Category: Nonfiction

Categories
Lessons Medicine Nonfiction Reflection

Repost: Control.

I wrote the post below over ten years ago during my last year of medical school. I was on an elective hospice rotation. This came to mind this weekend after I visited a mentor who is dying from cancer. Someone from a hospice service also visited him while I was there.

I will miss him.

We all die.

Really. We all die.

And people know this. Sort of. Kind of. Maybe.

Some people accept this fact that yes, we all die, with calm grace. Some, indeed, genuinely welcome death and look forward to shedding this mortal coil. Some don’t necessarily want to die, but they recognize the inevitable fact and actively choose to spend the rest of their days living, not dying.

And then there are people who fight death. Or maybe it’s not death itself that they fight; they fight their mortality. They struggle with the fact that life will end. They don’t want to relinquish control over their existences. They want to know how much time they have left, what exactly will happen, and how things will progress between this moment and that last breath.

Family members of dying people (but really, aren’t we all dying?) seem to feel more—sadness? anger? frustration?—whatever; they often seem to feel more than the patients. The Type A’s get super Type A, jumping all over the place, asking How? When? Why? What? How much? How often? How quickly? How slowly? Can I do this? What about this? And that? The angry people get angrier, but I don’t think the core emotion is anger. The sad people try not to feel more sad, but their cheery smiles are obviously superficial. And the crazy people just get crazier.[1. I wince at what words I used to describe people in the past. I hope the wincing means that I’ve gained some wisdom over the years.]

It’s not fair to say that this grief is entirely selfish, but in a way, it is: If the loved one dies, it is a theft from the person in question. There will no longer be any shared moments, quiet glances, bursts of laughter, or shouting matches. And if the loved one dies, it only reminds us of our own mortality.

Because we all die. We just don’t believe it.

A hospice nurse and I sat in a family’s house for nearly an hour this afternoon. The patient, an aging woman, lay on the gurney in the living room. She’s had multiple strokes and doesn’t interact with the world. Her eyes fix upon yours, but she’s not looking at you. Her pale lips, smeared with Vaseline, are parted. Her left foot writhes in the bed, as if forming cursive letters on the white sheets. Her skin is cool and she doesn’t really react to the touch of another human hand.

Her daughters keep extensive notes about her: How much did she pee? poop? sleep? Has her skin changed color? Is she throwing up? How much morphine has she gotten? (They won”t say “morphine” in the room; they call it “M”.)

They don’t want to give her too much morphine because they fear that they will kill her. And yet they want her to be comfortable—and the grimaces on her face suggest that she is not. The daughter who is administering the morphine will not—cannot—give her any more.

“It’s about HER comfort, not YOURS,” her sister said, trying not to shout at her.

“Well, you don’t want to give it to her, so I am, and this is what I’m comfortable with,” the sister replied.

“I know she’s declining… I know she is…” and yet she cannot accept this fact completely and buries herself in her dying mother’s urine and fecal output, her blood pressure and pulse measurements, the dosages of her medicines.

It’s about control. Lack thereof, really. And to sit there, actively listen, and be present with these patients is exhausting. You literally feel what they feel, and yet you also feel what you feel in response to their feelings, and your brain is running through the algorithms of disease. So you monitor yourself while you monitor them, staying in the moment, completely unsure of how the next moment will unfold. Part of you wants to comfort them and part of you wants to scream in frustration. Part of you wants to run away and enjoy the gorgeous world outside and part of you wants to give everyone in the room a big hug. Part of you wants to give up completely and part of you wants to fight for the life that remains.

God, it is so beautiful to be alive.

Categories
Nonfiction Reflection

Thanksgiving.

As my father and I came out of the clearing and saw the shore, he exclaimed, “Wow—it’s so pretty!”

shore

We started walking more slowly. The air was cold on our faces, but the sun warmed our backs. He squinted at the shining water and I saw his exhalation transform into grey wisps.

“Sometimes things are so good that it feels sad,” he murmured.

When I met a friend for lunch yesterday, I confessed, “Something about today is making me miss my mom. I don’t know what it is. It’s not the weather, because it never got this cold in California.”

“Maybe it’s because it’s sunny,” he guessed.

