Thursday, January 24, 2008

of mice and men

When I tell people I used to work in veterinary medicine they usually turn to me to say, oh I could never do that. I love animals way too much. We will be standing in a hallway, in scrubs and white jackets, charts and clipboards pressed against our chests, waiting for the elevator. Or sitting at the central station, pouring over lab results, or waiting for the CT imaging to upload. And they tell me this. Each one of them repeating, almost precisely verbatim, what the others say before them.

And then I become extremely uncomfortable, and fidgety. Because, basically, I find it alarming, that they say this to me, because here we are, in human medicine. In a broke down hospital in New York City. Surrounded by people. Most of them severely, seriously ill.

The difficult part for me is gauging whether people actually know what happens in much of small animal medicine, how similar it is to what we do to each other. I cannot tell if it's that they know this and that's why they say they could never do that, they love animals too much, or if it's because they think animal medicine is something even worse than what we presently do on a daily basis, to one another, to our own.

What most people are apt, often adamant, to point out is that Fluffy doesn't understand what's happening. But that is the perfect, tiny, enormous distinction. Fluffy doesn't understand what's happening. What this means is, when you are about to insert a catheter up their urethra or clean off their diarrhea or take an xray or place an IV or inject them with awful, toxic chemotherapy agents or maybe just clip their nails, they have no predicitve idea of what the fark is happening. So you can just kiss them all over their animal faces and use really high pitched, squeeky voices (which we all know makes their brains explode) or hold them down and hug them while all the bad, awful stuff happens to them and then they get up and (usually) wag their tails and say "Hi!!!!!! It's so good to see you!!!!! I haven't see you in 3 whole seconds!!"

Or they bite your face off.

But people. People know. Whenever a dog or cat has intractable diarrhea all over its hospital bed, regardless of its pathology, it is only a few things for everyone involved. It's potentially disgusting, inevitably smelly and more than a little inconvenient. What it isn't is embarrassing, mortifying or humiliating. Cats are arguably an exception if only because they are born indignant. Yet, this also means they are equally appalled if you move their beds as they are if they crap all over it. They are, by and large, democratically disgusted.

People know, usually, when they've lost control of their bladders, their bowels, their last shreds of dignity and independence. They know when we all tromp in for morning rounds and they are rolled over on their sides, naked and exposed and helpless for everyone to see, unable to do anything until the nurse finishes her cleaning. People know. They know that this is it, this what we all universally fear and ultimately face: the complete inability to care for ourselves.

This, this knowing, the explicit understanding becomes far more painful and excrutiating for me. It is this precise aspect of knowing, of cognition, that leaves me agape whenever people say that working with, taking care of, animals would be "too hard". Harder, it would seem, than caring for people.

And yet, whenever an animal would come in, terribly ill, dying, gasping for air or crying in pain, no matter how wrenching, how difficult, how agonizing it was to watch and to care for and to try to ameliorate, no matter how much it collapsed my heart, I could never escape thinking: what if this were a person? What then? What if this were someone's daughter, son, husband, mother, father, wife? What if this being, this creature gasping for air beneath the mask of oxygen were me? What will I do when I can no longer opt for humane, merciful euthanasia, when the bitter end must be met, no matter the distance it takes to get there?

It was exactly their not knowing that made it possible for me. Because everyone else knew: the nurses knew, their families knew, the doctors knew and none of the emotion got diluted out, ever. (It doesn't make it better to be able to say, with words, "the reason you can't breath is because your lungs are filled with fluid from your worsening heart failure. We can't do anything because your kidneys don't work either. Don't worry, eventually you will die of respiratory failure but first you're going to panic through the feeling of being suffocated for a bit"). Every family is devastated, always. There is no escaping the heart stopping anguish of a terminal prognosis, a failed attempt at all measures exhausted. There is no way to soften the blow. But somehow, somehow, knowing that Princess and Jonesy and Sam and Beulla were never, could never be, aware that they only had a week, maybe, a month, or two, to live made it a little bit lovely in a way I couldn't appreciate then. Because it allowed me, by proxy, to just live in the moment. Just in the moment of a sweet, brave face lick or a dutiful wag of a tail; the joy of eating chicken baby food directly from the end of a spoon.

