Leave It There

[I originally wrote this as a medical student working in the ICU. It’s one of my most haunting memories and comes to mind every time I work in the intensive care unit.]

“I thought I could beat the ICU, you know?” My resident looked into the distance abstractly as he spoke, talking to himself more than to me. “Sometimes you think you won’t let it get you down, but you can’t. It always wins.”

I wondered what he meant by winning. Did he mean getting to leave on time? Did he mean keeping a positive attitude? How can you “win” in the ICU? I thought about all of the patients we were caring for. A comprehensive list of their names was scrawled on a big whiteboard, a canvas where imminent changes were haphazardly heralded by beeping pagers and a flurry of activity. The rapid shuffling of names and the random clamor made it seem like a perverse scoreboard: successes were annotated with new room numbers and locations for transfer elsewhere, while failures were simply wiped away with minimal fanfare, leaving an off-white space that waited patiently to squeak out a new set of letters.

The resident’s pager went off. There were phone calls, some hastily scribbling, and we were off to pick up the next patient.

The night wore on and I kept my eye on the clock. Of my sixteen hours on shift, there were two remaining. Then one. Five minutes. Finally my resident dismissed me. “Go get some rest,” he said kindly, scanning the computer screen and mechanically punching in orders. “All that’s left is paperwork. Nothing more for you.” As per medical student etiquette, I thanked him, wished him a good night, and strode out of the ICU. I walked down a quiet hallway, paneled on both sides by glass. The view on the left faced out into the cold, dark, northeastern night. The right faced the surgical ICU waiting room, which remained lit with muted, tubular fluorescent bulbs. I glanced in and was surprised to see someone still waiting inside.

She was sitting alone. Her eyes were puffy and red, but dry. They looked as if they had been that way for a long time. A thin hospital blanket was draped carelessly around her shoulders, which were hunched forward with a palpable heaviness. Her motionless presence made the room seem more static than if it had been empty. Time himself had decided to stop in and say hello, that there was nothing particularly important for him to do, and that he could afford to wait around for awhile and sink into the vinyl furniture, listening to the ventilation hum while he got things ready for eternity to end next Thursday or perhaps the week after that.

My feet continued to move. I got in my car and felt immensely grateful that I could simply drive away. I could leave this place and the bodies in their beds and the score on the whiteboard and the timeless terror of the waiting room. I could sleep without nightmares and wake up without fearing that moment when I suddenly remember that everything is different now that she’s gone, ohmygod she’s really gone.

****

So tempting to take up a crown
of guilt around my head
and proudly wear another’s weight
of paralytic dread.
So hard to sacrifice the love
of self-divinity
And rather speak a better word
of true humility:

“Fear not the lack of task to do,
presumed irrelevance,
Or for the merit to survive
The deathly duty dance.
Recall instead the words they sang
to pause and leave it there
in callused hands long pierced by all
the burdens that we bear:

There is a balm in Gilead
To make the wounded whole;
There is a balm in Gilead
To heal the sin-sick soul.

Some times I feel discouraged,
And think my work’s in vain,
But then the Holy Spirit
Revives my soul again.

If you can’t preach like Peter,
If you can’t pray like Paul,
Just tell the love of Jesus,
And say He died for all.”

Ventricular fibrillation (perhaps torsades de pointes?) and then SHOCK resulting in ROSC. The only successful shock on a long night of ICU call.
Rhythm monitor strip; can you guess what it is?
Leave It There

Hands and Feet

[This was originally written years ago for a Christian campus publication, Revisions. It is one of my favorite reflections and will appear on the ESN blog tomorrow.]

St. Francis and the Leper
St. Francis and the Leper

The patient came in for a refill of pain medications even though it was his first visit to the family medicine practice. The front desk staff had a letter for the supervising resident from the patient’s previous doctor, which the resident read out loud to me: “Due to difficulties in our doctor-patient relationship, we regret to inform you that we can no longer serve as your primary care physician office.”

The resident’s eyes widened with recognition. “Ah! I’ve heard about him. They said that this doc was a saint for seeing him for so long, something about him being non-compliant and all that.”

