A Stitch in Time

At first I thought the beeping was coming from the television.  I had just settled back into the couch after tucking my daughter into bed for the second time.  Her tummy was hurting.  It had been doing that a lot lately.  Especially on Sunday nights with the specter of Monday morning looming large.  She was getting headaches, stomachaches, nausea.  It had been going on for some time.

My son is similar.  His headaches and bellyaches come and go.  He is famous for vomiting at any given moment and then feeling fine the next.  And to think of it, we have all been under the weather lately.  Our house, as so many, has been caught up in the hacking, runny nose, sore throat plague making its way though our neighborhood.  Katie was lethargic and had a headache almost everyday last week.

We were all coping though.  Getting better slowly as the body is wont to do.  There were no emergency room visits or trips to the pediatrician.  But we were all tired after a busy week and a hectic weekend.

So when the incessant beeping started, the first thing Katie did was turn down the volume on the TV.  When it stubbornly persisted, I grumpily made my way down to the basement to investigate the culprit.  Once in the basement, I tried to triangulate from which hidden corner the beeping was coming from.  The boiler?  The water heater?  The fire alarm? The beeping no longer felt benign as I held my fingers to my ears to keep from permanent hearing damage.  It was about when I focused on the CO sensor, that Katie called down to me.

It was the alarm company.  Our Carbon Monoxide levels were too high, and they called the fire department.  I rushed up the stairs, opened the house doors, and we gathered the children and coats.  Katie and the kids waited in the car, and I went to the front of the house and flagged down the fire truck.

It was not a false alarm.  The Carbon Monoxide level in our basement was 108 PPM.  According to the paramedic, one can survive in this range for about 10 to 15 minutes.  Katie's office was the next highest at 40 PPM (it usually takes about 8 hours for a person to be overcome at these levels).  The kids bedrooms were in the 30's.

The Firemen shut down the boiler and the water heater and opened all the windows.  Within minutes the levels had fallen to zero. We slept last night in a chilly home using our backup heating system that is meant for only half the house.  Slept is a loose term, I mostly tossed and turned.  We will see if the headaches and nausea disappear.

It's disturbing to think of all the possible scenarios that could have played out without the benefit of that CO detector.

Did I mention that we just installed it a few months ago?

An American Story

Sitting in the waiting room of the Oval Office surrounded by his family, Sam found it both fortuitous and ironic that he had changed his name years ago.  Amongst a flurry of millions of pressing yet inconsequential decisions, Americanizing his Iranian name, Saeed, would later save him some grief during 9/11.  He looked up at the line of government workers and their families wending it's way through the hallways and ending abruptly at the President's office.  One of the security guards had taken pity on Sam.  His eighty year old body hobbled by a bad knee, broken years ago in a tunnel explosion during his years as a foreman in Tehran, bought him a front row seat to the festivities.

Sam loved Iran. His mind could draw a straight line from a childhood spent sleeping on Hamedanian rooftops to his ascension as CFO of a multinational company.  His success and wealth, however, all crumbled that day he was jailed by the henchman of a new Ayatollah who was deeply suspicious of his bosses political leanings.  He won't tell us the details now, but his release, ushered by Shah loyalists at the prison, likely spared his life.

Months later, with visas obtained in Italy,  Sam, his wife, and three children boarded a flight into the unknown.  His wealth, property, and status remained in the country he loved.  There was a pact that if they were detained at the airport, his wife and children would flee to America alone.  A pact that would thankfully be allowed a single day reprieve.  One of Sam's colleagues was detained the next afternoon and never heard from again.

America was not easy.  Brutal in fact.  Sam's position as CFO carried little weight in the US.  He traveled hours on public transportation to jobs he was overqualified for to receive paltry wages.  His wife, a teacher in Iran, became a manicurist.  They survived day to day in a tiny two bedroom apartment.  The Iran hostage crisis insured that there was no shortage of discrimination and racial slurs thrown their way.

But Sam had no time to complain.  He was caught up in the most American of pastimes-providing a life for his three young children.   So he found a way.  When his shoe stores failed he scraped enough money together to buy an apartment building. And they had enough.  Never a lavish life like he had in Iran, but there was always food on the table.

Sam's eldest daughter became a lawyer and eventually worked for the government.  She had given much to her country including years of service in a very dangerous Afghanistan.  It was at her invitation that three generations of his family were gathered to meet our great leader.

As he walked into the oval office, Sam adjusted his eyes to the splash of light and color, flash bulbs and smiles.  A man who was forced to flee a country he loved for dubious political reasons, was now face to face with the leader of his adopted country.  Ironic that he hadn't voted for this president, or agreed on so many issues.  This was allowed here.  Celebrated.

It had never been easy.  Sam's family was nearly deported a few years after emigrating.  He had been held up at gunpoint in his shoe store twice.  He was a victim of far more crimes than any petty moving violation he may have committed while driving absentmindedly.  His family faced discrimination of almost every stripe.

America, however, was also a country of unthinkable kindness and good intention.  Her actions were often flawed, but her principles were unflappable.