I have not found that yet, as it is for me, in our own kind of medicine. I have not found a way to escape the clear and undeniable pain that knowing brings those around me. It is infinitely and entirely different, infinitely and entirely harder than the sweet heartache of animal care and I do not know if I ever want it to get any better.

Wednesday, January 23, 2008

and another thing

I want ankles. More than almost anything on my list--cedar chests filled with cashmere blankets not withstanding--I want ankles. I have what some might refer to as an "ankle issue" but can be more aptly described as straight up cankles. I covet ankles so much that there are times when I find myself saying, "and what the F did she do to deserve those ankles?" I mean, really?

The thing is, everything looks better with ankles. For starters and straight out of the gate, flats. Flats look adorable in ankles. In cankles, they look like colorful thimbles on the end of someone's thumb. The thumb, of course, being the metaphore for my
tree branches legs. But there's so much more: heels, slippers (i.e. "flip flops"), clunky shoes, swanky shoes and anything, and I mean ANYTHING with an ankle strap. Ankle straps are absolutely out of the question on an ankle-less leg. Then there's shorts. Shorts just look so much better when there are ankles in involved. It almost doesn't matter what the circumference of my thighs are when there's no distinction between thighs and feet. Also, mid-calf anything. Mid-calf _________ is 100% ruined by the lack of ankles in my life. Everything "mid-calf" and "below the knee" eliminates the minor change in contour that "knee" provides, thereby rendering the bottom half of my body something akin to sausages. Sausages with shoes on.

Sometimes I dream of the advent of ankle-o-plasty, a miracle, painless, surgical repair for my ankle-less, cankleful life.

morning rounds

From the where I am, on the outside, stuck in the impossible margins of trying to Stay Out Of The Way and Be Assertive And Available, much of my time is spent standing back and watching. I watch my attending as he establishes a rapid relationship of trust, attention, and admiration in 3 minutes 45 seconds, flat. Nearly every time. I study what he says, how he says, the things he reveals, the ones he does not. I listen to his daily litany of unyielding expectation even though I myself am ruefully far from reaching it. 

I watch as everyone gathers around their own: nurses to nurses, aids to aids, students of each discipline to each other. I notice the alignments we make, the ones we do not, and the foundations (reasons) of everything we do, and do not do.

Today I watched a grown woman undress her mother: elderly, frail, cachetic, hypertonic, frozen and unresponsive. I watched as the daughter leaned her forward, pulled her thin yellow night gown over her head and dressed in her a t-shirt, possibly one of her own. I watched as she moved her rigid hands to the side, making room for the sleeves, adjusting the collar, tucking in the ends. I watched her, singly softly, operating with such deft tenderness that will leave me breathless for days. I did not know her. Or her mother. Ever. Neither of them were patients of mine. I do not know for how long her mother's ability to smile or frown, to laugh or pout was lost to the permanent distortion of muscle wasting and grimace. But I do know that in that tiny, perfect, stolen moment I knew nothing else beyond the fact that we are each so human. We are so vulnerable, so delicate, so similar, so unique.

It is so easy to loose the intention, the reason, the cause. It is so compelling and distracting and instantly rewarding to divert your attention to the petty and mundane and caustic inconveniences of every day life, no matter where you are. Medicine is no different and so different. It is beautiful and cruel, and all at once.

It is a strange, sad privilege to be privy to such unusually private moments of living, dying. It is a strange, sad privilege to be in a world that makes our sicknesses, frailties, our failing, falling structures such a spectacle to witness. It is beautiful and cruel, and it is all of it at once.

Tuesday, January 15, 2008

evening report

I came to New York because I wanted to get my hands dirty. I choose this city (although, truth be told, it choose me) above the (however few) other options available because, I thought, it would garner me a kind of exposure, a particular perspective, I would have access to no where else. I based the decision and the formed the dialogue, to myself and others, on all of this; that I would come out of it having seen and done things I would not have had the opportunity to anywhere else. But the other part of the truth is that I would have been just as happy, if not more, to have gone to Stanford, to have stayed in Santa Cruz, to have maybe kept my hands just a tad bit cleaner.

