Babymoon blankets and public eavesdropping, part 1

IMG_9777Now that Match Day is Matched Day, a few things have changed: 1) I can stop taking all these meds I’ve been on because of my stress-somaticizing (which apparently my body does like a champ) 2) my dreams no longer involve envelopes (REMvelopes) and 3) I am this much closer to becoming an uncle! As a future pediatrician, I firmly believe that all children should have a healthy lifestyle with an adequate balance of nutrition and exercise. But as a knitting-enthused, enabling uncle-to-be, I firmly believe that all nephews should be sugar-high, spoiled, and fat, with a cozy blanket (and maybe some lantus) to cover them at night.IMG_9767I’m always torn about knitting blankets because of how long they take, and this one was no exception. But given that this is my incipient nephew we’re talking about, who (with any luck) has a future of early-onset diabetes and sleep apnea to look forward to, the labor cost seemed appropriate. Not to mention I’m also obsessed with this pattern, which you might recognize because I made a delicious cowl a couple months ago using the same purlsoho pattern. Initially knit in the round, I adapted the design to be knit flat for this blanket, adding some contrast stripes and then crocheting a border to give it a professional finish and also help flatten the edges pre-blocking.

It took a total of five weeks (80% west wing/black mirror/drag race binge + 20% therapeutic pre-match stress relief) to knit this blanket, which seems like such a long time to spend making something that costs a considerable amount of money and just kind of sits there not really doing anything, right?IMG_9823Seeing as how Jimbo is still unborn (and also unnamed! recs are appreciated but will most likely be summarily rejected as has been my experience), I gave my v preggo sister this blanket to commemorate her babymoon instead, which she spent visiting me beyond the wall (aka chicago in january) and when we almost died walking 0.8 miles to Lou Malnati’s (coincidentally, 0.8 was also how cold it was outside).IMG_0208For those of you not among the (personal record high) 126 people who read and liked on Facebook, I will be moving to Denver for residency! When I visited last fall, I had a chance to explore the city, eat some doughnuts, and hike alone without getting kidnapped and murdered (i also had a mysterious skin reaction that i blame on altitude sickness #milehivecity), so I’m excited to continue doing that (hopefully with friends and without hives) along with some minor work responsibilities here and there for the next three years.

But as things wind down here in Chicago (and as i’m actively exchanging all medical knowledge for jonathan van ness quotes), I find I’ve been more cognizant during my final clinical rotations, attentive to the various communications occurring throughout the hospital. Maybe I’m realizing that this is the last time I’ll be in a consequence-free environment, and that soon I won’t have the luxury of simply listening and taking everything in (also scrolling through reddit double-fisting lornas and a mini-can of seagram’s ginger ale). Maybe it’s dawning on me that, finally, after three short years (and one excruciatingly long and stressful one), medical school is coming to an end, and I’m trying to hold on to what I can in these last moments.

Or maybe I just love gossip (i don’t get coffee from starbs, i get tea from sleep-deprived, uninhibited, post-call seniors).

Regardless of why, the result is a list of gems I’ve picked up over the years. You can read them and my thoughts on them below.

Oh yeah. Also, in case there’s any doubt: as irreverent as I am towards the personal space and privacy of others (one time i joined an uber pool with two people going on a FIRST DATE and i put on headphones plugged into nothing so i could catch every word), there are some things, like HIPAA (and childhood obesity), that you just don’t mess with.


Public Eavesdropping: A Glossary of Medical Terminology, Part 1

compassionate extubation

Physicians weigh a delicate balance between providing care and maintaining an appropriate distance as to not become a hazard themselves. It is a basic tenet at the root of the Hippocratic Oath, urging us all to consider what is meant by ‘harm’ and to what extent we are guilty of it. And regardless of our level of expertise, the tension between the urge to do good and the fear of withholding it is ever-present. Sometimes it comes as paralyzing ambivalence, when we can no longer discern between the many shades of grey, and other times, when patients teeter on the edge of disaster and we’ve tried and failed too many times to count, it fuels our self-doubt, bringing to light the existential crisis we thought we’d resolved by practicing medicine in the first place.

But then there are moments when the clarity is painful:

A baby girl, one of two survivors from a hit-and-run (which five months later is charged as three counts of felony manslaughter), whose brain is battered and edematous, herniating through any hole in her skull it can find, and her mother—husband-less, son-less, daughter-less—who tells us she didn’t know a life could contain so much suffering.

The end-of-life discussion is brief, summarized in her chart by just two words: compassionate extubation.

Twenty minutes later, she is baby girl-less.

