The Give

It often seems like each rotation has something essential about it, and that essence often echoes the themes of my life (or vice versa - this is a chicken or egg situation, of course). For example, while I was on orthopedics, every day I saw desperate patients begging for (and often promised) a solution to their pain. In my life, I seemed to be making all sorts of rather desperate hail mary gestures (there is an entry in here somewhere, I promise). Now that I am on neurology, I am watching people deal with breathtaking loss of physical functions; my life this last month has been filled with a wide range of witnessed and experienced loss of people, ideas, expectations, and places.

What amazes me is that no matter the source of the loss, the outcomes all seem to converge. It appears that loss in any form distills the world down to something very small. Like someone who has suffered a stroke, an emotional or external loss leaves one childlike. Someone coping with loss moves from moment to moment (for how can you think beyond that?) and, similar to the recovering stroke patient, even the most fundamental activities become a challenge. Eating, drinking, moving, speaking, sleeping can be so difficult that they essentially have to be relearned. Sometimes it takes all the effort and concentration one has just to breathe - and there is nothing more basic than that. And those who lose are completely dependent on those around them to hold them, feed them, remind them to breathe until those activities are relearned. Loss, then, is so transformative that it serves as a sort of rebirth (although it's a rebirth partially mocks our fantasy of wiping the slate clean).

But it's only a partial mockery of the clean slate fantasy, since the loss of something familiar (and it has to be familiar, for we cannot lose something we did not know) results in at least the hope of pursuing the aspirations and dreams that were blocked from fulfilling before. "I will do this because I was never able to do this with them around/that plan in place." It's a partial mockery because the slate is not clean - it is not simply a free space, but an actual vacuum created by the loss. In other words, what was once there defines the "clean" slate. The decisions that follow in response to loss are wholly created and shaped by the loss itself. And in stroke patients, the parameters for how they relearn walking, talking, reading, eating are set by the nature of the functions they lost.

The Take

Strokes are not subtle events. They happen with a vengence. The onset comes with little warning. The symptoms may begin quietly, but they quickly crescendo until they reach an intensity impossible to ignore. Strokes rip away functions so fundamental that they only becomes visible in their absence. They are wholly changing events. The climatological equivalent of a stroke would be a tornado - they develop unexpectedly and cause focused destruction - leaving one thing intact while destroying something else. One day your house was there - strong, sturdy, filled with many years of improvements and memories. You knew how to skip each creaking step and where to leave the faucet handle so that the water temperature was perfect. The next day, your house is gone. Strokes are similar. One day you could walk, shake hands with a stranger, smile at a child, tell your partner you love them. The next day, you can't. And just like in a tornado, where your house is destroyed and your neighbor's is fine, a stroke doesn't take away everything. Instead, it picks and choses - so your right leg may be fine, but your right arm is unusable. You may talk, but you might not understand anything. You may understand everything, but not be able to speak intelligibly. Walking might be easy, but seeing difficult.

The recovery from a stroke thrusts adult patients into the role of a child. Like a young baby, they are forced to rely on those more capable for help with daily living. And like an infant, they must (re)learn how to do things. They have to take a first step, form their first words, eat their first solid foods, read their first book. It perverts the desire to be childlike in one's approach to life - for these patients are not childlike in mind, but rather are forced to depend like a child and learn the tasks of a child with the understanding of an adult.

May you Live in Interesting Times

I'm fairly certain Neurlogy is not for me. It is, as my attending declares, a field of nerds. And while I indulge myself with the label of nerd, he is referring to a very specific brand of nerds who are meticulous in their pursuit of the diagnosis. It is not just the highly specific diagnosis that they enjoy, they also love the pattern used to acquire that diagnosis. The art of physical pursuit is exemplified in neurology. The science of futility is also exemplified by neurology. While the diagnoses are specific and intricate, it is rare that something can be done to treat the condition (prevention of progression they can do, treatments of symptoms they can sort of do, but curing the disorder - rarely achievable). Neurologists define the label "academic," (as in he practices a very academic form of medicine).

