explanation point hang over

Ever had one of those mornings when you wake up, roll over and simultaneously think "holycrapshit I'm going to vomit holycrapshit who the hell is that?" No? Just me? Hmmmf.  Well that was the beginning of my day, status post writing what sits directly below this. I woke up, re-read my blog and promptly smashed my laptop into my face.  

yellow bricks

Hi! Oh my god! I think an anvil fell on my head while I was sleeping, at which point I died, and am now writing you from heaven. Seriously people, what the F is going on around here?

First of all (FIRST OF ALL) I didn't even have to report to my new rotation until 9:30 this morning. NINE THIRTY in the morning. That is practically the afternoon people. Why don't you just tell me to make a margarita for breakfast because that is an F-ing a VACATION that's what that is.

And then (AND THEN) I got to ride the real train, the grown up fancy train to work and OH MY GOD can I just tell you how weird that was. Weird! Look! I'm using exclamation points! That means things are REALLY CRAZY. First of all, it's completely packed. Which I'm not used to. What I am used to is sprawling out over 4 seats staring up at the ads for malpractice attorneys in Spanish trying to calculate the correct vector of force a moving vehicle would need to hit me with so that I wouldn't die or loose a limb or be incontinent but hard enough send me to the ER (but not my ER) for the day so I wouldn't have to go into work. But this morning I had to scrunch in with everyone else in their wet (and stylish! with the little belts! adorable!) trenchcoats and umbrellas all dressed up in their pointy shoes to go to their cushy offices in the financial distract and OH MY GOD can I just tell you about the diamond rings some of these woman are wearing? GI-normous! Ginormous! (look! again! the explanation points! wtf?!) I want to ask them if they tear their rotator cuffs every morning getting out of bed but I'm afraid they might hit me in the temple. And then I'd be a vegetable. Because their rings are the size of flower pots. Ginormous, everyone, ginormous.

(Which reminds me that I need to talk about The Real Housewives of New York City at some point, but not now, because I'm already diaphoretic and panting and yet another orthogonal diatribe might actually make my head explode so it's up to someone else, all six of you, to remind me. Because if you've ever seen it I've got some shit to say. Shocking. I know.)

And then. (AND THEN!) I got OUT of the train and I wasn't in the ghetto! People, I tell you what, New York ain't so bad when it's all cute cafes and narrow streets and glossy buildings and people with their pants covering their butt cracks. Really. I know it's hard to believe, but I am here to say it's true. It's so very true. I went into a little corner deli and DO YOU KNOW WHAT THEY DID? They said hello! Good morning! Can you believe it? I couldn't. I couldn't believe it. Could not. I almost jumped over the counter and made out with all three of them. Because I didn't know how else to express my awe and gratitude and figured inappropriate sexual advances are clearly the only answer. And then they asked me if I wanted my bagel toasted!! Toasted! And I did! I did want it toasted! And then THEY TOASTED IT!  I cannot tell you the glory of that moment. It was sheer ecstasy and quite possibly even the rapture, without the part about god and the Apocalypse and Mel Gibson. 

And then (and this is where you'll really understand why I am actually convinced that all of this is nothing but lies and fabrications and that I'm actually laying in a morgue somewhere because I've already died and I'm writing to you from the pearly gates of Jesus) I went into the hospital where I will be working for the next five weeks and promptly crapped myself. Really. No fooling. It started when the guard smiled at me (SMILED!! AT ME!! Who does that?) and asked me where I needed to go. And when I told him? He knew exactly where to send me! AND THEN HE TOLD ME TO HAVE A NICE DAY. And he MEANT it. He did. He really did. I just know it. And what he did not do was give me a sup white girl what you need? head nod nor did he fall onto the floor with full body exasperation that I would have the gall and audacity to ask him (him! the guard dude! the one you are supposed to ask these kinds of questions to!) that kind of question. Holyfriggencow are you serious?

