – and this includes some people I know personally, who are not published but are some of the most talented writers I’ve read. I used to be terrified of not writing again, that “it all” was gone. This was hardest when I was writing my undergrad thesis – if I went a week, almost two once, without anything writing itself – I was afraid there was nothing left. And then something would come, and for the time being, everything would be okay again. There’s a solution, actually – reading. Reading and going to readings. I was working on a book review, recently, for a book of Cameroonian poetry (The Oracle of Tears). It was difficult/impossible to get all the way through on an initial read – I kept putting it down to write. Anything that inspires others to write/think/read, then, is the sustainability bit. That more muses and Martians will be translated and expressed, that words will continue.

Lines that have been over my desk for many years –

“…open the notebook

and drunk with inspiration commence

describing.”

~Franz Wright “The Lemon Grove”

Relevance, irreverence

2011-05-03T02:47:00.000+01:00

Were I not taking a year off from med school, I could be a doctor soon.

This sounds obvious. Yes, in the practical sense, in 12 months I would be an MD.

Instead, I’m doing three months of fourth year before taking off for an MFA. The fourth year schedule (for later) is so flexible that I could actually spend an entire quarter not here, doing a third semester of my MFA in an entirely different city. And graduate with an MD.

Soon, I could be an MD.

I won’t be.

To take a leave of absence, you have to formally withdraw from school. The form asked what I’m doing - simple. Then it asked what the relevance is. Relevance. (the career advisor/head of ob/gyn department asked me the same question. Relevant. How is poetry relevant. I’m not going into ob/gyn, anymore*) .

*for many reasons, but the above was probably influential on some level

Sometimes, in progress notes, admit notes, presentations, we put this more delicately. Call it “pertinent.” What is the pertinent past medical history, pertinent family history, pertinent social history. “Go do a focused history and physical.” Then, present, giving the pertinent positive* and negative* findings.

* “Positive” is something in the history or physical that would support a particular diagnosis; “negative” is something not present that could have supported the diagnosis/could refute it by not being there. Or, in the case of some things things, including a diagnosis as generally benign as strep throat, not having a cough makes the case more likely that it’s strep. Pertinent negative.

Is his appendectomy 25 years ago relevant? No. (unless there was excessive bleeding or some other unusual reaction) .

Is her mother’s breast cancer at age 84 relevant? No, not to her health risks. (but did her mother die recently? Was she taking care of her mother? Did she live with her mother?)

What about my patient’s son’s other mother’s history of joint problems – was that relevant to his twisted ankle (broken or not?) after jumping down from the bed? No, the other mother (the mom sitting with me – her wife, she called her) wasn’t his biological mother, though it was her brother who was the sperm donor. (But in asking that one question of family history – lax joints/bone problems/connective tissue disease? I learned about the family structure, the genetics, the relationships in this child – my patient’s – life) .

Is the patient’s chest pain relevant? Well, we’ve effectively ruled out a heart attack, but there are a few other physical conditions it could be. (But, has he had any life changes? New stressors? Anxiety attack?)

The patient with insomnia doesn’t just get ambien – he gets asked why. And you should screen for physical conditions that could be contributing. And you should ask about depression. Relevant.

Doctors redirect because patients don’t know what is relevant and what is not. There’s something learned over time – the right questions to ask, and how to ask them. And in presenting, what's necessary to say.

There are patients who ramble.

There are patients with whom I dread doing a review of systems.

Technically, there are 12 points to go through. (How often are all really covered?)

Any changes in your health?

There are the favorites. We ask in one breath – as if a patient can remember them all, or anyone who doesn’t anticipate the list can answer them in order. These can be abbreviated by one letter each, usually, written with slashes in-between, after a +/- or denies*/endorses**.

*As if the patient might be lying

**As if the patient is selling a particular product: her body? how her body functions?

Fever, chills, weight loss? (No, you don’t have cancer) .

Changes in appetite/Nausea/vomiting/etc? (then I won’t worry about that system)

Any changes in your skin? (What kind of changes? Too many to enumerate, so it gets short-handed. Changes. Anything you’ve noticed (and if there’s something that you didn’t notice, what do I imply?)

More bleeding/changes in bleeding? (Are you losing more parts of yourself? Is there more blood inside your skin, or out of it?)

. . it goes on.

Anything else I haven’t asked about or that we haven’t discussed? Anything else you think I should know?*

*What should I know? What do you want me to know? I hear about divorces, children in jail, someone sick at home, someone dying or dead, a house being repossessed, an upcoming trip, evening plans. I hear family history and favorite colors, I hear how much they like my shoes (especially all the bright red ones) .

As we move ahead in medical training, we have to move faster. It does become easier, to take less time, elicit the needed information, and establish a relationship with the patient. I don’t have to write everything down right away, I can chat as I do the physical exam, I can remember. But I have to move faster.

I want relevance-to-right-now. There are the patients who will tell me about the one episode of indigestion a week ago, how their ankle hurt last week and there was that one day they couldn’t sleep very well and there’s one bruise they got 3 weeks ago, they’re not sure why but it went away. . .and then a few days ago he felt like he had a fever, but maybe not, and maybe it was a little warm at night. . . oh, and then his tooth kinda hurt in the morning, and he kinda had acid reflux after eating spicy things, but that just happened the one time, and then. . .he gained two pounds in the last 6 months, should he be worried about that? And actually right now he’s a little bit tired, and maybe his foot is sore again. . .