The patient interview usually involves the doctor asking some questions and the patient answering them. The doctor nods his head, the patient looks concerned. The doctor then turns to me, says about 20 words, only 15 of which I understand (only 5 of them are comprehensible to the patient, and those are: the, it, but, because, and patient). He then proceeds to nod a bit more, perhaps ask me an unanswerable question, tell an unrelated story about Chamberlain and the Battle of Gettysburg, and then say:
"Isn't this an interesting case. You know, the Chinese have a curse. . 'may you live in interesting times.' The medical equivalent of this is 'may you be an interesting patient.' Man, you never want to be interesting to medical students. Nope."

He then turns back to the patient (who is looking confused, concerned, and petrified) and says, "there's just not that much we can do for you," maybe writes a prescription for some medicine that may or may not relieve symptoms, and wishes the patient a good day.

OR, my other favorite patient interaction is by the bedside:
Imagine a patient, recovering from a very severe stroke, who can barely move the right side of her body, is confused about where she is, and can't get her words out very well.
Dr: "Wow. .you are doing much better than your MRI would lead us to believe."
P: Mmdfnek kitten throws?
Dr: Hmm. . well, really, believe you me, you are doing great. . Just great. I mean, you can move your arm on the right side. . that's just amazing. Yes, I would expect you to have some difficulty talking, but really, you are just doing awesome.
P: Mdhadfk group trial of words?
Dr: Ok, well. . we'll be back to check on you tomorrow. Have a great day. . I'm really quite impressed.

And that's about it.
In fairness to the doctors. . these are certainly exaggerated stories. There are many wonderful things that Neurologists do (seizure control, headache management, peripheral neuropathy management, MS treatment, etc - the list is endless). Their physical exam is a beautiful thing. And they do a good job of delivering (continually) bad news - they do it day in and day out, and they are better at it than most doctors.

So that's a bit of neuro. May you never have to see a neurologist.

Gone Fishin' (with photos!)

I went fishing on Saturday and although i discovered that my sea legs are not quite as strong as i'd like, I had a great time. The sea was calm, but consistently rolling and in the fog that made everything surreal and eerie, the horizon was nowhere to be seen. Apparently this was not a good combination for me, as I got queasy. But I held my stomach and learned that my personal solution to sea sickness is to sit down outside while holding a metal thermos - go figure. The fish were biting and we immediately caught a triple (every line had a fish), although I lost mine and we sent one lucky guy back to the sea. I caught some fish, I lost some fish, and I learned that when a pole wobbles with a fish, everyone gets very excited. I'm not sure I'd really call fishing the most relaxing thing I've done: each fish would go something like this:

Fish! There's a fish! Set it! Set it! Shit. . .Set it! Reel, reel, reel, reel. . harder, reel harder, STOP!!!!! Don't reel anymore, move back step back, steady, steady. . damnit. . bring it closer to the net, closer. . There! Got it in the net. . . . . . . .Thwock, Thwock Thwock (sound of fish getting hit on head with club). . silence, flop, flop, flop. . WOAH!. . Thwock, thwock, thwock.

Yes, I the animal lover did hit a fish or two on the head, but mostly it was because I would look in the cooler and see the fish still flopping and that would make me sad because I thought that they might be suffering, so I would hit them again. Sometimes it worked. I will admit that it was satisfying to get a good clobber in, but ONLY because I knew I was putting the fish out of its misery, I swear.

As the fish stopped biting and our cooler filled - silvers and pinks and bass, oh my - our captain turned the boat towards the sunshine and we headed to Long Island, which is just off of Kodiak. Kodiak Island was a major staging area for North Pacific operations during WWII. During WWII, Long Island housed Fort Tidball, bunkers, and gun emplacements. Per one of my guides, due to leaked PBCs, Long Island has the distinction of being the first superfund site in America. Apparently it's not safe to drink the water or eat the deer or feral cows that roam the island. Yes, feral cows. We boated past a puffin rookery and hiked up to a bunker site and lollygagged (love that word) in the sun for a bit.

Here's a map.

Here are some links with info about Long Island:
Military History (scroll down to the Long Island section)
Deer Point info


The boating adventure finished with a trip down cannery row (in the water) to a cannery that cleans and packs the fishies for winter eatin'. . and then over to the sea lions where we cleaned the fish. But don't tell anyone we did that, it's illegal. But goodness illegal things are sometimes awfully cool - it was pretty dang neat to be so close to such silly, big, slow moving creatures.