A cloud follows us for days after, and somewhere deep inside sits a stone, heavy and burdensome, but inescapably bright. It is an ember of good from a horrible fire, a hope carved in relief, clung to as proof of the instances in medicine when struggle melts away by the heat of its own fury and what’s left is a saddened conscience that is guiltless and clear, when we cure without touch and heal without harm, and we find we’re able to do both something and nothing at the exact same time.

 

cut*

A man with a small bowel obstruction experiences worsening nausea and abdominal pain. A nasogastric tube is placed and temporizing, but after two days his symptoms are unremitting.

“cut”

With laparoscopic scissors, we slice the stringy adhesions that have formed on his abdominal wall, which a loop of intestines has twisted around like a maypole. We make sure to run the rest of his bowel too, meticulously checking his mop of viscera for kinks and knots before closing him up.

A woman has a fever and a recurring, gnawing stomachache. When pressed just beneath her right ribs, it feels like someone has slid a hot knife into her side.

“cut”

We clamp and sever the gallbladder that bulges like a swollen coin purse tucked under her liver and catch it in a clear, plastic bag. We cinch the top and remove it through a small, abdominal incision. Emptying it out onto a surgical tray, the stones look like gems, each one a breathtaking, emerald green.

A husband tries to convince his wife that she looks yellow. She can’t help but take it personally, and then her doctor says it’s cancer.

“cut”

First we check the liver and mesentery for metastases, hoping we haven’t lost before even starting. Then the pancreas, nestled within a loop of small bowel, is mobilized and freed from soft tissue and off the large caliber vessels pulsing underneath. Watching it makes us nervous, but we keep it in sight at all times. We remove the gallbladder, tying off the narrow ducts that drain bile into the intestines, and then isolate and obliterate the small arteries feeding the lower stomach and pancreas. With a toothless clamping device, we staple off the lower stomach with a satisfying crunch, and with electrocautery, we burn the pancreas in half, using a Penrose drain like floss to lift it off the aorta and inferior vena cava. There are tiny, tucked away veins enmeshed in serosa draining the uncinate process, which curls in on itself like the tail of a seahorse, and we remove these, too, with delicate dissection and cautery. Then, we isolate the jejunum from a maze of bowel, and with the same, modified staple gun that we applied to the stomach, we divide her intestines bloodlessly. We take the run of viscera that we’ve released off the field and at last, like an artist poised before his array of tools, we assemble her anew. We leash the distal end of bowel through a skirt of fat that lays tangled with colon and plug what’s left of her pancreas, hepatic duct, and stomach into its stapled stump like a power strip. Standing back, it looks like a jigsaw puzzle put together by a stubborn thumb, but it works, and we’re satisfied, so we smile and take a deep breath and zip up her long, vertical incision, talking about dinner and traffic as Pandora plays ‘90s rock between E-Harmony commercials.

*In Linguistics, microcosmic synecdoche is a figure of speech in which a part is used to replace the whole, substituting a single characterization or physical subunit syntactically for the broader entity embodying it (My college professor, who watched cable news solely for their endless supply of linguistic variants, would mention the demand for “more boots on the ground”, pointing out with gusto how soldiers were people with agency and more than the boots they wore on their feet).

Synecdoche falls under the broad umbrella of metaphor, and ironically, I heard it most often among surgeons, purportedly the most exacting of medical specialties, hardly known for their extravagance or flair. I will admit, it falls in line with their brusque demeanor, reducing lengthy, complex procedures to the one, decisive action uniting them. And while each surgeon will claim no difference—the thin line between medical management and surgical intervention a common thread running through all their patients like strands of DNA—I swear, as they throw a world into chaos with a single word, I feel its weight: sometimes light and innocuous and other times a red-hot, block of lead, pregnant with slow, nail-biting time, when we combine anatomy with imagination and address each ugly creeping with the steady gleam of our scalpel.

 

baby gone bad

Among other things, physicians are fluent in acronyms, speaking a language as deceptively compact as a collection of nesting dolls. And as medical students, we spend a great deal of time memorizing polysyllabic atrocities describing heart failure, only to have them replaced by three or four tidy capital letters before ever getting to use them. It takes decades to become an accomplished physician, but only four years to learn how to write without using a single word.

46yom h/o COPD, CHF p/w DOE.

18yo G3P1102 a/f SROM.

4mof p/w RUE frx c/f NAT.

Acronyms become particularly useful when communicating across services. The standard text page has a limit of 240 characters, and it is a small, personal pleasure whenever I’m able to collapse an entire medical history, hospital course, and clinical question within such Twitter-like constraints. And as with Twitter, brevity is key, but clarity is paramount, exemplified that one night almost a year ago, when a 6-month-old girl who had come in with a cold began to lose the energy to breath, and her oxygen saturation stuttered down to a precarious 75%.

