March 30, 2013

post call

     It was supposed to be a slow night but only about two hours of sleep were hungrily devoured.  I stumbled home around ten in the morning after having started my shift at 6:30 the previous morning.  I'm not even sure what day it is or whether I'm hungry or not.  And surprisingly, but not uncommonly for a decent percentage of people, it's hard for me to fall asleep at this point.  Feeling wired from too much adrenaline and too much caffeine.  It's hard to shut off.  At some point I finally drift off to sleep and wake up later.  It could've been one hour or five hours later.  I wouldn't know.  The sun is setting so it must be early evening.  My wife mutters something about "avoiding dad" to which I take offense.  I try to defend myself to which my son bluntly states, "No, dad.  You're pretty pissy after call.  It's like poking a bear."  I have no idea from where he learned to be so straightforward.

March 25, 2013

little white lies

"Are you good at this?" the words came floating up from the hospital bed as the patient was lying flat on his back, talking mostly to the ceiling. His daughter seemed uncomfortable and excused herself.

"The best," I replied calmly. Truth be known I'd never take a central catheter out of a human but I figured if I could put a catheter into something as small as a mouse, how hard could it be to take one out of a human being? I didn't feel bad about telling the fib. The patient needed assurance that everything was going to be ok, at least at this moment. The uncertainties of the diagnosis still loomed large over him. The catheter came out just fine and I held pressure on the now open hole in one of his major veins for a goodly while to ensure said hole closed, especially as he'd been receiving a good dose of heparin. During that ten or fifteen minutes we chatted about life, mostly his and I was happy to listen to him recount his story. Every patient has a tale to tell, most of them interesting and it's one of the big draws of my wanting to become a family doc.

March 18, 2013

chief complaint

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

Abbreviated CC, it stands for chief complaint. It is supposed to be a verbatim statement of what is bothering the patient the most at that moment, in their own words. My favorite thus far was from one of my patients who was seen by a specialist. A delirious, but violent patient, they were put into restraints not only for the safety of the staff, but of the patient as well. The Chief Complaint one particular day read, and I quote, "I need me some wire cutters". Given that the patient didn't know where they were and was asking me about the blue cats in his room, I'll never be quite sure if the wire cutter request was a rare moment of lucidity or just more delirium.

March 14, 2013


An excerpt from Steinbeck's magnus opus, East of Eden. A modern retelling of the Cain and Abel story, the question of "am I my brother's keeper" runs heavily through it. I've been ruminating about it of late as I've been haunted by the manner of my brother's death both during my dreams as well as my waking life.

“Do you remember when you read us the sixteen verses of the fourth chapter of Genesis and we argued about them?”

“I do indeed. And that’s a long time ago.”

“Ten years nearly,” said Lee. “Well, the story bit deeply into me and I went into it word for word. The more I thought about the story, the more profound it became to me. Then I compared the translations we have—and they were fairly close. There was only one place that bothered me. The King James version says this—it is when Jehovah has asked Cain why he is angry. Jehovah says, ‘If thou doest well, shalt thou not be accepted? and if thou doest not well, sin lieth at the door. And unto thee shall be his desire, and thou shalt rule over him.’ It was the ‘thou shalt’ that struck me, because it was a promise that Cain would conquer sin.”

Samuel nodded. “And his children didn’t do it entirely,” he said.

Lee sipped his coffee. “Then I got a copy of the American Standard Bible. It was very new then. And it was different in this passage. It says, ‘Do thou rule over him.’ Now this is very different. This is not a promise, it is an order. And I began to stew about it. I wondered what the original word of the original writer had been that these very different translations could be made.”

Samuel put his palms down on the table and leaned forward and the old young light came into his eyes. “Lee,” he said, “don’t tell me you studied Hebrew!”

Lee said, “I’m going to tell you. And it’s a fairly long story. Will you have a touch of ng-ka-py?”

“You mean the drink that tastes of good rotten apples?”

“Yes. I can talk better with it.”

“Maybe I can listen better,” said Samuel.

While Lee went to the kitchen Samuel asked, “Adam, did you know about this?”

“No,” said Adam. “He didn’t tell me. Maybe I wasn’t listening.”

Lee came back with his stone bottle and three little porcelain cups so thin and delicate that the light shone through them. “Dlinkee Chinee fashion,” he said and poured the almost black liquor. “There’s a lot of wormwood in this. It’s quite a drink,” he said. “Has about the same effect as absinthe if you drink enough of it.”