(am I still listening? half. I’m also writing at the same time. Trying to pull out what I think I need to know. And I’m interrupting and redirecting, a lot. It’s necessary. The story – even if it’s a medically relevant story – is convoluted and confusing and I need to understand it in order) .

This is a patient who, in the ER, was told “he says” that he had the largest habitus they’d ever seen! on abdominal ultrasound. (Everything with him was largest/worst/shortest time to live any doctor had ever seen) . Habitus means space inhabited by the body. (Ie, in this case, abdominal fat seen on the ultrasound.) At least, here, I could assure him without a doubt, that, no, it wasn’t the largest habitus we’d ever seen (I tried to explain what it was. He kept insisting it was something pathologic) . Fine. But I promise we’ve seen larger habitus and that it’s not dangerous to him right now.

(Am I exaggerating? No.)

Problem with the above.

The patient (saying it’s one) actually has had a heart attack and actually has a potential mass on his liver. But who is going to listen, who is going to sift through the irrelevant for the relevant.

The patient doesn’t know what I want to hear. He doesn’t know what’s most important to me or what’s most important to his health. He wants to tell me everything – it’s what he perceives, and some is frankly medical. Some is not.

That he’s living in a trailer in his brother’s backyard and his brother might kick him out? Relevant, relevant, relevant.

And not just in psychiatry.

The head of the psychiatry department actually told me, “You might start out as something else. You might start out as an internist, and that’s fine. Eventually, you’ll be a psychiatrist.”

(do I think so? unlikely, but he’s a professionally perceptive person) .

He said to me, “If you don’t do psychiatry, there are whole parts of you that you won’t be accessing.^*” In psychiatry, you bring everything that you are and all of your experiences into your practice. Everything you’ve done is important. Everything is relevant.” Everything you are reverberates. Reverent.

*reference to writing, arts

Relevant to patients: where I’m from? I’d venture yes, but also allow debate on that point.

My religion? I move that back to the patient. The “it’s important what you think. What matters to you.”

My politics? – there’s one I may cross the line on, sometimes – I can’t help but speak my mind. Only in relation to healthcare and immigration status. (And this one isn't generally asked).

Are these irreverent? No. There have been almost no questions that I did not feel comfortable answering.

Diabetes, high blood pressure, high cholesterol, “lifestyle modifications”, medications? Most patients could care less about these, most of the time. But these (stress/tension) headaches. . . (I can’t do anything about) . Relevant to me. Irrelevant to the patient.

People look at me funny when I say what I’m doing next year. Pause. “and. . .how did you think of that?”

Relevant.

To end on a point that makes me irate everyday –

in many clinics, the patient’s insurance/insurance status is noted on the chart. Physicians have to prescribe by formulary, which is decided by each insurance company/Medicare and Medicaid.

Yet a lot of patients (my patients, past, present, and future) are not eligible for any of those programs. We’re deciding who might get to have a better quality of life or even live longer. I had a patient who was not deemed eligible for a kidney transplant because his wife, not him, was a polysubstance (drug) user, and you’re supposed to/required to have support to help you after the transplant. This counts for the transplant committee. He was deemed "futility of care." Nothing else to do.

Relevant? Yes.

Who are we prioritizing, as all the disqualifying factors are so complex and socioeconomically linked?

Should be irrelevant.

A year for patients

2011-04-22T08:31:00.001+01:00

For K and K

The first patient who died and the first newborn I took care of in the nursery – have the same name.
K--- .

I wish I could write it. Suffice it to say, it’s a beautiful name and an uncommon one.

The first patient who died, the first K, was 29, with metastatic cancer. Latina.

The first newborn in the nursery, the first birth after K and a string of other deaths, was 6 hours old when I met her. Half Japanese, half Turkish.

And they have the same name with the same spelling, and, most likely, the same black hair.

Born thirty years apart.

This year, I’ve kept track of all my patients who have been born and who have died.

For births, these were only the ones where I performed the birth, where my hands were on the body that became a child. I didn’t include the ones where I just watched. These were also the ones in the newborn nursery where I took care of them, I examined them moments after birth.

For deaths, these were the ones who were my patients. These were the ones whose families I had met and spoken with. And these were the ones who died in the hospital – that’s how I knew. I don’t count the ones who were discharged and who have likely died this year, as well. I don’t know for sure. I don’t count them. I don’t count the ones on my team who weren't my patients.

These patients are represented by beads on a thin, silver, malleable silver wire. Blue are born. White have died. It’s a small string, now, with knots and twisting between each bead. I keep it curled up in a box, and I plan to maintain it throughout my career. This small remembrance, this small tribute. Each time, I take the moment to think about the person, the patient, as I add them.

This started one week into my third year, the first time I was on labor and delivery. The last bead was a few months ago. None of the patients I directly took care of, on surgery, died. One is now in hospice, though, and has declined further treatments.