And then (yes, AND THEN) do you know what happened? Do you know?? I got into the elevator AND IT WORKED. The little buttons, they lit up and the doors closed and it went right where it was supposed to and right then and there I almost passed out from the shock of what I saw. The tiles on the floor were clean (!) and there was no trash swept into the corners (because that's sweeping? Because that's okay with everyone? Because we're all crack addicts?) AND THEN do you know what I saw as I walked into the suite of exam rooms and offices? Wait for it people, wait for it:

A sink.

HALLELUJAH a motherloving sink!!!!!

Not just one sink either. Oh no. No no no no no no no. There are multiple sinks. All over the place. In the exam rooms. In the lab room. In the medication room. In the hallway. In the bathrooms. It's like fucking Home Depot in there. And not only that (NOT ONLY THAT!) there was soap. Soap. Real live actual soap. With paper towels. PAPER TOWELS PEOPLE. Do you have any idea what this means?? It means I have died and I have gone to heaven and yes, I can tell you, in heaven there are sinks. Because even God uses Universal Precautions.

And please, don't even get me started on the medical records. It will only make me weep with joy and disbelief. Suffice to say that it's beautiful. They exist. They are right there. IN the OFFICE. I don't have to proffer oral sex or my first born to try to get them. And I can read them! I'm SUPPOSED to read them! People even HAND THEM TO ME. I almost stuck my tongue down the throat of one of the nurses because I felt that quite possibly I had never loved anyone so much as I loved her the moment she came and gave my first chart to me. Holyfuggenshit. I have died. There is no other explanation. I have died and I have gone to heaven and in heaven there are complete medical records and computers and everywhere you look, there are sinks.

adios

Sometimes life is so f-ing beautiful and lovely that it seems like the only thing you can do is stick your head in the toilet. Just to get some perspective.

On Friday Andy was being a little irrational totally insane kind of complete f'er particularly special kind of human such that while standing in the driveway, talking on the phone with the insurance companies, I had no other choice but to flip him off. Because I'm classy like that and really believe in communicating my feelings. Later in the afternoon I looked him in the eyes and apologized for giving him the finger. It's just that, it was because I wanted to punch him in the face.

And so is the end of our little lives in Santa Cruz. We've said our goodbyes, I've doubled my body weight in huevos rancheros and halved my Time To Full Body Face Lift. Andy got poison oak in an assortment of places that usually go along with the words: and that's when I realized it was poison oak and not, say, that barmaid in Bulgaria. And can I just say how it never ceases to amaze me how many people get poison oak in places only Bavarian barmaids and a few well trained physicians are normally privy to and that all it takes is one person to open up the conversation for everyone and before you know it you're openly discussing (in depth!) someone else's genitalia and I've just never gotten comfortable hearing the words my vagina in casual cocktail conversation? 

wilder

Willow comes in from San Francisco to see me. We walk around downtown in the sunny chill of April, contemplate Buying Things. We clutch cups of tea and coffee and talk about the heterogeneous ache of life, the disappointments of being human, our own small denials, our little lives in medicine. We use hard laughter, soft voices. I adore her deeply, wholly. I understand why we are friends. 

Vicki, my Hawaii sister in law's sister, leaves work early and we walk the trails of Wilder. I am saying goodbye to friends and family, tracing the blueprints of my life. Every place that I go is a place I have been to so many times before, during very specific times, certain sections of my chronology. This is where I came to outrun an old heartache, that is where I used to drink too much and smoke stale cigarettes, this is where a long ago friend once lived, that is where I would go to watch the water, regain my footing. Wilder is where we are are today. It is an old farm at the base of big, open meadows and I bury my head in the tangled manes of the draft horses, slip them slices of apples, breathe in their dirt. Wilder abuts the Pacific directly; it is sharp cliffs and strong waters and from the top of it you can turn around and see the whole world in front of you, bright blue and unending. 