It was my job as the medical student to figure out the rest of the story. His name was Mr. Thompson* and he had a dizzying array of pathologies. He was friendly and talkative throughout the interview, but I harbored a deep mistrust for him beneath my own pleasant and cordial exterior. I had been charmed and lied to before.

His chief complaint was not, in fact, a need for pain medications. It was a set of extensive and painful leg ulcers, which remained hidden underneath his pant legs. As he rolled up his clothing to reveal the layers of bandages covering both calves, a nauseating stench filled the small room. My eyes began to water and I wondered if it smelled of gangrene. Then I wondered if it would linger on my clothes.

According to Mr. Thompson, visiting nurses typically changed the dressings once a week, but recently they began telling him his legs smelled particularly bad and that the doctors should take a look. The resident came in and we began preparing for the procedure. Mr. Thompson continued to talk about his legs casually as if he were speaking of the weather. They swelled occasionally and leaked fluid, especially when he didn’t take his meds. The arthritis in his knees and ankles was worst when he sat, but he would stay seated for us. There was a large ulcer on the left side of the right leg to be careful of. He would yell to let me know if it hurt.

The worst part of the process had been removing his socks, which he admitted he couldn’t change often because of his inability to reach down and touch his toes. He usually just threw them away, so we did likewise. I knelt at his feet and, with gloved hands and a large pair of scissors, slowly snipped away at the old dressing. It was stuck to the skin, and as I it peeled away, diseased and dead tissue flaked off with the gauze. What remained was a mottle of purple and red hues, a blotchy landscape of crusted inflammation stretching from the knees to the tip of his scaly toes.

Mr. Thompson eyed the resident working alongside me and said, “You’re scaring me.”

“What?” the resident replied.

“That look on your face… you look scared – surprised.”

“Well, this has got to be one of the worst cases of this I have ever seen.”

“Oh, really? Well, this is actually doing well now. It’s normally worse.”

The thought entered my mind that these two legs should be amputated. The patient told us earlier that a vascular surgeon had suggested something similar, but that “so long as he could stand it”, frequent dressing changes could keep the infections at bay a little longer. The patient desperately wanted to keep his legs. He was content to amble around in spite of the pain and intensive wound care. He knew that time was not on his side, but he wanted all the time he could get. He was only in his forties.

But still, the thought lingered in my mind: these legs should be amputated. And it wasn’t because I thought it would make his life better. It was because it would make things easier for us: the visiting nurses, the vascular surgeon, the doctors, myself. I wanted those amputations to make things easier for everyone. I wanted to sacrifice those legs to lessen the overall burden of suffering in this world.

In medical school, we are taught to strive to be “humanistic”. We have an honor society dedicated to humanism in medicine, but we are never told exactly what it means. Humanism, as a worldview and a philosophy, believes in the maximization of human capability and possibility. Humanistic medicine believes that, by minimizing suffering, medicine and its practitioners enable others to reach a fuller potential. But this assumes that we are willing to engage in compassion itself – a word that means, “to suffer with”. The paradox of compassion is that its very definition calls us to take up the thing we wish to alleviate, to bear what we find intolerable in others. But what force can compel us to engage the very things we despise? In such a daily grind, should we be surprised that we think such profoundly disturbing and cynical thoughts as amputation for convenience sake?

As I gingerly picked at the remaining gauze, a story about St. Francis of Assisi came to mind. He came across a leper on the road one day and embraced the man, kissing him full on his rotting lips. St. Francis described it this way: “This […] is what I understood: all lepers, cripples, sinners, if you kiss them on the mouth — they all become Christ.”**

In that moment, I imagined that the diseased and scabbed feet I held were the feet of Christ. I thought about what it would be like to wash them and kiss them like the woman with her perfume and hair. I looked up at this man sitting before me, his face attentive and appreciative of the care we were giving. I looked up at the man before me and thought about all the factors that repulsed me from him: the rumors of drug abuse and non-compliance, the side-long glances between providers, the stereotypes I harbored, the ugly nature of the pathology itself. As I thought about all this, shame and love swelled inside me as my head swam among the putrid odors and silence. It made everything disorienting and holy, and I found myself deeply disturbed within my heart.