Samuel sipped the drink. “I want to know why you were so interested,” he said.

“Well, it seemed to me that the man who could conceive this great story would know exactly what he wanted to say and there would be no confusion in his statement.”

“You say ‘the man.’ Do you then not think this is a divine book written by the inky finger of God?”

“I think the mind that could think this story was a curiously divine mind. We have had a few such minds in China too.”

“I just wanted to know,” said Samuel. “You’re not a Presbyterian after all.”

“I told you I was getting more Chinese. Well, to go on, I went to San Francisco to the headquarters of our family association. Do you know about them? Our great families have centers where any member can get help or give it. The Lee family is very large. It takes care of its own.”

“I have heard of them,” said Samuel.

“You mean Chinee hatchet man fightee Tong war over slave girl?”

“I guess so.”

“It’s a little different from that, really,” said Lee. “I went there because in our family there are a number of ancient reverend gentlemen who are great scholars. They are thinkers in exactness. A man may spend many years pondering a sentence of the scholar you call Confucius. I thought there might be experts in meaning who could advise me.

“They are fine old men. They smoke their two pipes of opium in the afternoon and it rests and sharpens them, and they sit through the night and their minds are wonderful. I guess no other people have been able to use opium well.”

Lee dampened his tongue in the black brew. “I respectfully submitted my problem to one of these sages, read him the story, and told him what I understood from it. The next night four of them met and called me in. We discussed the story all night long.”

Lee laughed. “I guess it’s funny,” he said. “I know I wouldn’t dare tell it to many people. Can you imagine four old gentlemen, the youngest is over ninety now, taking on the study of Hebrew? They engaged a learned rabbi. They took to the study as though they were children. Exercise books, grammar, vocabulary, simple sentences. You should see Hebrew written in Chinese ink with a brush! The right to left didn’t bother them as much as it would you, since we write up to down. Oh, they were perfectionists! They went to the root of the matter.”

“And you?” said Samuel.

“I went along with them, marveling at the beauty of their proud clean brains. I began to love my race, and for the first time I wanted to be Chinese. Every two weeks I went to a meeting with them, and in my room here I covered pages with writing. I bought every known Hebrew dictionary. But the old gentlemen were always ahead of me. It wasn’t long before they were ahead of our rabbi; he brought a colleague in. Mr. Hamilton, you should have sat through some of those nights of argument and discussion. The questions, the inspection, oh, the lovely thinking—the beautiful thinking.

“After two years we felt that we could approach your sixteen verses of the fourth chapter of Genesis. My old gentlemen felt that these words were very important too—‘Thou shalt’ and ‘Do thou.’ And this was the gold from our mining: ‘Thou mayest.’ ‘Thou mayest rule over sin.’ The old gentlemen smiled and nodded and felt the years were well spent. It brought them out of their Chinese shells too, and right now they are studying Greek.”

Samuel said, “It’s a fantastic story. And I’ve tried to follow and maybe I’ve missed somewhere. Why is this word so important?”

Lee’s hand shook as he filled the delicate cups. He drank his down in one gulp. “Don’t you see?” he cried. “The American Standard translation orders men to triumph over sin, and you can call sin ignorance. The King James translation makes a promise in ‘Thou shalt,’ meaning that men will surely triumph over sin. But the Hebrew word, the word timshel—‘Thou mayest’— that gives a choice. It might be the most important word in the world. That says the way is open. That throws it right back on a man. For if ‘Thou mayest’—it is also true that ‘Thou mayest not.’ Don’t you see?”

“Yes, I see. I do see. But you do not believe this is divine law. Why do you feel its importance?”

“Ah!” said Lee. “I’ve wanted to tell you this for a long time. I even anticipated your questions and I am well prepared. Any writing which has influenced the thinking and the lives of innumerable people is important. Now, there are many millions in their sects and churches who feel the order, ‘Do thou,’ and throw their weight into obedience. And there are millions more who feel predestination in ‘Thou shalt.’ Nothing they may do can interfere with what will be. But ‘Thou mayest’! Why, that makes a man great, that gives him stature with the gods, for in his weakness and his filth and his murder of his brother he has still the great choice. He can choose his course and fight it through and win.” Lee’s voice was a chant of triumph.

Adam said, “Do you believe that, Lee?”