Vicki and I sit at the top and watch the whales cross the ocean. We try to spot the babies but are only able to make out the spray. She is not my family by blood but we are bound by strong love and shared history. We are so different and so much the same and we will always be a little more than family, we will always be friends.

the long road                                                                

Flying tends to give me migraines. I sit there like a furtive junkie, watching seven straight hours of Bravo and Animal Precinct, unmoving, tucked up like a small fish in my standard issue leather seat. I never drink enough water. I've always eaten a really bad slice(s) of pizza at the airport and I rarely, if ever, open the Cardiology or Nephrology texts I've lugged on to allay my guilt and neglect. 

Such that I return, bleary and famished and squinting, home.

Driving back late at night from San Francisco I stick my head out the window, drink it up. Suddenly and abruptly, there is sky. Stretched out and pin-pricked, thick and uninterrupted. Acutely, ceremoniously, where there was once dirtyfastloudloudscreamhonkpushtrashtrasheverywhere there is now the dark light of midnight and the unalloyed wash of moon. And instantly, unequivocally, I am better.

wind and sea

The bleached out bones of my life are here. I have not tired of Santa Cruz.  I still love the wide, patch work streets, the low trees, the quiet houses, the dank redwoods, my separated life. I love it fiercely now, today, two years out and away. It is notrashnosirensnohonkingscreamingscratchingbigrigsontheexpressway. 

It is quiet, it is only birds and seals--barking, scrapping, fussing over sun spots--and an occasional lawn mower. It is only open windowed sunshine and the clicking of dog feet on hard wood. 

We walk out in the strong on-shore winds to the ocean, lean on the iron railing, look down at The Lane. In the mornings we go to into the redwoods, padding quietly along the paths and needles, shady cool with little sun. The afternoons are all chilled, damp air hung out to dry in the sun; the mornings are full up with kettles of tea and coffee mugs.

The minutes go so slowly, are spent so quickly and I am better already.

distance, difference

The restaurant is like all the other places we go to in the city: dark, lush, quietly electric, expensive. I used to fight the urge to faint every time I sat down to order, anything, everything, it was all too much, so much, so unnecessary; now I walk in, know to greet the hostess, know to check my coat, know to kiss on the cheeks, know to wait for my napkin to be unfolded for me, my fast heart still a catch in my chest, an easy smile to compensate. At best I am ambivalent about these nascent social graces, at worst I am terrified of them, anxious about unintended implications.

They are there, my mother in law and my sister in law, leaning over their blackberries, looking up to say hello. I never know what to wear. I never feel as if I've gotten it right; something is always wrong-- my shoes, my jeans, my bag, my jacket. And I am proud and uncomfortable with this. In order to assimilate there is much to hand over. 

I love them each awkwardly and individually but the sum of our parts is often too much when we are together. The table is draped in burlap, the red wine has been poured, the votive lit, the menu--which is the same menu as every other restaurant we tend in New York--considered and the blackberries placed, for the moment, down. 

But I have nothing to bring to them. I have nothing to say. They don't want to hear about my life, the hospital, school. We each ask each other the requisite pleasantries, the necessary questions. How are the kids? Fine. How was your test? Fine. How was your day? Miserable. They ease into their lives in spoken format, what's to be done about the markets, are you still renting the summer house in Jackson, who's buying what pieces of art and from whom and for how much and from which dealers. The mortgage broker my sister in law referred messed up a big appointment, she was pissed and shot him a nasty email, duly noting that she was "happy" she hadn't referred him to one of her clients. Power. Money. Leverage. 

I sat and watched and listened, as I so often do, surprised by my loneliness, alarmed at what comes to my mind. This is my family now. These women in Prada. Across the table, so far away. I know better. I know I should be the one to rise above this. To be grateful. To remember that my dinner costs more than I used to make an hour; to breathe; to be present and without judgement. 

In this space, with the benefit of draft and edit, there are times when my internal intentions come out complete, in tact and in their entirety. It is rarely ever like that in my head. Often and in the moment I look at them and see nothing but distance and difference, allocating it to the tilt and shift of the life they live in, pushing it off of my skin to theirs. But when I am alone or reflecting I always return to me: what I could have said or done to make it easier to find connection, to make it easier to feel interesting, interested, relevant, loved. 