He had a point: It is usually not cloudless and sunny at this time of year in Seattle. When I stepped outside my face reflexively scrunched up; the sun was so bright! But I knew that wasn’t it, either: The sunlight in Seattle looks more “sharp” and white; the sunlight in Southern California looks more “soft” and yellow. (I assume that there is science behind this perception, whether it is actually a function of latitude or a function of my retinas.)

Later in the day I realized that we were close to the Thanksgiving holiday. Today I realized that yesterday was November 21st.

My husband and I were seated at a corner table in a restaurant in Sea-Tac airport on November 21st, 2013. I had ordered a plate of nachos. Our flight to California to see my parents was scheduled to take off in about 90 minutes.

My phone rang. It was my father. My father never called me. Something was wrong. I stepped out of the restaurant.

“Okay, Maria,” he said. He was trying not to talk fast. “Mom went to the hospital today.”

“What?” I blurted. “What happened?” Accident? Injury?

My father had worked as a computer programmer. He was trying to remember all the words the doctors had used.

“She’s on the second floor of the hospital, in a room by herself, a special care unit—”

“Intensive care unit?”

“Yes, yes, intensive care unit. They took her directly there. They said that she would be monitored overnight because she has water and blood in her lung.”

“Water and blood in her lung? Blood clot?”

“Yes, blood clot. I think in her right lung.”

Pulmonary embolism? From what?

I tried to not talk too fast, either: “Did they say how big the clot is?”

“Medium-sized? It was really hard for her to breathe.”

“And water around her lungs?”

“Yes, they said it was a lot of water. They also did some scans, see-tee? CT scans. They said that there is something in her lung. Both lungs?”

Cancer.

“Did they tell you what they think it is?”

“No, not yet. They said that the doctors will know more tomorrow.”

He then asked me if I could reschedule our plans to visit Disneyland the next day. I almost laughed out loud at the absurdity of his question.

I don’t know if I believe the idea that our bodies remember things that our minds don’t. I don’t disbelieve it, but I can’t explain it.

It’s hard to talk about things you can’t explain.

There are and will be plenty of blog posts exhorting us all to express gratitude this Thanksgiving holiday. I won’t run through a list of things you and I “should” be grateful for. To be clear: I do encourage you to go through the exercise (and not just on Thanksgiving), but these reflections are often best done in solitude.

As you we think about all the things we are thankful for, it’s not uncommon for us to feel a swirl of different emotions. That’s okay: We feel the way that we feel. Sometimes things are so good that it feels sad.

Categories
Consult-Liaison Education Informal-curriculum Medicine Nonfiction Observations Reflection

Teaching Moment.

The Chief of Service ushered me into the room, but said nothing. His staff of fifteen looked at the Chief with expectation and, upon realizing that he was looking at me and probably wasn’t go to say anything—including my name or the reason for my visit—the fifteen people joined him in looking at me.

“Hi,” I said, taking the cue and flashing The Winning Smile. This is my name, this is my title, and this is why I’m here: As a psychiatrist, I think there is overlap in the work that we do and in the patients that we see—

“Is it okay if we refer to your patients as ‘wackos’?” the Chief blurted out. Nervous laughter twittered among his staff.

“I’d prefer that you didn’t.” My voice was light; my face was dark.

“Oh. I guess another psychiatrist should have told me that.” He was still smiling.

“I hope I’m not the first one to do so.” When he finally saw the lasers shooting from my eyes, his smile dissolved and he looked down.

There are several reasons why I believe that social skills are not his forte:

  • He either chose not to or did not think he needed to introduce me to his staff.
  • As a Chief of Service he should have known better than to say such things in front of his entire staff.
  • This exchange occurred within five minutes of us meeting each other.

I think his question—“Is it okay if we refer to your patients as ‘wackos’?”—was his honest effort to connect his staff and me together. Everyone would have a good laugh, we’d share something in common, and we could move forward with greater ease. He thought his comment was benign.

It makes me wonder, though: Had he made a similar comment in the past to another psychiatrist? And had that psychiatrist laughed? Did a ridiculous repartee follow?

Did another psychiatrist reinforce this sort of behavior?

He’s not a “schizophrenic”. He’s a guy with a diagnosis of schizophrenia. Maybe he’s even a guy who is skilled guitar player, a father of two children, and has a degree in political science who happens to have a diagnosis of schizophrenia.