The day ended with a delicious feast on two of our fishies (a bass, a pink salmon, and a king salmon that Mark had caught a few days ago). I went to the house of the two docs who own the clinic and it was, without a doubt, my dream house - absolutely gorgeous with a great big open kitchen and living room. Right on the water with a gorgeous deck. They built it themselves (at least half of it). . and lived in a tent while doing so. "We never fed our children store bought meat and we never eat frozen fish." Sigh. . .I'm a bit in love with their life.

Click the photo below to see even more photos (look at me, I'm doing pictures - wow).

Gone Fishin'

Kodiak Island

Kodiak Island is BEAUTIFUL. I have been to many a pretty place in my life, and this may be the prettiest place I've ever been. It's a mixture of the dramatic mountains of the Pyrenees, the lush green of Guatemala, the coastline of the San Juan Islands, plus the wildflowers of Idaho. It's pretty in comparison to Alaska, which is saying a lot, since Alaska is, well, gorgeous.

I've just begun to explore Kodiak, but already I can tell that it runs on "island time." In other words, it's mellow. But more than that, it's got the energy of a community whose rhythms, at least to some extent, are determined by mother nature's. Things like the tides, the weather, migration patterns of fish all impact the days, weeks, months, and years of the people who live here. I like living somewhere where the local radio station includes the tide with the weather and both are significant beyond mere interest. The population of Kodiak wanes and waxes as the fishing boats and the Coast Guard patrols depart and return. Turnover is high - the hardship of fishing and the maximum of a 4 year station make for impermanence.

One week done and I really do love it here. Family Practice is back on the very short list. Folks here are so incredibly nice. The docs here love to teach and care for their patients in this calm, relaxed way that puts the patients at ease. 15 minute appointments are rare, so nothing is ever rushed. Being an FP doctor here would mean practicing primary care the way it should be practiced - more than a mere gateway, you are the center of your patient's care. You handle the things you are qualified to handle (and maybe a few that you aren't, out of necessity) and refer the very complicated things. In the lower 48, it seems like most FPs refer everyone and everything they are expected to and they can. Malpractice is on everyone's mind and no one general is given agency to make decisions they at one point were qualified to make. The primary care profession is leeched of confidence (and thus competence)

Up here on Kodiak, you build relationships with specialists in the big city (Anchorage) and call on them when you need help or advice - and they eagerly (and non-possessively) give it because they understand that in Alaska, referring to a specialist is not always possible. You deliver babies (maybe do c-sections if you are trained), work in the ER, and see patients in clinic. You tailor your practice both in the patients you see and the hours you work. And at KIMA, your fellow health care providers are amazing, inspirational people. This is one of those seductive practices (like Alaska Women's Health Services) that lures you into the field (family medicine in this case) by fooling you into believing that all practices are like this.

The separation of practice versus profession. How much of what I like about being an FP is dependent on location? What about with pediatrics?

I'm quite thankful I don't have to make my decision tomorrow (yes more loans, I knew there was a reason I signed on to you).

Steinbeck

Sitting in College Coffee in Fairbanks, AK. In a bit of a funk these days - a Fairbanks funk. Apparently it's de rigor for the rotation up here. And not surprising, really. The town is a bit strip mally for most folks (think Twin Falls meets Pocatello or Idaho Falls) and it's lonely. And for many of us, spending significant amounts of time with doctorly folks intently focused on the money in medicine can be disheartening.

But all that is beside the point. . .a funk is a funk is a funk. And it's dissatisfaction defined. It's unsettled and aching. It's a pity party, but a confused one.

And so I'm sitting in the coffee shop and I walk up to the board and see this written:

"Where does discontent start? You are warm enough, but you shiver. You are fed, yet hunger gnaws you. You have been loved, but your yearning wanders in new fields. And to prod all these there's time, the Bastard Time."

-John Steinbeck, Sweet Thursday

Ahh Steinbeck, your words are wise. Message received, funk in check, thank you.

Touch-up

In the last 3 years, I've noticed myself momentarily hesitating before I touch someone. Rest assured, this isn't the result of me becoming a born-again germaphobe, although medical school has afforded me a new found respect for protective barriers. Certainly I now ask myself, "are your hands washed," before I touch I touch anything (a patient, a door handle, my book, my food, a friend), but there is something else contained in my hesitation. It's more a pause to clarify the reason behind my touch, what I want to gain or communicate. Of course touch is significant - this is why we find comfort in it, why it makes us cry, why we are so stingy with it, and why we recall moments of touch (especially the first ones) with visceral clarity. It used to be that my reasons for touching were buried somewhere beneath my awareness - not repressed, but not considered either - like food, touch was simply a thing to receive or give, want (even need) or reject.