“Yes, I do. Yes, I do. It is easy out of laziness, out of weakness, to throw oneself into the lap of deity, saying, ‘I couldn’t help it; the way was set.’ But think of the glory of the choice! That makes a man a man. A cat has no choice, a bee must make honey. There’s no godliness there. And do you know, those old gentlemen who were sliding gently down to death are too interested to die now?”

Adam said, “Do you mean these Chinese men believe the Old Testament?”

Lee said, “These old men believe a true story, and they know a true story when they hear it. They are critics of truth. They know that these sixteen verses are a history of humankind in any age or culture or race. They do not believe a man writes fifteen and three-quarter verses of truth and tells a lie with one verb. Confucius tells men how they should live to have good and successful lives. But this—this is a ladder to climb to the stars.” Lee’s eyes shone. “You can never lose that. It cuts the feet from under weakness and cowardliness and laziness.”

Adam said, “I don’t see how you could cook and raise the boys and take care of me and still do all this.”

“Neither do I,” said Lee. “But I take my two pipes in the afternoon, no more and no less, like the elders. And I feel that I am a man. And I feel that a man is a very important thing—maybe more important than a star. This is not theology. I have no bent toward gods. But I have a new love for that glittering instrument, the human soul. It is a lovely and unique thing in the universe. It is always attacked and never destroyed— because ‘Thou mayest.’”

March 11, 2013

still confused

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     Despite being slight of frame and short, he was a spunky old man in his 60s.  He was alone at the doctor's visit where he was receiving the results of a recent CT scan after getting radiation.  Stage IV lung cancer was his diagnosis.  Four years ago.  Metastases to the liver, to the adrenals, to the brain not once, but twice.  Multiple rounds of chemotherapy, radiation, surgery.  And still alive and kicking.  He admitted being very nervous about getting the results, even to the extent of feeling low all weekend long.  I told him, if he feels low for a day or two, he has every right to feel that way.  He smiled sheepishly at the reassurance.  The results were good.  The new tumors shrunk substantially.  He'd live to fight some more and his eyes misted up.  He felt embarrased at it.  Again, I reassured him, he has every right to feel overwhelmed by the emotion.  He picked up his cane, stood up as erect as he could muster, and proudly strode out of the room.

     And inside my own head and heart, an argument was going on.  Why did this man get to be so lucky?  All I wanted was 4-5 years for my brother to allow him to see his kids graduate high school.  But he didn't even make it two.  But this man, who is far sicker, more frail gets to keep going after four years.  Why?  I have no answer other than simply it is what it is.  I also felt compassion at his struggle and wished him well.  I will not begrudge another's good fortune.  I had thought I was further along in my grief process at this stage but, apparently not.  Things were just as confusing to me a year ago as they are now. 

March 9, 2013

happy birthday

To be, or not to be: that is the question:
Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And by opposing end them? 

    What if?  Such a short question but loaded with implications of what follows the "if".  What if the stem cell transplant had not worked?  What if they hadn't found a donor?  Those fatalistic what ifs mean little to me.  They involve externalities which are beyond our control, beyond our realm of choices. 
     But what if my dad decided not to have the stem cell transplant?  What if he had decided to delay it?  After all, he was doing well after the chemo.  Why not try to eek out as much of a comfortable living as possible?  It's not as if stem cell transplant was not dangerous or did not require a serious cost to be borne.  The devil you know versus the one that you don't.  What if he never went to MD Anderson?  That, too, was questioned.  What if?  Those were questions not of fate, but of choice.  The scales were weighted with elements of the unknown, fear, hope, maybe, maybe not, danger, grief and something tipped the balance towards a certain course of action.  At the time, these were all very real questions, to be wrestled with as Hamlet anguished over the course of his fate.  Choices were made.  And a year later, my dad celebrates his new birthday - the day he gained another man's blood, and another chance at life.  Happy Birthday, Dad!

March 4, 2013


I sleepily kissed my wife good-bye and rolled back over, asleep again before she got out the door. Rounds weren't until 10 am and all but one of my patients had been discharged. That patient would take all of 10 minutes to see so I felt no guilt in sleeping in. I wished I hadn't. I gained an extra hour of sleep but any respite I gained from the slumber was quickly lost as the last dream I had before waking was of my brother's death. On days such as these, it takes an numbed effort to just get through the day. Trying to treat sick people in such a state seems to be a cruel irony.