Since I’m going into internal medicine, and maybe I’ll do another labor and delivery elective – but likely not – I won’t have new blue beads in the future. Maybe I can count babies born to my patients. I have to find some way to balance the white.

The first K I saw every day for two weeks, on my in-patient internal medicine rotation. It was July. She never complained of anything. She was wasting away. Everyone who walked into the room knew she was dying. And that it would be soon. Chemo and cancer made her look like that, made her so sick.

She wanted to keep going with treatments.

She wanted to see her three children again.

In the end, she couldn’t do both. And she died in the hospital. And the last days, she was unconscious. When I saw her, she knew everything.

Her last days, when she died, I wasn’t there.

I heard about it after. I hadn’t seen her in a week, at that point.

This is when I learned, first, to be afraid, to keep checking, to see people when they were in the hospital, to try to find out when they were there again.

K wasn’t the one who first scared me into this.

It was another patient – and he isn’t counted, because he didn’t die in the hospital. He likely died this year. But he likely died at home. It was a Friday. My patients were K, Mr L, and a third one, young, new diagnosis of a very serious, chronic illness. After rounds, my senior resident commented that Mr L probably wouldn’t be alive on Monday. It was like I had been struck – I knew he was sick. I’d never heard anyone prognosticate like that. I asked the resident, later, how he dealt with the death of patients. He said, a little surprised, “…I don’t think about it.”

I had class that afternoon, briefly, but I ran back to the hospital afterward. I had to know who my patients were – I had to know them as something, someone else than the sick and dying person I’d never seen out of bed. (Over the year, this has become much more natural and a regular part of my day – until surgery, when doing this would mean I was at the hospital more than 15 hours per day, and, after getting up at 4, I wanted to go home).

I went first to Mr L’s room – and my heart stopped when I saw it was empty. Frantically looking for his nurse, I was finally told that Mr L, per his wishes, had gone home. He would stay there. I was relieved, at least, that he would get what he wanted; I still didn’t know if he would be alive. (I didn’t count him).

Next, I went to K’s room. I was afraid when I saw the sign on her door “no visitors per patient request.” It was the first time the sign was there. So, now, again, besides my daily abdominal exam, cursory heart/lungs/edema/mental status, check of lab values and recommendations for more platelets – I didn’t go.

I did go see the third patient – the one who is and will be sick, but chronically. I stayed with her and her mother for over an hour. There was something vibrant, then, about that day.

The resident said, offhand, that I didn’t need to follow K anymore – we didn’t even need to see her on rounds, not really. Nothing was changing. There was nothing to do.

The second K.

The second K was sick, for a few days. My formal presentation for that rotation was on the reasons she might be sick. She got better. I spoke with her parents several times, got to know them a bit. I met her mother’s friend and her mother’s mother, tiny and not-English-speaking.

I saw them again in clinic, the next week, with the intern who is their new pediatrician. They were more relaxed, there. Nervous, older, first-time parents.

The first K and the second K.

It’s an uncommon, beautiful name.

The unbelievable odds of having two patients with this name, of the not-so-many on my wire (I haven’t had any others with this name. I’ve had, and seen on teams, close to one thousand patients this year. More? More. )

I know exactly where each K is on the silver wire.

The first K had only boys (three) . If she’d had a girl, I doubt she would have named her after herself. But it’s a beautiful name. Maybe someone in her family will name a child K – in memoriam, in memory, in homage. One of her friends, maybe. A sister. It’s not a completely unlikely thing to happen. Especially for someone who died so young. The first time she had cancer, she was 26. They thought it went away. The second time – same cancer, now everywhere – she was 29.

I wanted to read the obituary. I wanted a small idea of who she had been in life – I didn’t want to remember her (as I picture her now) as wasted away,sinking back into a hospital bed, clearly dying. I never met any of her family. I know they came. She was beautiful. Vivacious. Loud, it looked like. Bold. Extroverted. Loved.

I was invited to a patient’s wedding this year – I didn’t go, because I didn’t get to speak to her right before she left. I was hesitating (I don’t think I would – hesitate – now). I sent a card, though. A patient brought in his daughter to meet me – he’d shown me her photos, before. Other patients kept me updated on their children’s plans and relationships. Where they’re traveling. How another patient’s son was doing in school – I met him too. Patients’ children and parents and spouses – I met lots of those. Often, I could name them before I met them – I’d heard the stories. And sometimes they already knew who I was. The patients I joked with – we ended up making fun of each other. The patients who broke down and cried. The real reasons they were there. The patients who got better, a little bit, by talking about it. The patient who is (I hope!) getting a day job, after his night job, which will help with his anxiety and his insomnia…I think, too, about the ones who were “lost-to-follow-up” – the ones I didn’t see again, or who didn’t make the next appointment. And I don’t do enough to follow-up with all of them. There is so much more I could do that I – don’t.

Patients I’d see almost every day for weeks (in the hospital that long). The patient I saw one time in clinic – and he left, angry. Marginally housed. I couldn’t do anything for that. And then I saw he was in the ICU. I saw him there. I read the chart. I checked the notes and labs and radiology reports. When he came back to clinic – he made it through that, miraculously with how sick he was – he mentioned to me what had happened and how miraculous it all was. I told him I knew, because I had been there. There’s the patient who deeply disturbed me. We (the preceptor and I) almost hoped one of the drug tests was positive, it would explain things a bit more, his affect, something. . . the tests were all negative. I haven’t forgotten him either.