Outside of Jesus Christ, suffering has no real meaning except as something to be quantified and minimized. Outside of Christ, it is difficult to articulate the where and why and how of which interventions we permit and from which we abstain. Outside of Christ, our interpretation of suffering is entirely subjective and arbitrary, making it difficult to determine in which cases the magnitude of suffering and pity become “worth” the effort to draw near. Outside of Christ, drawing near to deformity makes us similarly deformed.

But in Christ, a transformation occurs that changes the both of us into more familiar and beloved forms. In Christ, the man of sorrows who took up our infirmities and iniquities and is now seated at the right hand of the throne of God, the object of our affection became deformed, and so now all deformity can become divinity. In Christ, we no longer see the futility of the flesh but the sanctity of the soul, and our hope is regenerated and renewed.

After all, it is by His wounds that we are healed.

When I survey the wondrous cross
on which the Prince of Glory died;
my richest gain I count but loss,
and pour contempt on all my pride.

Forbid it, Lord, that I should boast,
save in the death of Christ, my God;
all the vain things that charm me most,
I sacrifice them to his blood.

See, from his head, his hands, his feet,
sorrow and love flow mingled down.
Did e’er such love and sorrow meet,
or thorns compose so rich a crown.

Were the whole realm of nature mine,
that were an offering far too small;
love so amazing, so divine,
demands my soul, my life, my all.

-Isaac Watts

*Name changed.

**A Sermon for the Feast of St. Francis, 2008. St. Francis Episcopal Church, n.d. Web. 31 Mar. 2010. <http://www.stfrancisdunellen.org/sermon_10_5_08.htm>

I wish I had this on my wall.
I wish I had this on my wall.
Hands and Feet

Roasting Pan

In the middle of Target is not the sort of place

I would expect to receive bad news.

The extra twenty dollars I saved by finding

my coveted piece of cookware there instead of

at Macy’s thirty minutes ago seemed somewhat

trite by comparison, and I did what I could to

smile and talk about the weekend weather instead.

It wasn’t as if I hadn’t lost patients before,

hadn’t watched a soul depart or told a family,

“I’m sorry,” in that hesitant, sonorous tone.

So I wasn’t sure why hearing about this one

felt so different and filled me with such disbelief,

as if someone had used my new roasting pan

to beat me in the face and then catch the

dripping blood from my nose while telling me it

wasn’t actually anodized aluminum,

wasn’t even worth the forty-two dollars

and eighty-nine cents I paid for it

with the money I earned while thinking I saved

a certain patient’s life.

Roasting Pan

Rituals of Annotation

I am not exactly sure of what prompted me to do it, but I began keeping a tally of all the pronouncements I have done. I never really knew this before, but pronouncements are done in a remarkably simple and impersonal way. Most patients who die in the hospital do not go with a bang but with a whimper. While some situations involve spectacular theatrics involving beeping monitors, charged paddles, and the cracking of cartilage from chest compressions, most patients die with a quiet, gasping sigh. I am still not sure which is more unnerving, but the former is what we typically imagine or see on TV during a pronouncement: a sweaty and distraught doctor ripping off latex gloves in frustration and listlessly intoning, “Time of death…”

What usually happens, however, is that the person will expectedly but spontaneously expire. Death is typically spotted from a fair distance and in most cases the family is cognizant of this. Sometimes hospice arrangements are made and the patient goes home to die surrounded by family and friends. Sometimes a volunteer in the hospital will keep a death vigil of sorts, sitting in a chair while reading a book or watching TV to pass the time as they wait to fulfill a promise “not to let anyone die alone.” Sometimes a nurse will make the rounds and discover that the patient is simply dead. It happens at all hours and in most floors of the hospital. Regardless, whenever the death is discovered a page is put out to whichever resident is on call to come by and make the official pronouncement, even though everyone already knows the truth.

