National Poetry Month

The month of April has been set aside as National Poetry Month. I'm not one for celebrating the "themes of the month," I don't have the time nor the memory to dedicate an entire month in the rememberance of a particular people or event.

A couple of weeks ago, however, I subscribed to the mailing list for "The Writer's Almanac", a daily radio show (and now podcast), spoken by Garrison Keillor, whose voice contains the magic to sooth away stress and hurts of daily life. Each day, he recites a poem and talks about important events that have happened that day in literature history. In browsing the archive, I stumbled across this poem, that I thought was fitting for this blog.

Cases

Man in his late seventies comes in with his wife,
weak, lost twenty-five pounds, can't eat, hard to talk,
seeing double off and on past eighteen months,
been to a family doctor and two specialists.

They don't know, I've got some ideas. It's
beyond my scope, here in the rural north country.
I get him tucked away in the medical center
by the following morning. He's out in five days

with a diagnosis, I was right for once. He's
eighty percent better on treatment, says
he's two hundred percent. Gives me the credit
for once. The gray hair helps. Man comes in

to emergency with loss of vision in one eye.
works full-time, in his sixties. It goes away
and he wants to go home. Internist and eye doctor
find nothing. I find something and say, No.

Family says I'm overreacting but they all agree,
reluctantly. Urgent angiogram-surgery on the
neck arteries is booked for the following morning.
That night his opposite side becomes paralyzed.

Emergency surgery cleans out a nearly
blocked vessel. They don't appreciate the
postoperative pain. They don't appreciate my
style or anything about me. He walks out

saved from an almost certain permanent
disability. Woman comes in with a headache,
high blood pressure, in her fifties. I do a spinal,
few red cells, radiologist gets me on the phone.

He says the CAT scan's negative, I'm not
so sure and send her down country for an
angiogram. Radiologist was right and I was
wrong — no aneurysm in her brain. Young

mother of two comes in with seizures hard to
control all her life, and paralyzed on the right side
from birth. I consider a CAT scan a waste of money:
the gray hair stands for experience, remember?

She gets slowly worse over the years. Her family
doctor does a CAT scan, finds a malformation
of the brain. We just ain't so smart, my old
teacher used to say when I was an intern. A man

comes in, in his sixties, can't work, losing weight,
muscles are twitching, hard to swallow, hard
to talk. Do some tests, tell his wife and him
he's got Lou Gehrig's Disease, it will affect

his breathing, he's going to die, it will be
tough, we'll try some things. We do, he gets
worse, can't walk, can't feed himself.
I visit the house: a small cape with a screened

Porch behind a variety store in a small town in
New Hampshire. He gets worse, I
visit some more, talk some to him,
to his wife and son, the man dies.

~~Parker Towle, from Body Language. © The Library of America

(To read more poetry or to subscribe to podcast or email list for The Writer's Almanac, please visit http://writersalmanac.publicradio.org/)

Searching for butterflies

NHS Blog Doctor: Who breaks a butterfly upon a wheel? (Trackback link)
This past week, I clicked on the website of one of my favorite medical bloggers, Barbados Butterfly (http://barbadosbutterfly.blogspot.com), and to my dismay came to a page stating that the blog was only opened to invited readers, and I, completely unknown in the medical blogsphere was certainly not one of the elite. I was saddened. I read Barb's blog on almost a daily basis. As a newly graduated medical student, I virtually memorized her "Tips for Interns" because while I was not in a surgical field, these were vital tips for anyone fresh and green embarking into the medical world.

One of my faults is that I'm as curious as a monkey. I couldn't just let it rest that she had decided to close off her blog, I had to find out what happened to her. In a past life I must have either worked as a tabloid reporter or a sleuth (those skills do come in handy in medicine!). A quick google search revealed the above post. I guess that was my answer.

In interest of learning more, I clicked on the links that also discussed her disappearance and wished her farewell ... and quickly noticed something. Take a look at the various goodbye posts:
The Girl with the Stethoscope
Dust In the Wind
Dr. Dork
MSSP Nexus

Hmm.... there is one happy little anonymous around here! And the final link, that caused the secret to be revealed:

Tea at Ten

The same smiling anonymous who just happened to know all of the verses to "Call a Code." Coincidence? I think not.