I can picture the ones who died – most of them, some of them. I can picture the ones who were born – most of them, some of them.

The morning after the first baby I helped be born, after I’d been working for about 26 hours, I went to sit and think about him, on a beautiful overlook. Softly, ‘Happy Birthday’ to him – even though we didn’t know, yet, what his name was.

The angry patients, the happy ones, the ones who are frustrating, the ones who are frustrated.

This year was one of the harder and better ones. This year. The third year, the first year of the rest of my (medical) career – the first one that is spent, entirely, in the hospital and in clinics. (years leading up to this, actively working toward a career in medicine? 9. Years since I’ve been thinking about going into medicine? 16) . Of 48 weeks of work (and four of vacation), two weeks were spent in the classroom and in lecture. Two. And counting the weekends and nights we worked and the 60-80++ hour weeks – that’s still more days than you’d usually consider in 46 weeks.

And this is what it means, to be a doctor.

This is what it means.

The rest is a lot, a lot, a lot of learning, and a lot of practice, and a lot more terrible and wonderful things, and a lot more responsibility. That will happen, that’s ahead and on the way.

A friend asked me recently if doctors think about their patients, outside of the office.

Is it possible not to?

I’ve learned, this year, I’ve seen so many doctors go above and beyond what I ever knew for their patients. It’s an incredible privilege – all of this. And the conception of the third year, the necessity to be a part of so many specialties at shifting times, means learning about what it means to be a physician more than what it means to be a particular type of doctor. There are qualities of physicians that transcend their particular work, and those are the ones I want to be, in whatever I do.

You learn how to balance things. Each birth and death since the first ones has meant something to me, has had its own space – but not in the same way. You learn to incorporate things together. An amalgamation. All of these matter, each has to matter every time, but it can’t overshadow everything else, it can’t overwhelm the space of a day or an hour.

But you remember. You worry about the biopsy. You wonder about the labs. It isn’t just that.

If a patient gets sicker – but there are so many kinds of sicker.

If a patient gets better – but there are so many kinds of better. All of them matter. We know that.

This is what it means.

For the first K and the second K.

The first K and the second K.

If there is one thing about this year that is right, it’s that.

Forget you?

No.

The rooster that appeased the gods and saved a wedding

2011-04-16T18:52:00.000+01:00

*This was written as an oral narrative for a Peace Corps anniversary story telling event*

It was a village without a wedding. Two years, no wedding.

In the south of Cameroon, there aren’t a lot of ceremonies. Much of the “traditional”, what might have been there, was obliterated by missionaries of various types. The chiefs – installed as part of the government, partly, though still in inherited positions – call cobbled-together army uniforms their “traditional” costumes.

In the south, almost no one gets married. In Bulu culture, girls have to have a baby before they can get married, to prove that they can. And marriages, for the most part, are traditional. The couple who gets an official ceremony is seen – revered, almost – as serious. Probably a bit higher social status, too. It’s rare, in the south. (I knew maybe 3 couples who had, all “big men” in town)

I’d been to funerals. I’d been to a lot of funerals. I’d seen babies die, I’d known a lot of people with advancing AIDS. Malnutrition, malaria, TB, onchocercosis, measles, residuals of polio.

Before I left, I wanted a wedding.

I met Carine on my first site visit, before I moved in. She was president of the Tantines association for teen mothers (GTZ). When I met her, she lived with Alino, her boyfriend of some years, and her five-year-old son Willy (not his). They owned the largest bar in town, and the only one that felt – to me – like a comfortable place to hang out during the day. In the beginning, I talked with Carine about projects with the Tantines. I went to a meeting, I met the other Tantines, we talked about projects, family planning, HIV. . . But then, like many baby projects in village, this one fell apart as most of the women moved away – to other villages or to town to go to school (or just had other babies with more other men). For the next two years, I visited Carine – often – as a friend.

Carine’s Alino (to differentiate him from the other one in town) was/is one of the best men I knew there. Good-looking, smart, enterprising, friendly –a friend to me – and truly a father to Willy. Alino did 2/3 of a college degree in biology, but then his father died and the family ran out of money and he had to return to village. Typical story. Alino does Kung Fu, started the Kung Fu association in town – and on festival days, he and Willy (yes, age 5) would perform together.

It was two years and I wanted a wedding.

Anyway.

June of my first year in village, Carine had a second child. (It was another reason she couldn’t be president of the Tantines, again). I was away from village the week their son was born.

“Le Prince,” they called him. “The prince”, including, “the.” The happiest, roundest baby you’ve ever seen – at six months, he looked a year old, and more like a sumo wrestler than a future martial arts star. Alino couldn’t be prouder – of both of his sons. (And le Prince learned kung fu, too)

As friends came to visit me – other PCVs – we would always hang out chez Carine and Alino. My close PC friends got to know them well. And le Prince was a crowd favorite. I took my counterpart when we went out to eat. He was hard to convince sometimes – Carine had fish – he wanted to go where there was more bushmeat. Whenever we had conferences or meetings at the hospital, I would order food from Carine.