This means that I usually know nothing about the patient or the family. I have to make an effort to commit the name and overall disposition of the patient to heart long enough to speak with the family and request their permission to grant or deny an autopsy. It typically takes thirty seconds to do the examination and less than thirty minutes to speak to everyone and document everything I need to before moving on to other things.

My little tally is nothing fancy, nothing more than a series of hatch marks in a small booklet of mundane medical information tucked into my white coat. So far, there have been five marks in two weeks. I can hardly remember the patients at all, much less their names or even what they died from.

But I remember the families. I remember the different reactions of different people, some joking and laughing about the whole affair, some quietly sniffling in a brother or a sister’s shoulder. I remember their words, which are often filled with appreciation and deep respect for everything that has been done for this house of memories. And I feel unworthy and deeply unsettled because I had no part in it… in fact, I never knew the patient, because the only reason I came into contact with him or her at all was because there was only an it left.

If the family was particularly effusive, I will write a little note of it in the chart: “No pulse, no audible heart beat; no corneal, pupillary, or gag reflexes. Family expresses deep appreciation for all staff.” And every single time, I am tempted to then write, “Kyrie eleison,” as has become my habit to say whenever I am otherwise speechless with sorrow. But not all the patient’s family members might appreciate that sort of addendum, so I say it to myself, place a little tick in my booklet, and move on.

To “pronounce” means to state, often with a degree of finality and certainty. But to me, it has also meant to describe and therein impart an element of meaning. Pronouncements have become a ritual of annotation, one that is suffused with meaning precisely because it is routine without being mundane. Small wonder that the closest I have come to intimacy with God in this heavily secularized profession have been in moments like these, where that which is ephemeral proceeds into the eternal.

Making a note of it is the least that I can do.

But someone may ask, “How are the dead raised? With what kind of body will they come?” How foolish! What you sow does not come to life unless it dies. When you sow, you do not plant the body that will be, but just a seed, perhaps of wheat or of something else. But God gives it a body as he has determined, and to each kind of seed he gives its own body…

So will it be with the resurrection of the dead. The body that is sown is perishable, it is raised imperishable; it is sown in dishonor, it is raised in glory; it is sown in weakness, it is raised in power; it is sown a natural body, it is raised a spiritual body.

I declare to you, brothers, that flesh and blood cannot inherit the kingdom of God, nor does the perishable inherit the imperishable. Listen, I tell you a mystery: We will not all sleep, but we will all be changed— in a flash, in the twinkling of an eye, at the last trumpet. For the trumpet will sound, the dead will be raised imperishable, and we will be changed. For the perishable must clothe itself with the imperishable, and the mortal with immortality.

- 1 Corinthians 15 

Rituals of Annotation

In Memoriam

There are many reasons why I love medicine. One of them is the ability to dig into the real “stuff” of human existence: life, death, suffering, love, pain, loss, redemption. Another is the speed by which I can get down and dirty. In less than fifteen minutes, I can go from being a complete stranger to a trusted stranger who can ask questions about that strained relationship you have with your uncle or the heartbreaking romantic fling you had last week or that strange mole on your inner thigh. Usually these interactions involve intimate but everyday details, though there are times when it still catches me by surprise.

I was shadowing around a hospice service when a nurse came to me and said, “Come.” She introduced me to a family who had been there for several days. The grown children were there for their mother, who was expected to pass away soon. They had already come to terms with the conditions of her impending death and were only waiting for the timing and that last, eternal moment in which to finalize goodbyes. I was ushered into the room feeling stiff and uncomfortable in my short white coat, which stood in stark clinical contrast to the tasteful and deliberately calming wood tones of the hospital room that felt more like a hotel suite. The patient had been breathing in rapid, shallow gasps of air… a pattern I would come to recognize all too readily over the coming weeks.

The family wanted a distraction. That much was clear as they peppered me with questions about my life. For once, I had to describe those intimate but everyday details about what it was like at my college, at medical school, working in the hospital, the weather in my town. And suddenly, in the middle of some inane and rambling description of my suburban and otherwise unremarkable life, the patient stopped breathing.

