Thursday, June 30, 2005

Tiddly Widdly Widdly Pouf Puff Puff

Much to my maternal glee, the Rabbit has reached one of the major developmental milestones: namely, Beatrix Potter. Yes, the beautiful boxed set which he received when he was still in utero is now in constant use, with Mrs. Tittlemouse and Jeremy Fisher currently getting the heaviest rotation. We read them at naptime and bedtime, and at many other random times in between, and the Rabbit has taken to quoting his favorite passages at me. He finds the spider in Mrs. Tittlemouse saying, "Is this not Miss Muffet's?" hilarious, and he shrieks with joy at the "I trust that is not a rat" line in Mr. Jeremy Fisher. He also likes Mr. Jackson ("He opened his mouth most unecessarily wide. He certainly had not a tooth in his head.")

But his very favorite character is Babbity Bumble, the bee who "sidles" up and down the corridors of Mrs. Tittlemouse's house saying, "Bizz wizz wizz," in "a peevish squeak." Mr. Jackson's encounter with her delights both the Rabbit and me: "Round a corner he met Babbity Bumble; he snapped her up and put her down again....'Get away, you nasty old toad,' shrieked Babbity." Really, show me better prose in the English language. (No, Babies and Goats, that's not a challenge; I KNOW you could show me better prose; I'm just indulging myself here). So spare, so clean, so perfectly suited to telling the story at hand, so amused and restrained, every word working hard, not one second of whimsy or over-indulgence but every moment full of rich imagining. I think if I ever teach undergraduate fiction writing again ( during my stay in Purgatory, say) I will make them read Beatrix.

Babbity has also given rise to a new nickname for the Urplet. One evening just before the bath, The Tall Doctor was entertaining a fussy Urplet by holding him up in the air and making him zoom naked around the room, and the Rabbit, himself reclining in the Altogether Absolutely in the tub, pointed upward and shrieked, "That's Babbity Bumble!" And indeed, the Urplet's spherical design, fat jowls, and solemn expression did make him look a great deal like a mildly indignant Babbity. So now he's Babbity Bumble and there's just nothing to be done about it.

Monday, June 27, 2005

Comfort Over Cure

In the Wide Awake post I mentioned palliative care, and that that was a post for another day: well, this appears to be that day, because I've been thinking about it ever since. I think it interests me so much because it's such a departure from most of Western medicine--i.e. from the brisk, scientific, gallop-in-on-the-white-horse-and-cure-them-thereby-making-you-the-provider-feel-better-even-if-the-patient-doesn't approach--and also because it links two normally disparate (to say the least) concepts, namely comfort and dying.

The specialty itself is easily defined: palliative care aims to provide comfort, not to cure, and to that end employs a wide range of people and techniques, including doctors with drugs, nurses with therapeutic touch, radiologists with tumor-debulking therapies, social workers with family therapy, chaplains with prayers, and music therapists with everything from pianos to harps. Palliative medicine now has its own board certification for physicians, and is a recognized branch of medicine--many hospitals have a palliative care service just like they have, say, a trauma surgery service. It's also what hospice offers, and that's where I encountered it.

It fascinated me from the first, in so many ways. Tremendous existential issues aside, I knew nothing about dying--about the actual physiologic processes involved, and what I as a nurse could offer people to help them with the physical symptoms attendent thereon. So I had a lot to learn in that area. I learned that, as with babies, it's all about sleeping, eating, and, not to put too fine a point on it, elimination. I mean, think how cruddy you feel if you've got a flu bug and are up all night and can't eat. OK, now multiply that times cancer and several weeks of up all night/not eating, and see how you feel. Right. You'd kind of want to at least take a nap while you were dying. So palliative care tries to find ways to let you do that, from giving you sleeping pills to shooing anxious relatives out of the room to bringing in a special eggcrate mattress to soothe bony bottoms. Sometimes providing a nap means doing something as simple as turning off the TV. Seriously. When people are dying at home it can get to be a little bit of a circus, what with the hospital bed in the living room, the family clustering, the oxygen hissing, the nurses and health aides giving baths and taking vitals, the pastor stopping in, friends bringing large hunks of tuna casserole, and the animals piling on the bed (they do; they always know, and they usually want to be right on the dying person's feet, which is right where they should be if you ask me). So sometimes the nurse's job is to stand in the middle of the room and bellow, "Everybody OUT!" You laugh? I have done this.