Middle of my second year, Carine told me they were getting married. Real married, she said. Civil married. Status. She was planning the wedding for November – I would be leaving at the end of November. I told her that, hoping, hoping she would arrange it so I could go. . .and she did.

(You’re still wondering about the rooster. I’m getting there)

In Cameroon, the tradition for weddings is that the couple chooses a pagne that everyone attending the wedding has to buy, and then get clothes made out of. Everyone, then, is dressed in the same fabric, but in so many different styles, supporting the couple and really coming together as a cohesive unit. We talked about this. We talked about picking out the other things for the wedding, the bright pink and shiny bridesmaids dresses for the part at the mayor’s, the dowry (from Alino’s family), the invitations (I made them, printed in color in the city, took the picture of them for it) .

And then one day I went to talk to her – a light day, something out of the more difficult bits – to just sit and chat with a friend about her wedding. But it wasn’t that kind of a day. I didn’t understand, for awhile. “Régime, régime, régime. . .”

(In French, in Cameroon, this means – bunch of plantains – diet – or type of marriage).

When you get married, in Cameroon, there are two official choices – monogamy or polygamy.

Alino is Bamoun, from the West province, and Carine is from the East province but has grown up in the South. Two very very different cultures. The West is steeped in different traditions, polygamy. (one of my friends, from the West, became a chief (small one) after his father died. He had one wife at the time, but then had to take more, also inheriting – symbolically – his father’s 36 wives. It was supposed to be a secret, how many wives he took on after that. He wouldn’t tell. Until the day I said I was so sad to leave Cameroon, and he said, don’t worry, you can stay, I’ll marry you and you’ll be my 12^th wife, and you can work and do whatever you want!”)

Alino’s father was a polygamist. There, monogamy – the official kind, the kind that means a man can’t officially marry another wife – means he’s weak, and that his wife is, in some sorts, trying to be his equal. He can’t expand his family more (civil marriage means more in the West. It’s more common). His family was putting the pressure on him, and how. . .

And Carine was upset and wanted to call off the wedding. Alino tried to console her –“ just say polygamy, it’ll make my family happy – and then I won’t marry again.” She didn’t want any of that. There was no certainty in it for her, no security, and he would be able to hold it over her. . . and his family could find him a second wife and make him marry her too. . .no, no, no.

The wedding was getting closer, and nothing had been resolved.

His family made the very long trip down for the wedding, first time they'd been in the rainforest.

I had four Peace Corps trainees and two other PCVs at my house, including L, my closest friend and one of Carine’s.

Day of the wedding, things were tense. Alino wasn’t smiling, mostly – though that’s part of the aesthetic in formal poses in Cameroon (not smiling, short ties, photos that include shoes, and possibly holding cell phones). The traditional part, incorporating the south/east and the west, multiple languages, and the “important” people sitting inside while others danced in bags of rice and wine and fish, went well – except – the families were barely speaking. The official wedding, the civil one at the town hall, was scheduled for later in the afternoon.

They rode in by car – the doctor offered his for the 2 minute ride through town, the white official pickup strewn with pink streamers. Everyone filed into the town hall, dressed alike, except for the shiny pink bridesmaids. For this part of the wedding, Carine was in a very Western-looking white dress. The mayor went through the lines. When it came to the part about régime, he asked Carine first. “Monogame où polygame?” She waited. Dramatic or deliberating? We were holding our breath. Everyone was craning forward. Everyone knew what had been going on. And then she said it. “Monogame.” A sigh and a cheer went through the crowd – still quiet – but obviously supportive of her. Alino was next, and he had no choice but to repeat her words, softly and a little miserable-looking.

The crowd erupted outside. It was dark – the pictures I have aren’t in good light. It was a day (like 95% of them, in village) without electricity. Still hours to wait before the reception. Alino’s family withdrew. I don’t think they were talking to anyone else, much, at that point.And there was no power. That, they had planned for. They’d rented a generator for the community space, they’d bought gas, everything was hooked up and ready.

And it wouldn’t start.

No matter what they tried (and the generator had been tested the night before), it wouldn’t start. Nothing. And then the rain started.(It hadn’t rained in 2 days) . And walking into town from my house, we had encountered the fourmis mangeantes – the ones that ate a child in The Poisonwood Bible, migrated through town on occasion (with a path straight through my house,) and hurt like burning hell.

We went to the bar to see what was going on. Carine was panicking less than I’d imagine. Candles on there, kerosene lamps. She’d figured out what to do.

“It’s the Bamoun spirits. We have to find the rooster.”

“The. . .”

“Rooster. It’s the ancestral spirit. It ran away and we have to get it back. My brother’s going.”

L and I looked at each other. One particular rooster. In the pouring rain. At night. . .

Like anything else in village, we sat, and we waited. . . and we had another drink. . .three hours. Three hours after they’d started trying to start the generator, Carine’s brother came back with a rooster – the rooster, apparently. He had to sacrifice the rooster, and it had to be him.

Behind the house, with a sharpened machete. . . this part was fast.