She’s not a “brittle diabetic”. She’s a woman with a diagnosis of diabetes. Maybe she has a knack for training dogs, has a remarkable talent for singing, and was on her way to law school when she was first diagnosed with diabetes.

People are people with various interests, talents, and potentials. They are not their medical conditions.

No one is a “wacko”.

The Chief of Service sent me an e-mail later:

Thank you for visiting us and also for your gentle way of reminding me of my crudeness and insensitivity. I am sure you hear enough negative attitudes towards your clients that you would welcome the opportunity to create a more positive attitude towards mental health issues.

I actually don’t hear many “negative attitudes” about my patients. Perhaps this is because every moment can be a teaching moment and, over time, people learn not to use such language (at least around me). As I noted several years ago:

Doc­tors, like most peo­ple, often assign adjec­tives to patients because it can be hard to iden­tify and then acknowl­edge emo­tions. It is much eas­ier to say, “She is such a dif­fi­cult patient! She is never happy with her care!” than to say, “I feel angry and help­less when I see her because it seems like noth­ing improves her symp­toms!” Leav­ing out the sub­jec­tive “I” gives the illu­sion of objec­tiv­ity and professionalism.

I can only hope that the Chief of Service shared his reflection about his “crudeness and insensitivity” with his staff.

Categories
Nonfiction Observations

Border Crossing.

When we crossed back into the US yesterday, this is how the conversation went with the border officer:

Husband hands officer three US passports.

US BORDER OFFICER: So there’s three of you, huh?

HUSBAND: Yes.

OFFICER: How are the other two connected to you?

HUSBAND: That’s my wife in the back seat and this is her father.

OFFICER: Where do you live?

HUSBAND: Seattle.

OFFICER: Where did you go?

HUSBAND: To Vancouver.

OFFICER: How long were there for?

HUSBAND: Just for the day.

OFFICER: Why did you go to Vancouver?

HUSBAND: To sightsee.

OFFICER: Well, how was it?

PAUSE. HUSBAND and FATHER speak at the same time:

HUSBAND: It was fun.
FATHER: Great!

OFFICER: Are you bringing anything back with you?

HUSBAND: No.

OFFICER: Okay. (hands passports back) Have a nice day.

The car pulls away from checkpoint. MARIA exclaims: That guy was so easy on us! That was the smoothest border crossing we have ever had!

This is the conversation we had the last time we were at the border. I have not embellished it:

Husband hands border officer two passports.

US BORDER OFFICER: How are you two related?

HUSBAND: She’s my wife.

OFFICER: Where do you live?

HUSBAND: Seattle.

OFFICER: Where did you go?

HUSBAND: To Vancouver.

OFFICER: Where did you go in Vancouver?

HUSBAND: Downtown and Stanley Park.

OFFICER: How long were you in Vancouver for?

HUSBAND: Just for the day.

OFFICER: Why were you there just for the day?

HUSBAND: (pointing at MARIA) To see some of her friends.

OFFICER: Why were your friends in Vancouver?

HUSBAND: To take a cruise to Alaska.

OFFICER: Are you bringing anything back with you?

HUSBAND: No.

OFFICER (to HUSBAND): What do you do for a living?

HUSBAND: I’m a scientist.

OFFICER (to MARIA): What do you do for a living?

MARIA: I work as a doctor.

OFFICER: Where did you go to medical school?

MARIA: UC Davis.

OFFICER: Where is UC Davis?

MARIA: Near Sacramento. In California.

OFFICER: Is this your car?

HUSBAND: No, it’s a rental.

OFFICER: If you live in Seattle, why did you rent a car?

HUSBAND: We don’t own a car.

OFFICER flips through passports, scans the faces of HUSBAND and MARIA, then hands them the passports.

OFFICER: Okay. You can go.

Let’s be clear: In the grand scheme of things, this was not a terrible situation. No one asked us to get out of the car. No one searched our bags. No one got hurt.

Most of our experiences at the security checkpoint to return to the US, however, have been more like the second anecdote than the first. The officers often ask irrelevant questions (“what hotel did you stay at?” “what restaurant did you go to?”), make inquiries about the car (“where did you rent the car from?”), and never make pleasantries. In fact, as we were waiting to get to the checkpoint yesterday, we reviewed every single thing we did in Vancouver. We wanted to ensure that we knew all the answers as a group.