They don't ask, but I don't push. They don't know the name of the hospital I work at (although they do know that it is not an Important Hospital and so isn't worth mentioning), don't know that there are times when I come home and sit on the cool tiles of my bathroom, clutch my shoulders and sob. They are unaware that the man who I sat with and read excerpts of Robert Kennedy's biography last week died alone in a hospital bed, his loose red beanie still lopsided on his head. They don't ask so I don't tell them that I clung to the metal rails of the supply room for five full minutes just to stay upright because this world is beautiful and cruel and we are only given so much of it. They don't want to hear about it. My sister in law won't take her kids to see Rent. She thinks it is Too Much. They don't need to Know That. I am thinking, I will tell my kids everything that I know how to. And when I cannot use words, then I will show them. I think about my mom, who bought me The Tenth Good Thing About Barney after our first dog died, who sat there with me while I ran overboard with wet and easy tears. She held my hand while I inspected the remains of our dead bunny, surprising each of us early one morning. 

But they will tell me, what do I know? They will tell me, just wait, you'll see. When you have kids everything changes. They are unintentionally assuming that the miracle of childbirth will turn me into a different person. They would look at me with shock and disapproval, like when I reach for the bread, if they really knew what was inside of me.

closing credits

Yesterday was my last day on Geriatrics. My last day with my senile Attending, my last day on floor eight, with its green walls and lives slowly ending. My last day with the Lebanese Princess who, by no small miracle, I didn't push out a window. It's a day of goodbyes and thank yous and written evaluations. Most Attendings sit down with you, ask you how the rotation went, how they could do things better, what we liked, what we didn't. Sometimes they offer you a job or a reference or an extramarital affair. 

The Princess, whom I at once loathe for reasons that betray the inner school marm in me ands slack-jaw marvel for her audacity, makes the following proclamation, "I'm not going to ask (Dr. Attending) because he doesn't like me and he won't give me an A and I need all As because I'm Going To Medical School".

Right. Medical School. I forgot. You're Doogie fucking Hauser. 

She continues, "all my Attendings have given me 100% because I asked them to. I've gotten 100% on every rotation this year". 

Because that's something you really want to admit in public. To someone who openly wishes a a pack of feral pigeons will peck off your earlobes. Then I stood there, with my mouth open, aghast and astonished, as she proceeds to tell the Senior Resident that he HAS to give her a 100%, the best possible evaluation you could give anyone, the kind of grade you'd give Watson or Crick or maybe that guy who wrote the program for the Human Genome or something. If you were feeling generous. Not someone who has difficultly pronouncing pancreas. 

And he did it. He did it. It was really quite something actually. I was completely and utterly amazed. Astonished really. 

My hospital: medical integrity at its finest.

weekend edition

I went out "the country" weekend with my mother in law. Just her. This is not an unusual occurrence and proceeds a little something like this.

propriety

I do this every time. Every single time I go out to "the country" thinking that it will be, actually, in fact, just hanging out and lazing around the house no need to bring anything special we're just going to cook and enjoy ourselves and not, we're going to drive into East Hampton and I'm going to follow her around to stores that sell $25 hand soap and $350 cardigans wondering why on godsfucking earth I fell for it again and left without at least washing my hair. Such that the shitty little finicky gay boy behind the counter folding the $450 jeans with platinum inlay tissue paper will openly smirk at me with exasperation and pity and I will want to sidle up to him and say "fuck off Frenchie, I know you bought your jeans at American Eagle".