In the last few years, the significance of touch has risen into my consciousness. Now I am almost hyperaware of it's existence and completely dependent on it's power. Practically speaking, in the doctorly profession, it is through touch that we learn about the decay of the skin or the disease of the heart. A patient's response to our hands on their abdomen allows tells us to move appendicitis higher or lower on our differential (the running list in our head of reasons for symptoms). Pressing behind the ankle and on top of the foot, we learn about circulation problems. A toe dulled to sensation makes us concerned for diabetic neuropathy. We ask, "Does it hurt here? Can you feel this?" We say, "Your knee feels swollen. Your abdomen tight. The two sides of your lungs sound different to percussion (essentially tapping on the body)." Before we order the (very important and useful) blood draws and the CT scans and and the stress tests, we gather information by touching.

And then there is the other side of touch. Its less practical, but more human (and almost more useful) significance. It is through touch that we are concerned and passionate. Standing side by side, a hand on the back emphasizes that we, the patient and the doctor, are allies in the process of health. Running a hand up and down an arm a few times conveys sympathy. Two hands on the shoulder, looking a patient in the eye tells them we are heartfelt, serious, and speaking the truth. A long hug tells a patient it's O.K. to cry.

For the record, I am not celebrating the days when touch was our primary diagnostic tool. I do not believe that we can heal through touch alone, but I do think that without touch we cannot heal.

Touch is different for me now. I am aware of its significance, and so I try and choose with consciousness. And this new-found awareness does not stop with patients. Now before I shake hands with a patient or hug my dad, before I lay my head on my mom or test a patient's reflexes, before I feel a patient's heart or hold hands with a friend, I delay momentarily. And in that delay my mind runs through these questions: Who is this person? What is my relationship to them? What does this touch mean? And, of course: Do I need to wash my hands before this or after this?

Adventuring in Fairbanks

I just finished my first week of surgery rotation in Fairbanks, AK. I'm starting this rotation after 12 weeks of doing nothing related to medicine. Well, not exactly nothing - I had 6 weeks of psychiatry (the neglected underbelly of the medical world, not because it isn't important, but because it operates blind, with unpredictable pathology refractory to what few "treatments" are available) and then 6 weeks of nothing related to medical school (blissful, beautiful stress-free nothing). And despite my best efforts, time passes, so now I'm back in the med school game again.

A decision: I decided to expand my last year - meaning I will take 2 years to do my fourth year. This is great because it enables me to do some last minute adventuring before I graduate, postpone decisions I'm not quite "ready" to make, and basically revel in studentdom for that much longer. This is terrible because it means I am a student for that much longer.

A few first week tidbits to share.

1) I have heard arguments on both sides and I've officially decided that Fairbanks is not the best of what Alaska has to offer. That's really all I have to say about that.

2) Dr. Montano is an old cowboy who has been operating in Fairbanks probably before the hospital was even built. He's done surgeries that people spend 8 years in residency learning how to do. He's cowboy defined, and it's unsafe for patients, but he's grandfathered in because he has been doing it for so long. The other surgeons had to band together to convince him to stop doing craniotomies (hole in the head). He's thin and spindly, crotchety and irreverent. Reminds me of Harry Dean Stanton. He's the definition of a libertarian. And he's got a great sense of humor.

I told him Ross had told me to tell the docs that they shouldn't be mean to me. He said, "I couldn't be hard on you - it'd be like being mean to a puppy."

He found out I was from Idaho (I emphasized Idaho over California - it seemed like a wise decision) and his second question was, "Are you Morman?" He's not subtle.

His daughter is a pediatrician in Anchorage and he told me I shouldn't be a pediatrician cause I won't make any money.

He also has 5 houses, I think.

That's it for now. More stories to come.

Nighty?