The hospital where I am doing the bulk of my clinical training takes care of, by and large, the urban underserved areas that sprawl out around the pockets of wealth that glint like minerals in my small part of Brooklyn. My patients, its patients, the patients, rarely have regular doctors, those who do were lucky and got into the clinics. The hospital is a dreadful mess of limitless bureaucracy, social tension, and failing architecture. Nothing works. In order to go down the elevator you first must go up. The nurses walk around with buttons that say, "ask me if I washed my hands".
There are no sinks. We stand in the hallways during rounds and watch--in shock? awe? amusement?--as a cockaroach climbs its way blissfully up the wall besides us. Someone snorts. Another makes a disparaging retort, we all roll our eyes as if to say, "only in _______ Hospital". But this is the lifeline to thousands of people. This place that we all despise so much for its filth and malfunctions and inefficiency is the only place these people know to go, can go, will go. They trust us so much, regardless of anything, enough to come here, to stay, to heed our words, our warnings, our castigations. They deserve more, certainly more than this.

At the nurses station we all gather around, in our dingy, uptight coats, our stethescopes, our reference books, our manuals and cryptic scribble. We invade the nurses only work space. There is no place else for us to go. We have one computer. One. On which to look up lab results for over 50 patients. This is the same computer that the nurses must enter in the lab requests after we put in the orders. Everyone's work is important. No one concedes to budge. Eye contact is to be strictly avoided because it may remind you that we are all in this together and part of the very forward momentum of this wretched place is acrimony and vitriol. The nurses hate all of us. All we do is make their life a living hell. They know who and only who they cannot f-with and this is, believe me, a very short list. All else are subject to be fired on at will. The residents hate the PA students and the PA students in turn hate the med students, whom the residents fawn on, and the NP students, for reasons I will never understand. The doctors generally abuse the residents, who in turn abuse all of us, the charge nurse speaks a language indecipherable to anyone not holding a degree in Speech Pathology and no one will help you. Because someone, at some point, really pissed them off and now you're going to have to pay for it.

All of this is without even beginning to dissect out the fragile, tempermental, sensitive subject of race, culture, ethnicity. Or education. Or social status. Or economics. The reality is that the nurses, the clerks, the aids, the receptionists, the secretaries and the therapsits are trashed. They are over worked and under paid and no one ever says thank you so they stopped trying. And it stops being about asking nurse A to get a blood sugar on patient x. Instead it becomes,
that skinny little white girl with the big diamond her finger just told me what to do, oooh uh uh. Even though it was never about that. Ever. I don't think it is ever about that, no matter how arrogant the doctor or student or resident may be. It is only about getting the f-ing blood sugar on the patient, but suddenly, it's not. Because now she won't do it, for myriad and understandable and annoying and over-generalized reasons, but I still need it, that doesn't change or go away just because I'm white or she's not or I'm younger than her and she should be getting paid more. So when I really need it (during morning rounds) I will get yelled at by my attending and looked upon with pity by my peers because I couldn't even get a simple blood sugar. And somewhere behind me, she will be happy. And that's fine. Okay, whatever. But the thing is, patient x still needs his damn blood sugar checked. Maybe I was temporarily humiliated or embarrassed or frustrated and some small yet exquisite pleasure could be gotten from that in what will otherwise be a thankless day. But in the end, the person who suffers is patient x. Because he sat around with a blood sugar of 513 and did not get his insulin on time, increasing his length of stay and ever so minutely worsening his disease.

So this is what I do all day. I wait for hours to check lab results I should have been able to check during the first half hour of my day. I call for MRI reports, ECHO reports, CATH reports, surgery reports that are not in the computer, will never be in the computer, and am forced to try to translate the indistinguishable garble that I hear on the other end of a phone line by a person who is clearly speaking Russian. I cannot read the handwriting in 75% of the charts. It takes an expert in sanscrit to understand the orders. And while I am fighting the urge to jump out the window, the ones who suffer are laying in their beds, trusting. Trusting that we are getting it done. That we are on it. That it's understood and done. And they deserve that. If for no other reason than them we should be able to read the @#$%! medical records, access the reports, be made aware of additional charts from additional services. If for no other reason, we shouldn't be such a clusterfuck of chaos and anger and bitterness and incompetence.