And then they tried the generator again.

It worked. On the first tug of the engine, it worked (!!)

And then the rain stopped.

At the reception, the emcee asked who had gifts for the couple and wrote us all down on a list. Then, in order, each person/group was called up – and a different song was played for each – and we had to dance the gifts up to the married couple. Then we danced with them to the rest of the song. I was learning these traditions – it was my first wedding, after all. L and I danced to the front, holding the Peace Corps pagne (among other things) that we’d bought for them.

Carine’s mother-in-law told her, later, in private, that she was proud, and that Carine had made the right decision. She was one of multiple wives, and she didn’t want that life.

For months and years after a wedding, you see the clothes around town, as well.

So for Carine and Alino – who I got to see when I went back, a year and a half later, who now have the little girl Carine had hoped for, after two boys, and a larger house than the room behind the bar where they used to stay –

I’m wearing this for you.

Open heart, open book

2011-04-11T04:20:00.000+01:00

“Don’t faint.”

“Don’t worry.”

“Seriously, don’t faint. Maybe you should stand back.”

I grinned. “I’ve been looking forward to this for years.”

“Still. That might be worse.”

“I’m fine.”

And then he cracked open the chest and we could see the patient’s heart.

It had been slow and methodical up to that point. The skin incision, stem to stern – the open heart incision people are used to seeing. Someone has been inside you. Someone has touched the part of you that makes you alive. It was the usual things. Careful splitting of fascia. The muscles that separate willingly, that sometimes spring apart under your fingers. A lot of things in surgery are done with fingers, actually. We call it “blunt dissection.” For many things, no instrument is best.

He spread the muscle off the ribs – these, these are the ribs. Attachments of muscle left. These bones are alive. These bones are full of marrow – we saw that. It’s how they heal and why they – parts of them – do bleed. What protects the heart has to be already full of life.

Anyway. Ribs, sternum, everything we’d felt from the outside. Large, huge actually xiphoid process (bottom of the sternum) – we already knew that. Careful, careful cleaning for this things that must remain alive (they will), and then R, the fellow, took up the sternal saw. And then the sternum – the chest cage – was open. And then the retractors, and then we spread it.

It happens on ER, it happens on Grey’s Anatomy, everywhere. “Sternal saw.” “Rib spreader.”

We spread the ribs. The retractor, the tightened screws attached to the table, held them apart.

We were watching the heart before we saw it. The anesthesiologists were doing a continuous transesophageal echo. The typical one, the one you imagine ultrasound to be, which many people think is just for fetuses (I think), is transthoracic – through the chest wall – looking down into the heart.

You don’t see as much that way.

The esophagus is directly behind the heart. So the probe for this one goes through the patient’s mouth (patient is asleep), down, down, down and stops before the stomach. You are directly behind the heart. We are watching the grainy black-white-gray in real-time, on a TV screen. You can see the valves moving, the suggestion of beautiful, intricate leaflets. If you turn on the Doppler flow, you can see where and how the blood is moving, and if there are any holes in the heart.

Kribi, Cameroun

It was just me and R, at that point. He had to dissect the pericardium. That’s where the heart lives – it’s not unprotected within bone. It’s the shroud, the cocoon. I held it up with forceps( ‘pick-ups’, they’re called) so he could cut down the middle. With scissors.

You use these for delicate things. We also use fingers.

And it seems like it should be harder, that this shouldn’t work.

The bypasses – veins from his leg – are sewn into his heart with teeny-tiny thread on teeny-tiny needles. It seems like this shouldn’t work, and the shortest part of the surgery is actually connecting these veins, and arteries from the chest wall, from the outside map of the heart to aortic blood supply.

But before any of that happened.

We stopped his heart. When I helped to open it, it was still beating. It’s not the heart you even see in realistic photos or drawings – there’s fat around it. It protects it. Depending on the patient, there is more or less. The body, though, puts cushions where they are needed most. Otherwise, it would swing into the ribcage.

Pericardium opened, we saw the heart better, the attending came in, and I stepped aside and was twisted into a corner. They sewed – temporary – artificial tubes into sides of the heart, grafting them. Temporary. They turned on the special solution – cardioplegic – that stops the heart, that cools it down. Cold. You could use this to kill a person if you weren’t careful, if you weren’t using the machines.

And he was exsanguinated.

Blood to a machine. Bypass. Spinning, spun, oxygen put back in, returned to the rest of the body. The heart wasn’t beating anymore. We had turned on the clock to time this. His blood was cycling outside of his body. Patients can be on this for weeks or months. Nothing more dramatic than being kept alive by this machine. You don’t need lungs (you’re under anesthesia. There’s a tube down your throat. If the anesthesiologist stops pumping oxygen into it – they do – then your lungs don’t move).

You don’t need a heart.

Every time something like this happens in surgery, there’s a gasp (from me), an incredulousness, a wonder and absolute disbelief that anyone would dare do this to another person. The gall. The arrogance. The power. The saving of people, sometimes, by stopping their hearts. By clamping their aortas. By taking veins out and moving them. By cutting into their brains. While removing parts of their spine and grinding them up with pliers.