Immediately, the family members tensed up and asked me, “What’s wrong? You’re the doctor, right?” In my mind, I was surprised. After all, what were they expecting? Did they think she was going to jump out of bed and scream, “Hey, pay attention to me! I’m better now!”? They knew that she was dying; they knew that this was going to happen. I knew, and I had only been there a few minutes. But years of hospital training kicked in and the urge to do something forced me to stammer out a lame excuse to get the nurse.

The nurse was a pro. She had been doing this for years, and so she came in and calmly assessed the patient, whose heart was still beating faintly. The nurse listened quietly to the beat as it faded away, gently easing the children, those grown and adult children, into the reality that their mother was now gone. I still marvel at her skill and aura of tranquility. The family had time to say their final words and then they left quietly but gratefully. It was the first time I had watched a patient die without needles and tubes flying everywhere, without people scrambling for medications and defibrillators, without the repetitive creaking from a bed frame assaulted by the combined force of chest compressions on a stiff torso. I was literally overwhelmed with the sheer normalcy of it all, and what disturbed me the most was how this ritual of death had become, for a young doctor in training, the exception rather than the rule.

When did something so routine become bizarre? Have we learned nothing about death despite millennia of human existence and thought? When people ask me about the life of a “doctor”, they are most curious about the thrill of working with life and death. I see my own reasons reflected in their questions, but I am always baffled when they become uneasy when the discussion turns to their own mortality and fragility. I have asked most of my friends, “What happens when you die?”, and the most common answer is, “I don’t know, I haven’t really thought about it much.” More often than not, they also imply, “I don’t want to, either.”

Even though I hadn’t eaten all day, I waited by that patient’s room throughout the early afternoon because I wanted to see what happened next. So I helped tidy up the body. I helped straighten her out, removed the last offending bits of tubing and plastic, and cleaned up the sheets. I helped the funeral home director transfer her to one of those black body bags you see in the movies, helped zip the thing up and waved goodbye as she was wheeled down the hallway and through a set of heavy double doors.

These past few weeks have been filled with congratulations and accolades as I receive my medical degree and move on towards residency. I have told people not to celebrate too much yet and that the “worst” is still ahead in so many ways… and yet, perhaps there is something special in celebration because it remembers what we have come through and it looks forward to where we are going. A book I’ve been trying to get through talks about the theology of memory, that the act of remembering is to re-live in bits and pieces. Sometimes the act is intentional, as it was for those family members remembering inexpressible things about their mother. Sometimes it is not, in the same way that that family continues to spring into my mind. As we commemorate those who sacrificed their lives that we might live, let us remember. Perhaps doing so restores a little life, dignity, and meaning to those who have died. Perhaps it will do the same for we who share the same fate.

For everything there is a season, and a time for every matter under heaven:
a time to be born, and a time to die;a time to plant, and a time to pluck up what is planted; a time to kill, and a time to heal;a time to break down, and a time to build up; a time to weep, and a time to laugh;a time to mourn, and a time to dance; a time to cast away stones, and a time to gather stones together; a time to embrace, and a time to refrain from embracing; a time to seek, and a time to lose; a time to keep, and a time to cast away; a time to tear, and a time to sew; a time to keep silence, and a time to speak; a time to love, and a time to hate;a time for war, and a time for peace.

- Ecclesiastes 3

In Memoriam

Healing By Intention

To heal by tertiary intention is to leave the wound open
on purpose; you see it most often in the gritty sort of
traumas that leave large chunks of dirt and debris behind,
embedded in the still-injured tissue. People often
wonder why this is done, as it is natural within our impulsive
nature to cover up something so grotesque and unsightly
by hastily wrapping it together with hopeful wishes that
goodwill can do the healing on its own. But the reality
is that the body sometimes has a slow memory, allowing
itself to become inflamed and irritable long after the
incident has passed. Those are the sort of wounds for
which doing something may be worse than doing
nothing.