I have seen much and not enough during my short time on every rotation. I have seen much of how I never want to practice medicine, hospital environments I hope I never have the circumstances to return into, toxic pits of personality disorders and disorganization like one would never believe. But I have not seen enough excellence, enough empathy, enough kindness, enough understanding, enough meticulous, uncompromising dedication to medicine, to patients, to learning, to care. I sometimes wonder how I will ever enter into a job with this as my only compass without being thrown out immediately. I have a vague optimism that somehow a place like New Hampshire will be different, better, less...dilapidated. And then I come to realize that I have changed from being here. My hands are dirty now and somewhere, deep and elsewhere, I am worried about the stains.

Monday, January 14, 2008

za za gabore

As if the cow(s) weren't enough. Really. This is bordering on pathological. This morning, instead of, oh, I don't know...reading the third Internal Medicine text I've purchased now under the auspices of both Board Review and Not Looking Like a Total Jackass Every Morning During Rounds I am, instead, looking at horses for sale in New Hampshire.

Why lord, why?

Why did you plague me with such a dogged, obsessed brain? Because you know what? It's not
just the horses. Or the cows. Or the three sheep I keep threatening to obtain. Or the farm house we're going to put them all in. Assuming I don't actually expire from the cold or get sucked into a mud pit and thereby proclaim that our own little episode of Green Acres is officially fin, it will never just be cows. Or the horses. Or the sheep. I can assure you. Soon it will be the green house. And the garden. And the organic vegetable patch. And the tractor. And the 3,000 bulbs I want to plant every winter and the stalls and training for my highly anticipated Olympic return to Stadium Jumping (snort) and not, say, my red hot career as Pediatric-Neonatal-Internal Medicine-Emergency-Oncology bad ass PA.

Underscored completely by the fact that it is now 7:15am and I have yet to leave the house. Maybe this New Hampshire business is a bad plan. Staying in New York where the only significant distractions are my close proximity to Aveda and J. Crew may not be so devestating after all.

Sunday, January 13, 2008

old blue eyes

            Now that there's a 95% certainty that we (and by we I mainly mean me) are leaving New York I'm starting to get all preemptively cozy and nostalgic (I'm also spending an inordinate amount of time looking at farm houses in Vermont, but anyway). Driving (and by driving I mean in the back of a cab) into the city today aside from my usual, overwhelming urge to vomit (innate tendency towards car sickness + cab drivers + city = bad, bad things) I felt all caught up and included in the particular kind of loyal capitalism that only New York can engender in a person. Oh look, sweet little corner cafe here, incredibly amazing paper store there, shoes I could never afford to my right, handbags that cost twice what I used to make in an entire month (when I actually earned money rather than single-handedly hemorrhaging it). And that's the spirit, the allure if you will, the moth/flame equation of this city: no place else makes you want to spend money like New York City. It is a collective genius of promoting consumption and even I--especially I-- wild-eyed bumpkin reformed, can't help but succumb.

Things I might actually die from missing:
Rai Rai Ken.  
2. Toasted Salt Bagels with Butter. 
Pinkberry. I'm considering an outpatient program as we speak.
These people.

Saturday, January 12, 2008

Friday, January 11, 2008

one more for the road

You know what I don't miss? Bars.  Dive bars, swanky bars, clubby bars, dirty bars, smelly bars, bright bars, darks bars. Basically all things bars. I don't miss sidling up to the counter, trying to ingratiate myself to some shitty bartender in a leather corset to pay some exorbitant amount of money for something that's going to ruin the next 36 hours of my existence. I don't miss bar bathrooms, or bar talk, or bar hook ups or bar meet ups or bar outfits. I don't miss spending half the night trying to get some guy to come talk to you, only to spend the remainder of the night either wishing he'd shut up or puking in a house plant. And I really, really don't miss the inevitable sightings of your former best friend/roommate/ex-boyfriend-girlfriend-both-at-the-same-time. Moreover, I reeeeeally don't miss running into professors and teaching assistants while out at bars, because that's just uncomfortable for everyone.