I also learned a lot, obviously, about pain control, which deserves its own post, because pain is such a complicated subject, and a problem which is so undertreated. I learned about Roxanol, which is liquid morphine in a preparation which can be dripped right under an unconscious person's tongue and absorbed through her mucous membranes, so she doesn't even need to swallow (no needles, hoorah!). I learned about Ativan, which is in the Valium class of drugs and also comes in easily administered oral forms. I learned--one of the most important things--not to be afraid of dosing high, and I learned how afraid the medical community in general is of those same high doses. At times it could be tremendously frustrating, trying to get some sleepy oncology resident on the other end of the phone to give me an order for ten times as much morphine as he'd ever ordered before. (I quickly learned how to phrase things so I got what I wanted: "Dr. Shah, I'll tell you what, if you could give me an order for 10-40 mg q 1 hour then I'd have enough dosing flexibility that I wouldn't have to bother you again," sounds very attractive to said doctor along about 3 am). At times it could be wonderfully satisfying, coming into a situation where someone had been in pain for a long time, and getting him comfortable for the first time in days or weeks. I mean, what nurse wouldn't love a job where she gets to show up and just push that morphine until everybody's happy? And after a while I began to learn how to manage the drugs a little more elegantly, so patients could have some sleepy time and some awake time, and could kind of surf out on a tide of morphine if they wanted.

I learned, too, that when it comes to the end of life the physiologic options narrow down and down to the final pinpoint of death. People in hospice had all kinds of things going on: cancer, obviously, but also heart disease and lung disease and Alzheimer's and dreadful long degenerative neurological diseases. But in the final days and weeks, patients pretty much followed the same course. They'd stop getting up. They'd stop eating. They'd stop pooping much (nothing in, nothing out). Then they'd stop drinking. Then they'd often stop talking much, and then they'd stop peeing, and then, in the final days or hours, they'd stop being conscious. As people's bodies began to shut down, they would get a waxy, yellowish look, and their noses would get beak-like. At the end, their extremities got mottled and cold, and the coldness progressed inward and upward, toward their hearts. Their breathing slowed to strings of gasps interspersed with periods of apnea (not breathing). Their temperatures fluctuated wildly. Their hearts rushed frantically, then slowed. Their blood pressures dropped. I was often in awe, watching the way the other nurses, who had years of hospice experience, could use these signs to predict almost to the day when people would die.

And then, people WOULD die. Usually I arrived after they did, but once or twice I was there while they were dying, and once I had my stethescope on a woman's chest as her heart slowed, and stopped. I cannot tell you how eerie that is, the sound of no heartbeat. It is the ultimate silence: no breath, no rustle, no heartbeat. The ultimate stillness: dead people don't move. I know, I know, but until you've sat with someone's corpse for an hour or so, waiting for the funeral home to come, you don't really appreciate how much movement is involved in even the stillest living person. Death is, quite literally, stasis.

I think I'm going to stop there. I could, and probably will, write a lot more about the other aspects of hospice; about the morning I walked out the door from being up all night with a dying woman who lived down the street from my own house, and found my husband and baby waiting for me; about the extraordinary care I've seen two old people give each other; about the way love often looks like sitting by a bed wiping drool for hours. But I think I'm going to stop here tonight, with the body, because that mystery is worth a little pondering. The patient is there, and then she isn't, and....where did she go?