But instead I have to suffer standing in front of those full length mirrors in jeans that are too big for me a white long sleeve tee with a coffee stain on the elbow (I have no idea) and flip flops waiting for her to decide on Mustard or Mud. Or maybe both? BECAUSE WE WERE SUPPOSED TO BE HANGING OUT AT THE HOUSE. While shit head with a pompador behind me shakes his head and my mother in law, who has given me the kind of stuff that could have funded a small nation, sifts through the hangers wondering why her daughter in law can never figure out how to put together decent outfit already.

glass house

My mom calls. Often she feels left out and far away, living an entire continent and half an ocean away. She is in an unsettled place, getting ready for retirement, watching my niece and nephew grow by inches and feet, helping my father, her ex-husband, say goodbye to his parents, her ex-in-laws, over the last few months. She is resltess about life and not wanting to let anymore time without each other accumulate. So she calls. Because she knows I am out there, because she knows what I'm up against. We talk. About the kids and our plans for this summer, when will the house will done, when will the construction will even begin, when will you be in New Hampshire? All questions I don't know the answers to, and she knows it, but we talk about it anyway, because it makes her feel included in my everyday life. I hang up the phone and smile, thinking about my mom, so far away, plotting our final escape as far west as it will take us. My mother in law says:

"God, I can't believe you have to put up with someone who talks so much. I mean, she talks all the time, does she ever stop talking? I could never put up with someone who talks so much. I mean it just seems like all she does is talk and talk and talk and talk and it must have been so hard for you, you must be very scarred".

"Um, no, not reall-"

"I mean, she's so self centered, all she thinks about is herself. I would never do that to my children. I would never call them up and ask them so many questions. I mean I just think if they want to tell me they will. I'm sure it's because I had boys and your mom was never close with your brother, so she never learned these lessons, but I would never go about interacting with my children, how do you get a word in edgewise?"

"Well, actually-"

"I mean, I could just never be with anyone like that. Just the other day I had to tell _________ that I can't spend time with her anymore because all she does is talk about herself. She calls me up and just starts talking about herself and it's like and I just can't have that. I have too much going on in my own life to have to listen to everyone else's problems, you know? I mean, what with everything going on with ________ and then there was the _________ I just don't want to do it anymore. I can't see how you do it. I wouldn't do it. If it were me I woundn't do it. I mean I know you feel like you have to do it but I woundn't do it I don't know how you do it. You must be very scarred."

"Yeah, it's really not like-"

"I mean she's a lovely woman and all, but if she were my mom? Well."

"....."

stones

My husband's best friend died eight years ago. From a drug overdose. His family is a Very Big Deal. Like in a Global way. Every year people fly from all over the planet to gather at his grave and remember him. It is many things. It's a still sorrow existing in dozens of people who come, year after year, to remember their friend, their cousin, their nephew, their brother. It's a hard beauty, surrounded by so much spring. It's a lot of laughter as people gather together whose lives have otherwise splintered apart, it is a reunion, a recollection, an embodiment of joy and remorse. I have been twice now, and each time I walk away thinking it is a thing of beauty, it is an amazing feat and a testament to the strong bonds of love and sorrow.

She asked me if she could come with me this year, she hadn't been in years. I was going alone, Andy back in California tying up our loose ends. I said yes, of course, how lovely. I had no idea.

Saturday night, before leaving the next morning to the cemetary.

"God I do not want to go to this thing tomorrow"

"...?..."

"I mean, this is so fucked up. This whole thing is so fucked up. His parents killed him, they're the ones to blame, they probably want to die from the guilt. It's all their fault, if they had ever said no to him once in his entire life he'd still be alive today".

"...."

"I mean, it's so absolutely fucked up. Everyone around him is to blame. Every single one of his friends is completely to blame here. If they had just picked up the phone once, just once, and told his parents, he'd still be alive today. I will never forgive any of them for not speaking up."

"Um, actually-"

"I mean, whatever. He killed himslef. There's nothing any of us could have done. He was totally self absorbed. He thought he ruled the world. He was a little Prince and untouchable. There's nothing any of us could have done to save him. It's all his parents fault".