Anyway. His heart was stopped and restarted again. And in the middle, with tiny thread and tiny needles, human hands – no better, no worse – sewed new vessels into his heart.

Open heart surgery is why I’m in medicine.

(Not that I ever wanted to do it).

I was always afraid of blood. Little, I was more squeamish than I can even imagine or remember. Even the sight of meat that was a little rare made me sick.

And then I decided I wanted to be a doctor. I had to get over it – no choice. At the Science Museum, in the human body bits, there was a video of open heart surgery. Just the chest open, the heart, and the surgeon hands. I made myself stand and watch it twice, all the way through.

And that was it.

I remember the day I first held a heart in my hands. It was my cadaver’s heart – we had been through much of the body at that point (it was November), and we took out the hearts. Back then, everything we did felt slightly anathema and extremely bold. Removing the intestines. Cutting through and exposing each layer of skin and muscle. Opening organs. And this is for a person who didn’t need them anymore, who had gifted them to us so we could learn.

That day, we took out the heart. It was election day, 2008, Tuesday, because later that night, Obama was elected. Earlier that day, I held a heart.

My cadaver had had a valve replaced. Even before getting to the heart, we knew she’d had surgery – there were the obvious scars.It was one of the most beautiful things I’d ever seen. The valves have two or three leaflets. Delicate. You can imagine them fluttering. This, this is what keeps us alive, keeps blood moving and not moving in an ordered fashion. They can be replaced. They can tear. But for the most part, they do work, and forever (as long as that means something). I was cradling it for awhile, with two hands. It was heavy. I couldn’t put it down. I couldn’t believe that this, this was the heart.

(excerpt from a letter/poem I wrote to my cadaver)

Your heart.

Your exquisite

heart. Aorta,

fleur-de-lis.

Scalloped

edges of left ventricle fluttered

open.

Butterfly chords. Parachutes.

Staples in the louvers

of your chest –

you had been opened before.

You had been reconnected.

Later this week, in surgery again, we took out a man’s esophagus and reconnected his stomach to the top end of it (for cancer). It’s amazing that this works. It’s amazing that patients have, essentially, normal swallowing and digestion. At any rate. The incisions are in the abdomen and in the neck. The stomach has to be pulled up in-between, to be the new esophagus. The stomach has to go behind the heart. And we don’t open the rib cage. The surgeons are dissecting “blind”, with their fingers, separating the esophagus from surrounding tissues. Gently. In typical med student fashion, I was holding the retractor, hard, needing both hands, holding one with a light on the end that pulled up the area where they were working and helped them see deeper inside. It’s painful to hold something that way for a long time. When I could relax – when they did – at first, I thought the pulsations were just from my hands in their very tight gloves. And then the pulsations started to bounce my hands, up and down, up and down, with a vigorous, exuberant force. I knew, but I asked anyway. “Am I on. . .”

“You’re on the heart.”

Dance is a good complement to medicine.

2011-04-03T21:30:00.000+01:00

I’ve been doing a few different types of dance, lately, and I just spent an evening watching semi-professional break dancers and circus performers and aerialists and capoeristas and…whatever else…just play. There were photos of Cirque de Soleil-type poses around the performance space. Having seen the spine, knowing some of the physical mechanics of the human body – it’s astounding to me to see that it’s capable of this. It seems as if it shouldn’t be possible. These are the things we learn.

When I see patients in the hospital, they’re in bed. The note, in fact (assuming the patient is doing well) will include something like this in the General subsection of Objective findings. “Comfortable, resting in bed, NAD (no acute distress).” If it’s a psych note, it will also state “dressed in hospital attire,” and I might make some comment about the state of dress (disheveled?) or hygiene – as indicators of state of mind, situation, possible delirium, connection to the outside world - or supposed to be. I might say “looks older” or “looks younger than stated age.”
(I rarely do this, but I had two patients in clinic the other day – same disease, basically the same operation. One was 62 and one was 82. Having read the charts, then going into the rooms, I had to double-check the names. The 82 year old looked much younger). Same for the 87-year-old who plays 18 holes of golf everyday and catches very large fish – he had a huge abdominal aortic aneurysm, without any symptoms, and by all rights, he should have symptoms, or have been sick. He wasn’t. It could kill him, so it had to operated on. Otherwise, he was very, very much alive.

Yaounde

There’s not much that makes an awake person look more vulnerable than lying in a hospital bed in a hospital gown. Regulations. It’s easier access for everything we have to do. Add lines and catheters and other things to make them look/be more trapped and helpless. There’s privacy and there’s not. We try. Some are better at it than others. But in the hospital, there’s an endless parade of health professionals of various types, all day, coming in to exam you. In, out, in, out. Physically, it might depend on your particular reason for being in the hospital as to how intimate/invasive an exam might seen. Some things, though, everyone gets.