Saturday, June 25, 2005

Happy Birthday, With Sparklers

We went to a wonderful one-year-old birthday party this evening. Big Boy had a rather traumatic birth last year, but recovered like the sturdy and sensible dude he is, and tonight was holding court dressed in a diaper and an alphabet onesie, his curly hair slightly limp with the soggy humidity. He speed-crawled around the yard, unbothered by the two immense chocolate labs who are basically his siblings, and dispensed gorgeous grins to those who flirted with him. At cake time, he viewed the sparklers and candles with due deliberation, then hid his face in his Daddy's neck while the assembled company sang Happy Birthday. Then he smiled, the purely happy smile of a child facing an iced cake which he is about to be allowed to attack. Then he attacked.

Like most one year old birthday parties, this one was populated largely by adults, because with that first child, you don't really have a cast of kid-friends at that point (in contrast to the two year old party, which involves herds of racing toddlers). But all very baby-friendly adults. The Urplet got hauled around--all eighteen pounds of him; we went to the doctor for his checkup yesterday and he's HUGE--and thought it was great, and I lost track of him and eventually found him lying naked on a blanket, flirting and cooing and peeing in arcs. The Rabbit went exploring with Daddy and came back to me with a cup full of what looked like cherry slush and a mouth stained very red.

All very well, except I happened to know that Big Boy's excellent parents had rented a margarita-making machine for the party, and were making strawberry margaritas in the kitchen; I had one in my hand, so I was pretty clear on this point. "Honey," says I, "what's that The Rabbit's drinking?" "Oh, the drink mix," says Daddy, all innocent. "You mean the margaritas with tequila in them?" I say, allowing my voice to rise just a little--to get his attention ,you understand. "Oh, the alcohol's already in them?" says Daddy, brandishing his own cup. "Well I can't taste anything." (He doesn't drink, and hates the taste, so usually spits out anything that's ever been NEAR alcohol.) "Well, honey, I can," I say. "Would you maybe try to take the cocktail away from the two year old now?"

It took a very large piece of cake to convince The Rabbit to surrender his drink. Let it never be said we don't live in the fast lane here in Iowa.

Friday, June 24, 2005

Wide Awake At All The Wrong Times

I was a hospice nurse for a year once--here in Iowa, actually. I took call for a seventy-patient hospice service from five pm Saturday to eight am Monday every fourth weekend (insane, yes: I will never do a call schedule like that again), and covered an area one hour in every direction from the IC. I learned a lot about palliative medicine, a lot about dying at home in the Midwest, (both posts for another day) and a lot about constipation (because delightful as high-dose morphine may be, it does have certain drawbacks). I also learned a lot about the hours from one to five am, and so I think about hospice sometimes when I'm up with the Urplet, who has recently decided that it is impossible to sleep more than one hour at a time at night.

I think about those times at the beginning and end of life when the normal rules and schedules just don't apply, when you are operating out on a physiologic ledge off of which you may tumble at any moment, and from which the view is often surprising and spectacular. (I really, really hope everyone appreciates the contortions I went through to avoid ending that with a preposition). I think about tending another person's body--washing, wiping, massaging, cleaning--and about the difference between tending a baby, with his satin-and-cream skin and excellent fatness, and a grandmother, with her gnarled feet and papery skin. I think about the exhaustion of keeping watch for someone else, and the way that exhaustion changes when the watch is for life--for a baby who needs to eat--or death--for a mother who can't sleep from pain. I think of the way dawn almost always brings change: the baby sleeps, the grandfather dies, the caregiver is left alone in the growing light to face an ordinary day.