"...."

sunday
Driving home, at last, after its all over, all done, listening to New York NPR. There is a discussion on Fur: Couture At The Cost Of Morality? There is a man on the panel, giving out all the names of "fabulous" designers who design without fur, would never use fur, whom all the stars love and adore.

A woman interrupts him. "Yes, but David, I had this problem just the other night. I was going to the Opera and thought to wear my grandmother's fox stole. I mean, it's already dead, why waste it you know, AND BESIDES, David, if you can't wear fur WHAT WILL YOU WEAR TO THE OPERA?"

At which point I rolled down the window, unbuckled my seat belt, and jumped into traffic.

daylight saving

So it was finally sunny yesterday, and warm. I mean, really warm. Like pushing 70 warm. Holyfriggencow. And really, honestly, no joke, the first thing I thought to myself was thank fucking god. I was THIS close to locking myself up and eating oven cleaner.

And now my hypothalamus is finally happy and  balanced  normal  without searing dysfunction and order has been restored. And yesterday was one of those days that frankly make you want to punch yourself in the face. What the hell was my problem? What? What's wrong with New York? Look, its all beautiful and shit.

Ok, maybe that's a lie. But still. It really made me wonder, for a second, why I'm such an impossible cad and couldn't get suck it up and endure. Seven entire months of unremitting trash and noise and freezing cold grey. What? Like that's so hard?

maslow

Uncertainty

Sometimes everything is cloudy and my mind feels like its wearing the wrong pair of glasses. Sometimes I stand there, wishing with every cell in my body     for the escape hatch to materialize, for the lever to pull it, to miraculously, mercifully fall into the floor. Sometimes I have no idea what the point of these last 9 months has been, save to serve clear concern for my mental sanity. Sometimes all the information is right there, I've got it. Sometimes, usually, the paltry information fed to me on small spoons isn't enough and I take huge heaps of more, and I love it, sitting late in the lamp light of my bedroom, paging through texts. Sometimes, though, it's like I'm  living in a bank of fog and I can only vaguely make out the shapes and sounds of all that I thought I'd learned so far. Sometimes all I think I've learned is how to beat the shit out of multiple choice exams, but that I know nothing in practice. Sometimes all of it is on the tip of my tongue, it's right there but not; sometimes its something I've looked at a million times before, but have only organized it in my brain as the answer to a test question, not a clinical entity in real life. Sometimes I'm certain it's because I have been taught little to nothing, except that I "need to know that". Sometimes I'm certain its because we are routinely ignored and alternately chastised but rarely instructed. Sometimes I blame it on the fact that I've yet to get my hands on a complete medical record, one with writing I can decipher or pathology/imaging results I can correlate anything to. Sometimes its so easy to blame this system, the institution. But sometimes, lots of times, sometimes I'm pretty sure its me. 

Therapy

Running is the only thing that makes me feel better, so I do it. I'm no longer strong, am deeply deconditioned, and there is no peace or quietude to be found within the distances I can run to. So instead I try to outrun the static and manic, reliable pieces of this life I'm in, my head or my heart. I'm not sure. Running is the only thing that makes me feel better, so I do it, trying to quiet the quick pulses within. There is no quiet to run into and there is little space to open up and there is no dirt to pound over, but running is still the only thing that makes me feel better, so I do it. Running forward, running ahead, running away, around, before and back again. Peace through exhaustion; quiet body, unsettled brain.

Joy

In the slanted, half-empty light of spring I can still walk barefoot through the sand. It's been a long journey to come here, to my mother-in-law's house, amongst the auspicious lawns of East Hampton, but I am ever and always grateful for it. And just like that, it's still and settled. And I can wear flip flops and jeans, easy in a sweatshirt. And I can walk to the shore and bury my feet and see the ocean and look out, again, to the big wide blue. Standing, dizzy, breathing deep, happily again at the very ends of the earth.

serenity now

Wading today through the new puddles of April, dutifully on my way to the train, I pass by a man in a black SUV at the exact moment that he lays on his horn. For seven full seconds. Seven. One Mississippi two Mississippi....all the way to seven. It's 6:35 in the morning.