At least until recently.

Sam's youngest daughter, my wife and mother of my two children, accompanied her father that day in the oval office.

He waited in line with the rest of his family.  He smiled when the President stood in front of him, and offered his hand.  His English still broken after all these years, his voice was almost a whisper as he spoke his given name in greeting.

I am Saeed.

I Hear the Water, I Hear the Birds

Hello. hello...Pause.  You know my heart jumps every time I see your name come up on the phone!

Every child secretly creates a story about the adult they will eventually become.   A fantasy adorned with all the trappings of honor, success, and beauty.  We imagine a world in which we will make a difference; touch those we come in contact with.  Especially if you aspire toward the medical profession.  Our particular daydream involves rushing into a room with stethoscope bouncing back and forth around neck.  With expertise we bark a series of orders, maybe grab defibrillator paddles.  The patient sits up and blinks.  He immediately knows his life has been saved.  Family members bow.  The nurses swoon at our physical prowess and the medical students at our intellectual.

And then reality hits.  Medical school and residency teach that heroic moments are few and far between.  We learn that medicine is never a sprint, but more accurately a laborious iron man.  Tenacity of spirit, a never ending curiosity, and a deep well of humanity become the characteristics we most strive towards.  Our story has changed.  Our identities have pivoted to a more realistic and passionate ideal.  The rewards become long lasting.  Durable.

The practicing physician's story is idealized into that of Kwai Chang Caine from the TV series Kung Fu.  Humble and quiet, we wander the earth alone.  We come upon misery and despair.  We bend with the wind but don't break.  Our powers are administered gently and patiently to affect injustice when possible, and to cushion the blow when not.

This is a quiet, romanticized story.  We cling to it dearly during the daily blizzard of current medical existence.  It creates warmth and shields against the daily fear, anxiety, and disquietude that haunts this profession.

It's easy to forget that those we administer to also have deeply ingrained narratives.  And when those narratives involve illness, disaster, and death, the physicians role as protagonist is in doubt.  While I have forgotten thousands of patients who have died, their family members remember me quite clearly.  I am the one who told them their loved one was dying.  Or gave a horrible prognosis.  Or it was my phone number that came up that day on their mobile phones.  The day that disrupted their lives.

It was me. In so many stories, I was the last vision before life spiraled.  My words.  The way I stammered or the fidgeting that they will remember as the harbinger of catastrophe.

I can't help but think that this story is wholly suffocating.

I dreamt of being a hero.

Then I dreamt of being the gentle breeze, warm and calm.

Never, never did I dream of being someone's worst nightmare.

Master Po: [after easily defeating the boy in combat] Ha, ha, never assume because a man has no eyes he cannot see. Close your eyes. What do you hear? 

Young Caine: I hear the water, I hear the birds. 

Master Po: Do you hear your own heartbeat? 

Young Caine: No. 

Master Po: Do you hear the grasshopper that is at your feet? 

Young Caine: [looking down and seeing the insect] Old man, how is it that you hear these things? 

Master Po: Young man, how is it that you do not?

Palliative Care Is...

Palliative care is...

I wait intently as the board members rearrange themselves in their seats and look up expectantly.  Silence.  I wasn't going to let it be that easy.  I repeat myself and pause again.  This time a few tentative answers flutter up to the podium.

hospice...comfort care...end of life...giving up?

Now this is something I can work with.  I clear my throat and smile broadly.

Palliative care is a philosophy.

I can't help but launch into a series of idioms.  I talk of the difference between the forest and the trees. I invoke Osler's famous quote about how the great (palliative) physician treats the patient and not the disease. We talk of the sanctity of quality versus the expediency of quantity. I can see heads shaking in agreement now.  The ideas are starting to sink in.  I mention patient-centeredness and I can feel the the room stir.  I talk of dignity.  The goal is to face illness with the same dignity that we attempt to face health.  The participants inhale and exhale with each word.

Palliative care is a skill set.

Palliative care is a consultative service just as a cardiology or nephrology.  Board certified physicians in hospice and palliative care treat pain, nausea, anxiety, as well as a host of other symptoms.  We also are skilled in advance disease planning.  Counseling on end of life, and not so end of life care.  Helping guide the decisions about code status and hospitalization, and timing and duration of care.

Palliative care is a team sport.

Nurses, social workers, chaplains, therapists, volunteers, and nursing assistants.  Relieving pain and suffering is complex and multifaceted.  It is not only a physician's domain.  Each skills set brings it's own version of comfort to the suffering.  But mistake me not, we all speak the same language.  It is neither medicine nor religion.  It's compassion.

Palliative care is not hospice.

In fact hospice is a small part of palliative care.  If palliative care were a bus, hospice would be a few rows of seats in the front (or back).  It is concomitant care  of chronically ill patients coordinated with other specialties.  One can continue any treatment they wish.  Chemotherapy, surgery, hospitalization. And it is not a substitute for hospice.  Hospice is a medicare benefit appropriate for up to the last six months of life for those who wish to discontinue curative treatments.  It brings with it a host of services not otherwise covered by general palliative care.  