So I'm driving into work today (yes driving, working on that) and in front of me is a much-too-large SUV with a license plate that says "Nighty." And I say to myself, "Nighty," what does that mean, or, more importantly, what does the owner intend that to mean? I'm thinking . . maybe they like night gowns, maybe they are trying to say good night, maybe they associate with the night and intend "Nighty" to mean "night-like." In that vein, it's possible that they are middle-age enthusiasts and couldn't fit the K on the plate. It also crossed my mind that maybe they wanted to say "Naughty," but that was already taken. In any case, the message was lost in translation. This is the problem with free vanity plates.

Butterflies

Well, so much for promises n' resolutions n' stuff. One week, one month. . . what can I say.
In my defense, I did write something between my last entry and this one. Unfortunately, it was in desperate need of a fine tooth comb-through. . . and, well, that never happened.

So yes, I am on psych. And yes, this is one of those rotations that affords me with quite a bit of free time. It's also one of those rotations that is rich with stories. These are ridiculous, unbelievable stories. They are incredible, fascinating stories. They are heartbreaking stories and they are not my stories. These stories belong to other people. Without a doubt, the stories that I have told during other rotations are other people's stories too, but there is something more intimate about the stories of the mind.

For one thing, the majority of the patients that I am working with do not have the capacity to understand their own stories, at least not in the way that the rest of us understand them.

For another thing, these are difficult stories. The insane trace paths that are frighteningly close to the sane. In the beginning, the stories sound and feel the same; their potential is limitless. But somewhere they split. More than just diverging away from each other, they come to exist in a completely different reality. Indeed, I'm beginning to find that the sane and the insane seem to live parallel lives in entirely different universes. And sometimes it is so easy to see how they jumped into their reality. This scares me because it makes sanity seem so fragile. It makes me wonder what will set me off. Other times it is impossible to dissect a patient's movement into psychosis. Their stories are indecipherable, completely obscured. These patients underscore the tragedy of a psychotic break because it is impossible to tease out the person inside their illness.

For a third thing, these stories are funny. Devastatingly funny. It's hard not to laugh, but I feel guilty for laughing. I don't know how else to cope, because I am depressed by what we, "the healers," are forced to force the patients to do. So I laugh. I'm not sure if that's fair to the patients. I am laughing at them, for they do not have the ability to laugh with me. And so I tell the stories to those who are capable of laughing with me - and we laugh together. I am fairly certain, however, that we do not laugh out of humor. The laughter seems to come from a place of uncertainty, discomfort. I think we laugh out of disbelief.

And so I tell these stories out loud and the little conscience butterflies I keep in my stomach flutter self-consciously. Which is why I have yet to be able to write them down. But I'm working on it.

That Entry

Hello world.
I'm back.

This is the requisite, "I'm back" entry. The entry where I apologize for being so MIA and thank my readers profusely for sticking with me. The time in a blog where I explain that I was busy and then busier, and then just exhausted and taking a break from everything that involved anything, and then I got caught up in some stupid, stupid, stupid, poorly written books about stupid teenage vampires. And then when I finally had time to write/realized how stupid the vampire books were (and continue to be), I was a little unsure about how exactly to get back on the proverbial horse. But then it dawned on me: Just write an entry about how you are going to start writing, about how you are sorry that you have been gone, but that you are back again.

And so that's what I'm doing.

Also required in this sort of come back is a brief update of what I have been doing for the last several months. . . it should be a sentence, no more.

Since November, I finished medicine, went to California, came back to Alaska, started and completed my pediatric rotation (right now, I am about 95% pediatrician, 5% family medicine doc - more on that dilemma later), went backcountry skiing, got new skis and bindings, went backcountry skiing again on my AMAZING new skis and bindings (thanks Luc and Tarby), broke some pipes in my apartment, saw Josh Ritter (love the boy), went out dancing a few times, have generally been enjoying myself despite the fact that I continue to have agonizing dilemmas about what I am doing with my next year/life, and am welcoming back the sun. Speaking of the sun - damn, it's nice to have it back. Speaking of the weather - it's been all over the place. No global warming up here, Sarah Palin says so.

And last requirement of this entry (self-imposed) is a tantalizing teaser of things to come:
I'm on psych now, working at the state lock-down psych facility, need I say more? My goal (if you put goals up in public, you are more likely to hold yourself to them) is to write at least weekly.

So to recap:
I'm sorry I've been gone for so long, I did some shit, fat skis rock, there are some crazy folks in the world, most importantly, thank you for your patience, encouragement, and continued attention, and I'm back.