So there you have it. I was never one for bars, even in the heyday of my bar hopping youth. I mean, I remember having fun at both bars we hosted parties at on the nights before our wedding (except the one night I drank enough Amaretto to forget how to use my brain or operate the English language, which was klassy). But there's something about bars, in New York especially, that just makes me say out loud everytime: thank f-ing god. I'm just so glad that I don't have to get all dressed up, sit in dark smokey room listening to some guy drone on about his recent third attempt to complete his dissertation in Advancements in Basket Weaving in the dismal hopes of not meeting a serial killer or a tattoo artist (not that there's anything wrong with that, I'm mean, I totally dig LA Ink) or worse, a Finance Guy. Finance Guy is the friggen worst. Second only really to Girl Seeking Finance Guy (but thankfully I've never had any interest in dating her). I don't know, it all just seems so desperate--what with everyone trying to one up everyone else---my job that pays me this, my school where I studied this, my apartment that's located here, my clothes that I bought there, my house in the country my studio my warehouse my restaurant my venereal disease(s).

I didn't really ever wonder about what "married life" would be like. I never drew a line between one particular day when I happened to get all dressed up in a big white dress and invited about 300 people to come, watch and get wasted and any other day of my life with Andy. But suddenly you have this overt and recognizable symbol that exists externally in the form of a wedding band (+/- engagement ring) and all a sudden its this great sigh of relief because no one (well, that's an overstatement but the numbers are pared down significantly) is going to come up to you and ask you if  you feel like a dirty martini because "baby you sure look like one to me". And that's just really fantastic that's what that is. Because guys tend to look kind of terrified half the time they do things like that (assuming of course that they can open their eyelids) and the girls look like they've just had a root canal without anesthesia and really no one in the whole of the place looks like they're having any kind of fun whatsoever, but half of them will swap mucus membranes by the night's ending and well, that's all I need to say about that.

Thursday, January 10, 2008

the big red barn

Is it wrong to want a cow? I mean, is it? Because one cow, singular, would probably be lonely. So that means you need to get another cow, plural, to keep the first cow happy. And lord knows how I feel about happy cows. But that also means doubling the original endeavor, which was a questionable one to begin with, even before we started exponentially tampering with it.

It's just that, well, I want a cow. And I want one for mostly all the wrong reasons (they're spotted, they have enormous wet noses, they have cool, floppy ears, I really dig udders) and only a few kind of righteous ones (I'd like to stop having an anxiety attack each time I think about eating and knowing that at least my milk--a commodity I consume daily in the form of well creamulated coffee--is in good conscious. Plus, have I mentioned the spots?)

But really, it's rather dumb-founding. I dropped out of my college major pretty much entirely because of cows. It was essentially cows and all things cow related (cow comma boys, cow comma shit, cow comma farts) that single footedly (hoofed?) stopped me from going to vet school, jettisoning (oh the rapture) me from Middle America comma Colorado to Santa Cruz comma lovely. And apparently somewhere in the wash of beachy Santa Cruz and life in the hood I've acquired the common misconception that cows and cow barns and milking sheds and tractors are all kind of quaint little accessories, requiring little to no actual work. At least, nothing too hard. If anything, they are an entire category of reasons to buy more and different clothes from J. Crew. Cows don't die unexpectedly and almost without warning in the middle of the night when the temperature is just south of negative ten degrees, they don't crap all over their cow pants, they don't necessitate the use of stubborn, diesel spitting tractors with temperamental carburetors and they always come running, obediently (gleefully really) tossing their enormous cow heads in the light summer breeze, whenever summoned.

Yup. One. Hundred. Percent. Malarkey. But you know what? I still totally want one. I can't help it. And you know I'm going to name them Bessie and Maude. Because I'm original like that.

Monday, January 7, 2008

Moriate of Potash

Alright already. I give. I cave. You got me. I really will, I swear it, only buy organic, local foods, positively, whenever possible. I haven't even gotten halfway through "Corn" and I'm already feeling anxious. In additional to all the other distracting and consuming concerns I've already amassed for myself ----what with my factitious fatal arrhythmia, my pheochromocytoma, my lipoma, the infertility that I just know is waiting around the corner (gathering speed) and my abdominal tumor(s)...really, how will I find the time?---I now have freak out about being made up undividedly of corn carbon and the catastrophic global doom I'm causing by my unrelenting love of grapes.