Why the difference yesterday? We still used a rental car, everyone in the car still appeared Asian, and we still came from Seattle.

Was it because there were three of us? (Does an algorithm suggest that trios crossing the border are less likely to cause trouble?)

Was it because we had an elder with us? (Does the US border patrol have a lower suspicion of illegal activities when a genial senior citizen is part of the trio?)

Was it because the officer we saw yesterday was in a good mood?

Does it mean anything that Canadian border officers are less intrusive and kinder to us than the US border officers when we are returning home?

Categories
Informal-curriculum Nonfiction Observations

Name-calling.

Let me start by saying that it actually doesn’t happen that often.

The yelling and screaming usually comes from men who aren’t under my care. It often happens when I’m talking with my patients or when I am just walking past a cell block.

Sometimes, it is repetitive yelling that sounds like a metronome:

WHORE! WHORE! WHORE! WHORE!

Sometimes, it is a tirade:

F-CKING SLUT, you’re a F-CKING SLUT, d-mn whore, F-CKING C-NT, YOU HEAR ME? YOU’RE A F-CKING SLUT, YOU F-CKING B-TCH, yes, YOU, you’re a F-CKING BITCH…

Other men take issue with my short hair and assert that I am a lesbian:

You’re a LESBIAN, aren’t you? What the F-CK is wrong with you, LESBO? Why don’t you like dick? F-CKING LESBIAN, you and your F-CKING SHORT HAIR…

For reasons I don’t understand, it is uncommon for men to yell racial slurs at me.[1. No one in jail has yet to call me a “chink“—at least not to my face or when I am in earshot. I did have a patient who would intersperse his sentences with musical phrases: “Ching chong ding ding ting tang…”. He didn’t do this with anyone else. He also refused to believe that I am a physician. He insisted, “There’s no way you’re a doctor. Women can’t be doctors. You’re probably just a clinical assistant. Women aren’t smart enough to be doctors.” I steered the conversation elsewhere.]

I have since learned that those men who yell synonyms for commercial sex workers at me or insist that I am a lesbian become more enraged when I ask them to stop yelling. Usually it goes something like this:

Maria: “Hi. Could you please stop yelling for ten minutes so I can talk to the guy over there? It’s hard for me to hear him.”

Inmate: [spewing more hatred at a louder volume and a greater frequency]

This response differs from other men who yell for different reasons. Often the men who scream about the crimes of the government, the arrival of the aliens, the ghosts in the machines, and the coming of the Antichrist will acknowledge my request and kindly stop yelling. Some can’t stay quiet for more than three minutes, but they try.

On occasion, the men who are my patients—and sometimes these are the same men who proclaim that they are actually machines and not humans, or they can’t string together coherent sentences—will scream past me to the men yelling malicious things: “SHUT THE F-CK UP!”

Their imperatives often go unheeded.

Hearing this vitriol doesn’t bother me too much. I mean, it bothers me enough to write a blog post about it, but such behaviors make me wonder more about the suffering of these men. Perhaps these men are screaming at me because I am on the other side of their cell doors and they feel anger with their lack of freedom. Perhaps these men don’t like the inherent power differential between them and me in a setting like the jail. In an effort to assert dominance a man may shout misogynistic things at me because he is trying to close the gap between his status and my status. Maybe women in his past have done terrible things to him.

My male colleagues have mentioned that these same inmates might insist that they are gay. Otherwise, most of the commentary these men lob against my male colleagues are death threats. This is in contrast to the threats I receive; men usually threaten to rape me. (Let’s be clear: Such threats are rare.) And it is not necessarily the men who scream hateful things at me who threaten rape.

What people say and what they do aren’t always congruent, whether in the jail or elsewhere. Consider the men in jail who have been charged or convicted many times of sexual assault. They may never shout anything at female staff. Some of these men show great courtesy; they look me in the eye; they say “please”, “thank you”, and offer gracious social smiles.

One wonders what they do not say out loud.

Some people will judge you just based on how you look. To some men, women are malignant deviants; they induce fear and loathing. Some men decide that the best course of action is to hurl hatred at women.

Sometimes, they might do even worse things.