When I worked for hospice, I quickly stopped being surprised by the number of phone calls I got around five am. I could almost count on it: I'd be busy delivering meds and changing dressings and checking "final days" patients from five pm to ten pm ("final days" was our designation for people who could die any minute but probably/certainly in the next week), and then there'd be a lull, while almost the whole world slept, and then at dawn, the phone would ring. Often it would be stoic farm wives who'd gone through the whole night in pain and not called until now "because I didn't want to wake you" ("Wake me up! That's my job!" I'd tell them, but they'd just smile, all that Iowa courtesy deeper in their bones than even the cancer). So I'd buzz out (hoping they didn't live an hour away) and deliver the precious liquid morphine, and wait until they relaxed enough to sleep after a sleepness night. Other times, the voice at the other end of the phone line would say, "She's dead," and I'd have to figure out a tactful way to say, "I'm so sorry, and by the way, who are you?" And then it was off to the house of the newly deceased, to help the family call the funeral home and wait until they came, to help move the body (there was the time one patient died in her Barcalounger in her Airstream in a trailer court...not so easy for the maneuvering there) and take away the oxygen tanks and IV bags and pill bottles and bedpans, to console whoever wanted consoling from me and to stay out of the way of everyone else's grief. Sometimes the dawn call was good news--"She's had a really good night, just wanted you to know," or full of small practicalities--"Could my primary nurse come out this morning and bring another of those mattress thingys?". I never knew, and I never got over the heart-in-the-mouth reaction when I heard the phone at five.

I still get that reaction when I hear the baby fuss in the middle of the night, but it's more dread (now I have to get up; oy, vey) than nervousness (what's coming at me and can I deal with it?). But I keep trying to remind myself that I'm keeping watch over life, that barring accident, death or destruction my night watches will end someday with a sleeping toddler, and that the other watches are going to come around soon enough.

That said, does anyone want to rent a baby for a few months, so I can get some sleep?

Sunday, June 19, 2005

Professional

So yeah, I got a job. With a group of nurse practitioners who have their own company that contracts out to provide care for other firms. Right now they work for the Emergency Department of Regional Hospital about half an hour away, and they also have a Zip Clinic (yes, I know) in town here, which does flat-fee, straightforward walk-in care. They're just starting up, so I expect there will be bumps, but I like the women (there's one, we'll call her Danielle, who runs the company and two more who work for her or maybe have some kind of partnership deal, I'm not sure) and I like the work and I especially like that I will be working for other NP's. Big University Hospital here in town uses some NP's and refers to them as (I love this) "midlevels." As in, "Mrs. Jones, your care will be provided for you today by a second-best professional," the doctors I suppose being the best and the RNs being, what, the lower-levels? So it's really good to work with people who don't aren't invested in maintaining a hierarchy which considers me second-best, and it's REALLY good to think about getting back to my job, which I miss.

Why do I miss it so, anyway? I have been thinking about this, and I can certainly name a lot of things I DON'T miss: getting up and getting out of the house on time; working late; being at the mercy of patients' timing, not my own; trying to keep five plates in the air at once; failing to do so and having them crash onto my head; working when I'm exhausted from small-boy nights; feeling stupid because there is just so much medicine I don't know; not having summer and Christmas and spring vacations. I don't miss any of that. But I do miss the combination of hand skills and experience and memorization and drama which makes medicine so unique, and I miss hearing the endlessly weird details of people's lives (they don't call it "taking a history" for nothing), and I miss feeling useful in a discrete, immediate-gratification kind of way. In short, I miss my profession, and being a professional.

Because honestly, not having the demands of being professional at least some of the time has been one of the hardest things about this last year, wherein I've been writing and looking after small boys. True, writing is a profession, and I do it every weekday, and I try to be positively Trollope-like about regarding it as a job, but it is a profession which I can do in my boxer shorts while eating giant SweetTarts and listening to my beloved iPod, and so some of the pull-yourself-together aspects just aren't there. And the pulling of myself together is a lot of what I miss about practicing a profession. When I say professional, I think of someone paying me to do something I've trained a long time for, of someone or some situation demanding that I rise to an occasion consistently, reliably, and not at my own whim. That is good for me. I can't sulk, avoid, blow my stack, throw tantrums, or spend the day in the aforementioned boxers if I have to show up in an ER sometimes and remember whether to use 4-0 prolene or 6-0 vicryl to suture a facial laceration. I just have to show up and suture, and if I do it well, they give me a check. Not necessarily easy, but at least it's defined, and it's not about me as me so much as it's about me as a role--the NP.