I think I won't be deleting her from my list of bookmarks just yet, because I have a feeling that Barbados Butterfly will be unfurling a new set of wings.

:)

Firsts

We mark our lives with milestones, tattoos of events on days that would otherwise slip into oblivion.

Today, I told my patient that he was going to die.

My resident told me that I did a great job. Professional and compassionate. I remembered my training, spoke in matter of fact terms, simplistic, realistic. No false hopes. Chemotherapy was an option, but only to provide comfort. The cancer that now riddled his insides could not be cured and he needed to discuss with his family what his end of life goals were. We would make him comfortable. I don't know how long it will be, how long he had. We have to wait for answers, for the biopsy results. The death word didn't pass between us; as much as I wanted to convey exactly what was going on, I couldn't bring myself to say it. He understood anyway. He took the news as his family had the day before when I first broached the subject. Stoic. Shocked. Asked the appropriate questions. Until I paused and said. "I'm sorry."

The sobs started then, and he clung to the hand of his relative beside him. In the stark hospital room, I could only stand there, touching his knee, without any kind of reassurance that it would be alright. He had fought cancer twice before and conquered... he had come to the hospital with the dreading thought that it had come back, but confident that it could be overcome, just like it had in the past. I dashed all of those hopes in a ten minute conversation. Ten minutes and I changed his life, put a stamp of expiration on his outlook on the future.

Ten minutes. I delivered the news and dashed off, another patient to see, another page to answer, another note to write.

Memorable

I watched her struggle for breath--short, rapid, gasping sounds, lips ashen. Her procedure had proceeded normally, but when she roused from the anesthesia, she couldn't breathe. We all knew the reason for it--a large tumor had grown across her lungs, collapsing the right and constricting the left by more than 50%. We gave her medications and prepared to intubate her. Within a few minutes, however, the meds worked; her airway opened enough that her one lung could receive the oxygen she needed and she was transported to the ICU for overnight observation before her operation the next day.

She became my patient, and I visited with her several times over the night. She was a school teacher and until a month ago had been doing pretty good. She had had this tumor for almost a decade, had undergone four rounds of chemotherapy, but in reality it changed her life very little. She continued to help out on their farm and did aerobics three times a week. But she stopped being able to sleep lying down. And a month ago, she started needing oxygen all the time and the aerboics classes were slowly weaned. We bonded over my red hair--her sister had red hair and was a nurse, so red headed people must be smart. Her husband was there, holding her hand, asking details about surgery, which I tried in my limited way to answer. She seemed more resigned to the surgery than anticipatory, and in fact, asked if she would still be going through with it now that she was "breathing better." I listened to her lungs and heart and dutifully noted the decreased breath sounds on the right, but otherwise "clear to auscultation," then wished her well with the surgery and left. By the time I returned from my teaching rounds, she had already been taking down.

Lunchtime came, and we were to present chest x-rays for the class to interpret, and with hers, boy, did I had a doozy. I even stumped the chief resident with it. It was great--I raved about the ICU and all of the interesting patients that I've seen and cared for. Then, being post call, I went home. I didn't know that the surgeons were finding her tumor to be inoperable. Or that the pulmonologists were struggling to maintain an airway. That I found out this morning, when we were looking at her scans, and the pulmonary fellow talked about all of the complications--the tumor was so large, it blocked them from opening up the stent, and they had a difficult time getting central access. It was an excellent story, one that an action film couldn't compete against and I listened with eagerness and wasn't prepared for the climax of the story: "We couldn't keep her airways open, so we went to talk to the family and withdrew care. She died in post-op."

*****

This is the first time that I've lost a patient that I had cared for and it's really hit me hard. I've been fighting back tears all day--I think I frightened the poor passengers on the train when the tears and sobs finally slipped out. Since being on the ICU, I've seen death, but it was to others' patients or to those that were so sick that they had hardly been alive. Only hours before she was smiling and laughing and looking forward to going back to her kids that she taught. And just as suddenly she was gone. She was dying from the tumor--without the operation, it would very slowly compress all of the air out of her lungs, but I wasn't prepared for the sudden failure.

You don't forget your first kiss, I'm told. As my first death, she will be as memorable.