To heal by secondary intention moves to the next stage,
when we are prepared to begin cleaning out the leftover
mess after the body is done venting itself. It is usually a
daily exercise, in which new and clean bandages must
be applied in order to gently and gradually draw out the
last vestiges of reactive poison. The more severe
the wound, the more futile the efforts might seem at
first, but the deliberate lack of provocation and the soft
presence of something to absorb the weeping, mixed
residue is surprisingly, though subtly, effective.

To heal by primary intention is to bring out that piercing
needle and stitch those last, ragged edges of a wound
together, laying them side by side so that the two bits of
flesh that were once so violently torn apart now have
no choice but to cleave together again. It is painful,
often messy, and decidedly uncomfortable as the nature
of the wound is to pull against the unyielding sutures that
unceremoniously bind it up. But it is also the form of
healing that leaves the smallest of scars and restores
as much strength as is possible after so traumatic a rift.
It is the preferred method, and one that stands the test of
time.

Healing By Intention

Leave It There

“I thought I could beat the ICU, you know?” My resident looked into the distance abstractly as he spoke, talking more to himself than to me. “Sometimes you think you won’t let it get you down, but you can’t. It always wins.”

I wondered what he meant by winning. Did he mean getting to leave on time? Did he mean keeping a positive attitude? How can you “win” in the ICU? I thought about all of the patients we were caring for. A comprehensive list of their names was scrawled all over a big whiteboard, where imminent changes were haphazardly heralded by beeping pagers and a flurry of activity. The rapid shuffling of names and the random clamor made it seem like a perverse scoreboard; successes were annotated with new room numbers and locations for transfer elsewhere, while failures were simply wiped away with minimal fanfare, leaving an off-white space that waited patiently for a marker to squeak out a new set of letters.

The resident’s pager went off. There were phone calls, some hastily scribbling, and we were off to pick up the next patient.

The night wore on and I kept my eye on the clock. Of my sixteen hour shift, there were two hours left. Then one hour. Five minutes. Finally my resident dismissed me. “Go get some rest,” he said kindly as he scanned the computer screen and mechanically punched in orders. “All that’s left is paperwork. Nothing more for you.” As per medical student etiquette, I thanked him, wished him a good night, and strode out of the ICU. I walked down a quiet hallway paneled on both sides by glass. The view on the left side faced out into the cold, dark, northeastern night. The right side faced the surgical ICU waiting room, still lit with muted, tubular fluorescent bulbs. I glanced into it momentarily and was surprised to see someone still waiting inside.

She was sitting alone. Her eyes were puffy and red, but they were dry, and they looked as if they had been that way for a long time. A thin hospital blanket was draped carelessly around her shoulders, which were hunched forward slightly as if carrying a palpable heaviness. Her motionless presence made the room seem more static than if it had been empty, as if Time himself had decided to stop in and say hello, that there was nothing particularly important for him to do and he could afford to wait around for awhile and sink into the vinyl furniture, listening to the ventilation hum while he got things ready for eternity to end next Thursday or perhaps the week after that.

My feet continued to move. I got in my car and felt immensely grateful that I could simply drive away. I could leave this place and the bodies in their beds and the score on the whiteboard and the timeless terror of the waiting room. I could sleep without nightmares and wake up without fearing that moment when I suddenly remember that everything is different now that she’s gone, ohmygod she’s really gone.

*****

So tempting to take up a crown
of guilt around my head
and proudly wear another’s weight
of paralytic dread.So hard to sacrifice the love
of self-divinity
And rather speak a better word
of true humility:

“Fear not the lack of task to do,
presumed irrelevance,
Or for the merit to survive
The deathly duty dance.

Recall instead the words they sang
to pause and leave it there
in callused hands long pierced by all
the burdens that we bear:

There is a balm in Gilead
To make the wounded whole;
There is a balm in Gilead
To heal the sin-sick soul.

Some times I feel discouraged,
And think my work’s in vain,
But then the Holy Spirit
Revives my soul again.

If you can’t preach like Peter,
If you can’t pray like Paul,
Just tell the love of Jesus,
And say He died for all.”

Leave It There