This in complete contrast, you understand, to my other job of Mama, which has no borders, few boundaries, no remuneration, and no demands to which I can rise reliably day after day. Some days I cope well, and some days I don't, and some days I lose it, and this is bad for the tidy image I would prefer to have of myself. It's all much too revelatory and long-term and diffuse and intense, this Mama gig, and I am finding that I need some balance, i.e. a job I can actually DO. I'm too much in my own face when I'm home all the time: I need to get out and get outside myself for a few hours. You know that wonderful alchemy which works itself when you're doing something you love--that way you get so focused outward that you become completely unselfconscious, and yet completely yourself at the same time? I am granted those moments when I write, or sing in a choir, or climb, or ride horses, or practice medicine. Somehow, when I'm with my kids, I don't have access to that kind of unselfconsciousness right now, and so I guess I need to turn to the old reliables again to find it. (Note: I get along much more easily with adolescents and others who can actually speak in sentences, so I suspect I may find what I'm missing as my children grow?)

Of course, when they're grown, they will not say things on the order of what The Rabbit said this morning. He pointed at The Urplet and said proudly, "He's little. I'm older." "Yes," I said, "you are." Whereupon the Rabbit said, "Where does older come from?"

Answer THAT, gentle reader.

Saturday, June 18, 2005

Lost

I have now lost this post FIVE times in the course of trying to write it, and clearly it's not meant to be. I mean, I'm not even going to try to allude to the subject matter, because when I do, my computer or this site or something erases it. I am feeling bedeviled, rather literally. So I will go to bed right after I note that my novel has decided, at long last, that it does have a life, and that I got a part-time nurse practitioner job in an Emergency Department nearby. So these are good things.

As for the rest, the immortal musings on being an imperfect mother of small beings with immortal souls will just have to stay out there in the ether where they (the musings, not the beings) probably belong.

Night.

Tuesday, June 14, 2005

Patients Lie, Part Two

Actually, since the original Patients Lie post ended with me concluding that they lie for good reasons (such as, to quote a dear and wise friend of mine, believing that the truth will mark them as unacceptable and unlovable), I'm not going to go back over that territory. But now I can't stop thinking about some of my other favorite things patients do.

1. They invent terminology. I have been told that, "My father's heart exploded," (the patient went on to say his father was now fine), "My father died of a massive internal fart," (massive myocardial infarction?), "Uncle Hank had angel plastic surgery," (angioplastic surgery), and "I have trouble with my prostrate gland" (I don't think I've ever had someone use "prostate," actually). Come to think of it, I think I'd like some angel plastic surgery of my own.

2. They bring lists. You know you're in trouble if you sit down and say, "So, are there any things in particular which you want to make sure we talk about?" and they pull out a list of ten or twenty items. Numbered, with subheadings, because these are people who take their pathologies very, very seriously. Your schedule is going to be shot for the rest of the day, because they're not going to budge from your office until you address everything, and I mean everything. By the end of the visit you will have a list of your own pathologies going strong...

3. They come out with one-liners. My very first patient was Beulah May, three hundred pounds and bedridden and it took my best friend in nursing school and me about an hour to give her a bed bath, after which she, um, did something in the bed which necessitated another bath and a change of sheets. So as my friend and I are trotting back and forth to the bathroom with little bits of poop wrapped in toilet paper (we didn't yet have our nursing stripes: now you present me with a bed full of any bodily production and I'll have that puppy cleaned up spit-spot on the double)...anyway, as we're trotting, in comes a medical student to draw Beulah May's blood. As he's filling up his little tubes she asks him, apropos of nothing, "What's your religion?" "I'm Jewish." She considers. "Well," she says at last, "You're a good-lookin' Jew.