I hate it when books make me feel all trapped and powerless and skeptical. Particularly when they're good. Because then I'm driven by compulsion and insanity to read them. And then I sink into an existential mire of despondent tribulation and despair about the human condition, our sad, savage, surreptitious ways blah blah blah blah blah blah blah. Because goddamnit, Chinese food is delicious and you know that s**t ain't organic, free range, or even sexually satisfied. You're counting yourself lucky if it's actually chicken. 

So leave it to Michael Pollan--eloquent, rational, intelligent, funny, totally reasonable--to ruin Cottage Chicken and Scallion Pancakes forever not to mention making grocery shopping in Brooklyn even more friggen challenging (I mean, it just so rules out Fresh Direct from here on forward). I don't even want to talk about how I'm going to give up Indian take-out.

Oh my god, then there's my coffee. Truly, I can't even imagine. Flown in from far off  locations here, product of exploited, third world workers there, this one picked by a deaf mute child with no arms, that one the end result of a bloody shoot out a plantation. Here I am, all worried about my organic milk, running halfway across my neighborhood to get organic cane (not corn) sugar, grass fed organic milk from free roaming, sun bleached cattle with social agendas and two hours later I'm pouring myself a nice hot cup of conflict coffee, teaming with the toils of Stegosaurus juice. Flown from Gautemala, roasted in Seattle, ground in Santa Cruz and brewed New York. 


And no, I don't want to talk about my engagement ring, thank you very much.

Saturday, January 5, 2008


It pretty much starts on Halloween: seemingly innocuous orange pumpkins heralding a fun sized Snicker's-Starburst-M&M-KitKat-MarsBars induced metabolic acidosis. Before you can unbutton your pants or reach for the mumu, there's Thanksiving --- a nationally sponsered exercise in holding the thin line between laying catatonic on the couch and eating your body weight in sweet potato pie. And gravy. And sweet peas. And butter. And corn bread. And apple pie. At midnight. Because the 8:30 pm slice just wasn't enough. Really. I need more. Beyond this, there is no feasible plan. All attempts of resistance are in vain. The battle has been lost. You are now deep in: ice cream sundae this, chocolate cake that, toasted bagel with butter here, four slices of pizza there. And it takes until somewhere in the neighborhood of January 5th (to put a rough estimate on it) before you're so sick of yourself you can barely stand it.

Really. It's disgusting. Oh look, time for a burrito.

Tuesday, January 1, 2008


Thomas Wolfe said it:  "you can never go home again".  A boyfriend quoted that to me years ago in college.  It must have driven me mad at the time. I hated how he was always quoting Kant or Proust or Heidegger. It made me want to aim a Chemistry textbook squarely at his head. Regardless, I remember this quote. I remember where we were at the time--Walnut Street, night time, summer. I think about it every time I return home, though I've never gotten around to reading the book and despite the fact that I do not know if home is home any longer. 

I return bi-annually now, twice as much as I ever have before, to a small island in the Pacific; I return to a patch of land, the mercy of weather, assailing memories, the clutch of everything I left behind. I can never make sense of it. I can never wholly dissect everything out, lay the pieces out before me, give them something like names. I feel it all at once: sadness, joy, pride, shame. The muscle memory of the land returns but slowly now, my family grows older, the children taller, my parents frailer. Somedays everything, everything seems small, and spent. Somedays everything, everything feels exactly right, achingly familiar. 

There are sacrifices to living where you are, if not always choices. The singular sacrifices to live in New York City are stark and stern and burdensome. There are times when the numbers add up, when the math makes sense and I can live in the columns--when the light is long and the days are thin, when it is June and the fire flies hang lazy in the air or when the clear distance between me and Manhattan, the span of the East River, is bright enough to read by. But I can see that I am going bankrupt slowly, gradually running aground. 

When I go home I begin to try to count the obvious sacrifices to return. I have no scale to weigh and measure the options, the good, the bad, what will be left, what will be gained; I am too taken by my own evolution, how much I have changed, how little the spaces are now to fit into, how unquickly I have grown, the time that has passed. 

My niece and my nephew look exactly like my brother and I, running sandy and dirty and wet through the small world of Mokuleia. I watch them from the shore of the house we grew up in, my brother and I, waterlogged in my too-big emotion, watching their lives get bigger before me, clumsy in how far I have gone.