I’ve had patients from the hospital then follow-up in my primary care clinic. They looked like completely different people. (Good lesson, that). Home, able to dress and shower as they liked, in their own clothes, and standing and sitting and walking around the room. Comfortably. Some patients do put on gowns, but mostly, they don’t (or didn’t, in this particular clinic). Even if they did, I usually saw them in street clothes either before or after. They walked in. They didn’t look as vulnerable anymore. In the hospital, I sit down next to the patient’s bed, when we’re talking, and at times I sit on the bed. But there’s a major inequality there. In the office, we meet more collegially. Longer term problems are more of a team thing – for my patients to stop smoking (three did) takes both of us talking and working on it. Hypertension, diabetes, anything. It can’t be just me and it can’t be just them. In the hospital, though, you’re more helpless. Other than the powers of positive thinking (true), things are happening and being done to you, in the acute sense. You have no control over food. You might not be allowed to get up (fall risk) without another person around, and if you do get to take a walk, you’re dragging an IV pole. You can’t cure your own pneumonia or small bowel obstruction or COPD exacerbation or lupus exacerbation, while you’re in the hospital. There’s not much agency there.

I had a 15-year-old patient with acute kidney failure, and we were severely restricting his fluid intake to make his body re-equilibrate sodium (the treatment). To know if we were doing this, we had to know “Strict I’s and O’s” – input and output. Fluids. His rebellion against the medical system was to not to use the specially-designed urinal to record volume (important? actually, yes). He forgot, or he didn’t, and this was the one way he could – not – do what the doctors were telling him, in this instance. So little participation required or asked for in those settings.

Sequoia national forest

Anyway, patients are vulnerable. On a work basis, I don’t see bodies in motion very much. The moving targets are the doctors, rushing around, up and down and rounding and rounding and having team discussions while running in the stairwell and…if you don’t keep up, if you linger riefly to do something else, you will get left behind. I write notes while walking, sometimes. The mandatory alcohol hand sanitizers in the hallway? You never stop to use one, it’s a drive-by thing. Most things are. And the times we run – the codes, the emergencies – are full of adrenaline.

Even in the office, patients get up from chair to table and back again. I know if they walked in. I ask about activities. I might test range of motion, so I see how – actively – they can flex and extend, and then I check passive motion and move the joints for them.

The amazingness of the body is the physiology, in this sense. It’s hearing the heart and lungs, feeling the liver and spleen in the abdomen, finding neurologic abnormalities, seeing internal organs from the outside. In the OR, it’s everything that’s still alive, pink and pulsating, and that, gods, all the structures we learned about and then saw in cadaver dissections are really there. Each part is full of life; so is the incredible whole.

Around Nselang...things that shouldn't be possible, but are

Patients don’t always get to show me their amazing. One patient, who was supposed to get open-heart surgery last week, had high blood pressure up to 250 systolic in pre-op and then 315 when anesthesia was starting to put him under. I’m still incredulous – though I knew, and I knew – that you can be alive with a blood pressure that high (‘normal’ systolic is < 140).

So that was amazing. But it was a physiologic response. The patients who are so sick you’re not sure how much better they can get – and then they do – are amazing. The patients with completely uncontrolled diabetes that has been so uncontrolled they can no longer feel their feet – who work hard and get their blood sugars under control – they’re amazing.

I had a teenage patient, post-severe concussion, who’s a dancer and told me about his ethnic dance group. There’s the kid who broke his hand playing basketball. I know, I talk with them about what they can do physically and how important it is to them.

But I don’t see it.

Seeing bodies in motion, then, seeing things that shouldn’t be able to happen due to gravity and bones and ligaments and facet joints between vertebrae – is a reminder of why what we do matters, in the long run. It’s the why. The living that isn’t just being alive, but the celebration thereof, and everything concomitant. They why does come up – operative or medical choices and how they impact a particular person’s life. With the basketball player – he had championship finals coming up the next week. To me, that meant that if we let him go with just precautions and no splinting or formal treatment – he would certainly reinjure himself or fracture what, at that point, was just an “almost.” For the dancer with the head injury, I needed to know if he was dizzy when dancing, if he was falling over, and if he had trouble remembering dances that he used to know well, or learning new ones. For my patient who worked nights, I made sure to get him the latest possible appointments in the afternoon, so that he could sleep. All of that is there in the encounter – particularly in the outpatient ones. And we talk about it, and I try to remember. But we don’t see it. In the hospital, especially for the sickest ones, I try to remember – and to find out, to ask – what they do, who they are, who they were when they weren’t sick. I want to imagine that. This is why it’s a good reminder. It’s absolutely incredible what people are capable of, what they can persevere against, and in the moment, all you can do is watch and be awe-inspired.

Addendum...

2011-03-16T22:32:00.000+01:00

A word on iodine... after talking to a thyroid surgeon. What I didn't know is that, for various reasons (including reactors releasing radioactive iodine), thyroid cancer is the most common neoplastic sequela of nuclear explosion/accidents (Chernobyl...). You can't prevent leukemia or lymphoma, obviously. But if you give supersaturated potassium iodide (SSKI), it...supersaturates iodine receptors on the thyroid, blocking immediate uptake of radioactive isotopes. And iodine has a pretty short half-life, so those go away within...not too long. Other isotopes, though...are around much longer.
And apparently Homeland Security has stockpiles of SSKI at various undisclosed locations in the US in the case of such a disaster.
And iodized salt, in general, is a major public health advance/success of the 20th century.

Iodized salt poster! N'djamena, Chad