Then there was Ima, another of my first patients, who was so confused after a car wreck she didn't know where she was. She'd talk, but make no sense. One day a resident came in to assess her--it must have been the 1000th assessment she'd undergone. "Raise your leg, Ima," he shouted at one point, and Ima blinked her filmy old eyes and said dreamily, "Says who?" "Says me," the resident said. Ima sat up suddenly and frowned. "And who the hell are you?" she said. That ended that.

And of course, there was my patient who, when I asked her what she did for fun, said, "Chihuahas." I asked her to elaborate and she said her son had bought her a girl Chihuahua the year before, "and I liked it so much I asked for a boy, and after that it was just chihuahua after chihuahua."

4. They bring you little presents. One of my favorite patients, who was the nicest drunk I've ever met--not drunk so much as just skating along on a thin layer of beer all the time--brought me a blue glass bird that he'd found in his next-door neighbor's trash. One gave me a crocheted angel. On the Rez, several patients got together to give me a beaded stethescope, which was gorgeous and slippery as a snake. And another Rez patient made me a beautiful, pastel baby star quilt (it hangs over The Urplet's crib; some of you gentle readers may have seen it).

5. They let you in. This is why I do what I do, and why, no matter how cynical I get about medicine and its populace, both patients and providers, I will always love it and be grateful to it. Having that stethescope around my neck and that windowless little office and that legal confidentiality agreement allows me stunning access to people's lives. I have sat in a hut in Kenya and listened as the husband and wife explained to me that he didn't want any more kids (they had 15) but she DID, and what were they going to do about it? I have sat here in Iowa City and listened to a dignified matriarch from Ivory Coast explain, through her daughter/interpreter, how she finds the USA very uncivilized (too fast, too loud, too much waste and not enough family). I have heard more stories of sexual woe than I can count, and learned bits and pieces about traditional Ayurvedic and Native American medicine, and handed out tissues by the boxful to the brave women who spend their lives looking after everyone else and who, when I say "But hon, who's looking after YOU?", burst into tears. I have been yelled at, and had things thrown at me (usually for refusing to prescribe narcotics), and told I was "almost as good as a doctor," (intended, most sincerely, as high praise and so taken as such). I have sometimes been bored (pediatric physicals: not so enthralling) and often crazed, but I have always been privileged. It's a good job I've got: I'm grateful for it.

And speaking of which, I had an interview today for a job about which I'll write more if I get it. Wow, that really couldn't have been a worse sentence. But it was fun to put on Real Professional Woman clothes and walk back into an ER and talk medicine with people and just be out of the house and in a world whose framework can provide a useful scaffolding to hold droopy mamas upright. I'll let you know if I get the job.

Sunday, June 12, 2005

103.5

Yes, everyone's sick again. Well, not everyone. Not even a majority, really. Just half the family: namely, the baby and the toddler. But a sick two year old combined with a grouchy baby can make you feel like the whole world's sick and YOU have to fix them. It's been a long weekend.

I think it's the incessant nature of it all. You gotta feel sorry for the little guys as they thrash and sweat their ways through the nights, and I do actually have memories from childhood of how dreadful it is feeling so hot and achey and sore-throaty and stuffed up and miserable, so it's not like I don't sympathize. And I remember my father sitting on the edge of my bed fanning me with a record jacket, or rubbing my back with alcohol when I had a fever (alcohol rubs were in in the 1970's; they're out now, medically speaking, but I remember them fondly), and my mother singing to me or lying with me in the middle of the night, and I want to do that for my kids. I want to make them feel better, and failing that, I at least want them to feel loved while they're sick.