Palliative care is important.

It is something you, your family, and your institution need to know about.

Us and Them

I think about her from time to time.  More often than I should.  Being mere acquaintances, there is a certain frequency that goes above and beyond coincidence.  I contemplate what it must have been like working as a second year resident in the ICU (I was an intern at the time). Getting a severe headache and wandering down to the emergency room in a daze.  Strangely similar to what happened to my father.  But she didn't die.

Maybe worse.  She was diagnosed with Glioblastoma Multiforme, a uniformly fatal brain cancer.   She suffered through a stay in the same ICU she was scheduled to cover for the month.  She tolerated surgery and chemotherapy.

She married her boyfriend during a prolonged stay in rehab.  Her head was partially shaved in the wedding pictures.  And one day, she showed up to round with our team on my second year rheumatology elective.  She stayed with us the whole month.  Some days she worked the entire shift, others she became fatigued and left at noon.

We laughed, we learned.  Mostly we pretended she was no different than any other resident.

I assume she died long ago.  Sadly I can remember her face, but no longer her name.  The  years have erased much.  As I said, we were never particularly close.

In retrospect, we were fooling ourselves pretending she was like any other resident.  That day in the emergency room she ceased being one of us, and became one of them.  The sick people.  The people we have dedicated our lives to treat and care for.   The people we keep at arms length.

Pain and suffering are tolerable as long as there is separation.  Us and them.

It works for the most part.  But I can't help daydreaming that maybe she was one of those few percent who survived.  That she has a family and a busy rheumatology practice in some spectacularly boring suburb somewhere.

That she came back to us.

Or that we learned how to be better at being with them.

I really wish I could remember her name.

I think.

Bear Claws and Veterans Who Never Die

Every morning we awaited ravenously for the bear claws.  The director of The VA would saunter by the residents room and refresh the cardboard box with various pastries, Danishes, and bear claws.  Like zombies, our sleep deprived bodies would communally aggregate in the corner and devour our prey.  Stacks and stacks of sugary pastries.

The VA was located conveniently in the middle of a food desert.  The neighborhood was so crime ridden that no delivery person would agree to drive up.  There was no cafeteria.  So we ate bear claws.  Sometimes, during a thirty six hour shift, for breakfast, lunch, and dinner.  Or a late night snack.  The only abundance greater than sugar, of course, was fear

As second year residents, we ran the show.  Supervising a few interns and medical students, we covered the entire hospital.  Hundreds of sick veterans with every imaginable disease.  More often five or six of them at once.  We had no backup.  No support.  The patients got sick and coded.  They suffered almost every complication.  But they never died.  Veterans never died.  They just got more sick.

It was one month out of a three year residency.  The month that made me into a doctor. Upon it's completion, I had learned to stick a needle into most any human crevice.  I pounded on chest after chest during endless nights of CPR.  I brought blood pressures up and took them down.  I admitted twenty new patients over night, covered the ICU, and still somehow had time to show up the next morning and get in line for the only breakfast that was going to present itself to me.

I still wake up in a cold sweat reliving those days.  It's my most dreaded stress dream next to being late for college finals.  A months experiences compressed and splayed out over a lifetime.

I will never be the same.

Since that rotation, there is nothing medicine has been able to hurl in my direction that I can't handle.

And the sight of bear claws makes me ill.        

Thrive

It was only later that I discovered the underlying reasons for the move.  My parents purchased a home in neighboring Wilmette.  The contract was signed and a date was set.  Being in second grade, I doubt I worried about the details.  Maybe I was concerned about enrolling in a new school, I don't remember.  It was nothing in comparison to the tumult I would feel when we relocated after the wedding, before high school.

When my dad died, I assume the contract was nullified.  The overwhelming upheaval to our lives was so great, that a seven year old boy couldn't possibly comprehend the complexity of adult decision making.  We were going to move and then we weren't.  My dad was with us one day, and then he wasn't.

And my life was afloat in uncertainty.  Stalwart in the idea of becoming a physician like my father, I struggled with a learning disability profound enough to keep me well below the level of my peers.  I sat in homeroom coloring while my classmates read from textbooks. I had an army of school provided tutors as well as a private learning specialist.  The picture would have been fairly bleak if I had been old enough to recognize.

But children can be unfalteringly ignorant toward melancholy.  Their unfettered engines continue to run.  They continue to run free.

My two memories left from that year color almost all that I am. In the living room surrounded by family, as my mother whispered in my ear that dad was gone.  And months later, the day my teacher placed a textbook in front of my face and I read.  Surprised, she place another.  A slightly more complex.  And I read.  Then another.  And another.  The children looked up in awe as a pile of textbooks formed on the side of my desk.

My reading and writing improved so much, it was decided that I indeed could matriculate to third grade. Which was incidentally the reason my parents had planned to move in the first place.  They were going to hold me back, and felt it would be less devastating if I transferred to a school where none of the kids knew me.

Years later, my mom would remarry and move us into the same district that I narrowly missed in grade school.

And I would thrive.