«rm457 baby gone bad!!!» her nurse paged. Pagers blared like sirens and residents fled the workroom clutching stethoscopes studded with cartoon figurines.

An evening of close calls and anxious, watchful waiting ensued, which, now in retrospect, has taken on a genuine, light-hearted warmth. After all, with the ever-increasing streamlining of information and depersonalization of medicine, it is reassuring to see that there is still yet no shorthand for the parent in all of us, no acronym to capture the soft, sentimental, hot mess of an adult that lies just beneath the surface, ready to abandon all sense of propriety when the most vulnerable of us are found in harm’s way.

 

air hunger

Clicking through the electronic medical record of a boy with muscular dystrophy was a depressing affair, made palatable only by the dry, wordy, medical-speak of the house staff documenting his hospitalization. I appreciated how they sanitized his deterioration, because it provided the distance required to love him without mourning him, allowing me to read of his steady crawl towards immobility without admitting he once used to be able to run, and to learn he was G-tube dependent without acknowledging the licks of pizza he was allowed to remember his favorite food.

I skimmed progress notes and nursing updates and scrolled through chest radiographs, studying ghost bones and a backlit silhouette of his heart. And then my eyes passed the words “air hunger” and I lost my place.

Muscular dystrophy is non-discriminatory in its degeneration, and all skeletal muscle eventually loses function—the arms and legs most noticeably, but then, with enough time, the diaphragm as well. Even the small muscles nestled chevron-shaped between each rib, giving the chest its gentle rise and fall, are ultimately affected. And then there comes a point in the disease when the lungs, as weightless and pliant as two plastic bags, come to a complete standstill, when air, and by extension words, become as hopelessly yearned for as food.

I went to see him the next day. He lay unnervingly still in bed, without so much as a twitch, his eyes semi-closed and a frosty tube down his throat. A bedside LTV inhaled and exhaled perfectly on his behalf, and a television across the room played Zootopia for an absent audience. A slow and steady drip of fentanyl held him under. It was a sad sight, of course, but, surprisingly, not as sad as I was expecting. I could easily trick myself into believing he was simply asleep, that he looked peaceful, almost, in want of nothing except a few more moments of rest.

I visited him the day after that, and the day after that, pulled to him somehow. And each day he was clinically the same, lying stone quiet, obedient to the steady hum of his ventilator. I studied his chart, too, lurking as doctors and nurses transcribed his days, which he now spent in Cinderella sleep. They reported how far is endotracheal tube sat above his carina and how much carbon dioxide he produced. They reported how much pressure they needed to keep his lungs lofty and buoyant. They told me so much, but danced around what I was most curious about, refusing to answer a question that only a heart broken by a shadow can ask.

What did his voice sound like, and how long did he hold onto that final, physiologic breath?

 

liveborn

I pick out ‘liveborn’ from a string of auto-populated text in a baby boy’s birthing history note on Epic, and it leaves a bad taste in my mouth. It’s grossly sweet, like a packet of Splenda, and at the same time unsettling, because it gives a subtle nod to the alternative. It’s unabbreviated and formal, and that creates distance, and casts doubt.

What a sobering thought to recognize that a child can be born as anything other than alive, I think to myself, that the first moments of life are not, by default, vigorous and vital. I don’t believe any mother expects to count to a number less (or more) than ten, or hear her final push followed by absolute silence, her screams of labor unreciprocated and lonely, like tossing a bottle out into cold, unlit water. But those who have witnessed an errant trisomy or delivered the products of an intra-uterine demise know full well the many different ways a pregnancy can end, and that a healthy, normal baby can, at times, feel coldly arbitrary.

It strikes me as pathological that I’m unable to fully enjoy something as purely good as uneventful childbirth. But as with so many other things in medicine, I’ve found that the happiest, most inspiring moments are only so because of their proximity to the devastating, and it’s difficult not to experience the euphoria of a pink, screaming baby without also the chill of the nearly missed, the two orbiting just beyond collision about the thin dash of the death-defying. I admit, I tend to err on the side of cautious in most cases, ready to expect, and even sometimes deliver, the worst that medicine has to offer.

But perhaps there is truth to the inverse as well, and the horrible and nightmarish are not without their gentle glow. It is a sign of compassion that the counterpart to “liveborn” bears no mention of death or loss, and that, at its worst, a child could come into the world as still, as if in a game of statue, playful and ignorant of the tense reality. I take heart in that even in unequivocal darkness, medicine holds onto its humanity, and though we cannot always stop death, we are unceasing in the words that we use (and those that we don’t), the technical, anatomic, sometimes uncouth but often powerfully accurate terminology, which never leaves the page and yet has a way of casting a breeze, giving movement and air, if only just briefly, to the still and lifeless.

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