Thing is, after three days of somebody always being awake and unhappy 24/7, I am short on forebearance. Somebody seems to be always grabbing at me, or flailing around in my lap, or flinging himself OFF my lap, or spittting up down my cleavage (a baby specialty--always urps down the shirtfront--why is that?), or screeching, or weeping pitifully, or doing that grunting complainy baby whine which you know will escalate in about two minutes to full-on yelling but which might yet let you finish chopping the vegetables if you can just do it reallyfastbeforeallhellbreaksloose. It seems so lame to get pissy about this, but I am, embarassingly so. The Tall Doctor has been doing heroic acts of patient Daddying, and so I have nothing to complain about, and all of this is taking place in a nice house in an easy town with good health care, and we have insurance, and drugs, and the kids have boring old viruses, not horrible diseases I don't even want to name, so in the grand scheme of things, this is a mere bagatelle, a medical minuet, just a blip on the child-raising screen. And yet there are moments I want to hurl myself out the window, shrieking with sheer irritation and exasperation. Oy, vey.

Then, in the middle of the night last night (working on the if-I'm-up-all-night-I-might-as-well-enjoy-some-of-it principle) I picked up The New Yorker debut fiction issue and read a story about a street family in Nairobi. I could see it very clearly, since I used to live there (not, however, on the street), and I loved the Swahili words, the turns of phrase, and the references to places I remember well. But what really got me was the long description of a long, cold night in the family's tiny shanty, when they're all on top of each other (lots of babies, of course) and trying to spread one thin blanket around, and nobody can get comfortable and it's just basically miserable. And no, I have never been there, and I am NOT comparing my situation to theirs, because that would be grotesque. But just for a moment I got it--the sheer discomfort of it, the rank, stretched exhaustion of never sleeping more than an hour or two at a stretch, the endless fidget and squirm of bodies in close quarters. And I thought I should, if not welcome a housefull of sick, sleepless children, then at least remember what it feels like next time I'm looking at a shantytown or doing a clinic in a slum, or whatever. I should remember it when I pray. I should suck it up, because the rest of the world does it all the time.

And from that high moral plane, I of course descended immediately to mumbled curses and bleary-eyed stares as I shuffled out of bed to feed the baby yet again. And oops, he's sounding off again now, so again with the cursing and fidgeting...

Stay tuned.

Friday, June 10, 2005

Patients Lie

I was lunching with ladies today, and the topic of doctors came up, in particular a TV doctor who maintains that "patients lie." The ladies laughed, but the thing is, it's true: patients lie. They confabulate, obfuscate, embroider, embellish, omit, dodge, and duck. People do all sorts of strange things when confronted with another person dressed in scrubs and a stethescope who's demanding their life history, and you know, I can't blame them (them being the people doing strange things). Well, when I'm feeling kind and in my right mind I can't. When I'm the person with the stethescope, I alternate between amusement, bemusement, and exasperation, because when I'm trying to see a lot of people fast and do right by them, their lying slows me down, thus assuring that the NEXT patient will get after me for going too slowly and making him/her wait. (Though I did discover a good answer when people say, "I've been waiting three hours here!" I just point to all the people in the waiting room and say, "Yup, that's why.") And since I'm making lists these days, here's another one, of things patients do.

1) They lie. Usually about narcotics. I have been told that the dog ate the Percocet, the son drove to Arizona with the Percocet in the glove box, the patient was roofing and dropped the bottle of pills in the tar (which begs the question, what were the pills doing on the roof in the first place), the next door neighbor stole it, and, the perennial favorite, the patient dropped it down the toilet.

2) They forget strange things. Like surgery. I say, "Ever had surgery?" They look at me like I'm nuts. "No," they say. We proceed. Eventually we get to the physical exam. I raise their shirt and discover a long surgical scar stretching across their upper abdomen. "Gallbladder out?" I say. "Yeah," they say, unperturbed. I refrain from saying, "That would actually qualify as surgery," and keep going, hoping to find no more scars.

3) They omit crucial information and only remember it AFTER I've done a huge workup (aka a Grope-a-gram) for what turns out to be the wrong problem. Like the girl who came to the ER after she fainted. "Ever had a head injury?" says I. No, no--no head injuries. So I do the usual workup--blood sugar, blood pressure, hemoglobin and hematocrit, kidney and liver functions, EKG, HCG, blah blah blah. Later, as I'm telling her she's probably fine, her friend says, "Oh, there was that time with the motorcycle." "What time with the motorcycle?" I ask. Turns out she was in a motorcycle accident the year before and was helicoptered to the nearest big-city hospital where she was in a coma for three days. She's had blackouts ever since. But, evidently, that didn't qualify as a head injury.