A few feet front of me a woman is pushing a stroller, all wrapped up in plastic, through the cracks and pools of rain. She stops abruptly such that we almost collide and as I pass her she reaches out to the front of the stroller, screaming Goddamnit Johnny stop fucking with the plastic!

I am this close, I think, to buying a box set of Nature Sounds: Call of The Wild to Ocean Blue. Because the few intact shreds of my corpus callosum are about to explode.

********

I am shy. I hate attention. I fight the urge and act of fainting whenever I have to talk in front of more than one person whom I haven't known for a year, minimum. I sit in the front of class because, when I have to ask a question (because I always have to ask a question) no one can turn their heads and look back at me, face me full and frontally, make my heart pound and sweat. I am not an eye contact maker. When people compliment me ever, on anything, I am always so shocked and mortified that I invariably say something really inappropriate and aprospo of nothing. "Oh wow, thanks. I actually stole this from an old lady. HAHAHAHAHAHAH". Hands flapping uncontrollably at my sides like an encephalopathic ostrich. 

And yet, I walk now--in the hospital, on the streets, along the crowded sidewalks--belligerently making eye contact, unyielding in my hellos. Especially in the hospital, always in the hospital. It is, I can see now, the only way to survive. To force contact, to create connection, to make me human, to make us collective, to make me to others tangible and real. And when I say I would never have done this a year ago, it is both that never before would I have willingly, intentionally, systematically called the attention of a stranger onto myself and also that I never lived a life like this, feeling so separate from those around me. In this way, in this wonderfully curious way, I am so very changed by this city.

*******

My patient is dying, very painfully, of metastatic prostate cancer. It was diagnosed late, as it is with so many of our patients, after it had spread to his lungs, invaded his bones. He came to us like something out a textbook: elderly man presents to ER complaining of back pain. An xray is taken and on it you see lytic lesions in the lumbar and sacral vertebrae. What's the most likely diagnosis? But he, despite this sadly generic pathology, is nothing to me most likely. He is a 79 year old man, lucky enough to have a bed by a window, spending his days slowly in pain.

We met at the beginning of the week. In a rush of informality I was assigned to him, patient is in room *** go get his history and present his case. Almost as an afterthought, distracted by his discharge papers, the resident brushes me away to him. 

I read his chart, review the CT, the MRI, the series of xrays. The lab work is dismal but nothing is worse than his films. He has a 4 x 3 cm metastatic lesion in the middle lobe of his right lung. There are lytic lesions in 4 of his 5 lumbar vertebra, and they have all collapsed onto each other. His has a lesion on the 4th and 5th cervical vertebra and they are threatening to collapse. If his spinal cord becomes compressed he will be a quadriplegic. If the lesions go any farther up, it may paralyze the nerve that allows the lungs to inflate.  There is much to worry about with him. The least of which seems to be his pain. The constant, unremitting, intractable pain.

We sit in the thin grey light of early morning in a room with a window. Every movement for him is agony and I have forgone the physical exam beyond any region not immediately accessible. The bones of his sternum protrude out by inches, the inappropriate invasion of a distant enemy. This, he tells me, is where it hurts more than anything. All fundamental actions: breathing, talking, shifting his weight render him breathless and panting. I have felt this so many times before, this powerlessness, this inability to ever make it better, and I am no better at it today. It is everything I can do, it is a minor miracle and a major accomplishment, to get the resident to prescribe a pain patch, to consider a pump that he can press himself for some relief. 

We stand in the dark part of the hall, near the wall at the back, outside the door, looking in. He needs to get well enough so I can send him to subacute rehab, the resident frets, I don't want him dying on my floor. And in that moment I am struck by such anger and awe, and it is all I can do to keep from wondering, as I peer into the face of one of my teaching doctors, if this is the inevitable outcome for me: worrying about my monthly statistics, angry that "yet another" patient has died on my shift?