4) They tell you they're fine when they're not. And then after I've spent a year thinking I'm giving granny such good treatment, her daughters come in and demand to know why I'm not treating her depression. Um, because I didn't know she had it?

5) They quit taking meds (and lie about it), borrow their neighbor's meds (and lie about it), sell their meds (and lie about it) or hoard their meds (and don't mention it). Or, if they actually take their meds, they don't refill them until they've run out. Then they call: gotta have those drugs by yesterday. I try to oblige and resist pointing out that what, they couldn't see the pills getting lower in the bottle?

6) They do all this and then I find out the real reason why--they've been giving meds to their uninsured kids, or being distracted because their mom just died, or not wanting to take something because they're terrified of getting addicted, or not taking anything because they're so busy looking after everyone else in their lives that they forget themselves--and it breaks my heart and I'm willing to do anything for them to make their awful lives just a tiny bit better. I mean, it never fails. Every time I think I have someone's number and start passing judgement on them, I'm wrong. (And yes, I'm aware that "someone" is singular and "them" is plural, but it's late and I'm tired and I'm just going to let my colloquial grammatical mistakes sit: so there). And yet I start all over again with each patient. And I've been doing this eleven years. Does this make me a slow learner?

Tuesday, June 07, 2005

Ten Good Times and Places (In No Particular Order)

1. Waking up early on a crystalline New Hampshire summer morning and having my father appear and say, "It's a mountain day." He packed cheese sandwiches and water and Hydrox cookies (anyone remember those? Far superior to Oreos) in an old Boy Scout pack and we drove to Mt. Lafayette or Washington or any one of the others in the Presidential range. He wore an antedeluvian green sweatshirt with the sleeves cut off, cut-off shorts, and moss-green hiking books with wool socks: I wore shorts and tennis shoes. We set off up the trail: boulders, earth, steepness, green-gold leaves on birches, trailside grottoes with tiny springs trickling over moss and wet brown leaves, calls of red-eyed veerios and hermit thrushes. If I got restless my father told me the plots of Shakespeare plays (I learned Hamlet going up Lafayette, as I recall, and Romeo and Juliet coming down). Atop the mountain were rocks and sky and sheer exhilaration. Sometimes it snowed up there. Once, on Washington, as the cog railway went by full of fat tourists, my father waved at them and yelled, "Get out and walk!"

2. Galloping my pony on the beach on a freezing November day, just tearing along, all out, hoofbeats drilling along the sand. Leaving the sedate three beats of the show-ring canter behind for the exhilaration of the reckless, four-beat gallop. Being part of that animal surge and power in the chilled, salty air; being twelve and wiry and having enough skill to stay on board the horse; shouting to my friends, ages 13 to 65, who were galloping alongside me. Can you see why I thought field hockey and lacrosse were idiotic and undeserving of the name "sport"?

3. Getting up at dawn near the top of Mount Kenya. The peaks forming a jagged bowl around the meadow where we'd camped; the lake reflecting the sky; snow on the glacier above. Tiny wildflowers, so we felt we were in Switzerland; thin air, so we had to stop every few steps and pant. 16,000 feet up in tennis shoes on the ice and rock, greeting a morning so fierce and cold and fine it seemed drilled from the rock itself. Going high after a year at sea level in the heat. Being in the silence which comes when the nearest human habitation is two days' walk downhill. Being admitted to a view we'd had to earn.

4. Evening in Joshua Tree. Hidden Valley campground, everyone coming in from the day's climbs. The sun gilding the blond rocks, sparkling off the quartz; lanterns and campstoves filling the air with hissing and kerosene; murmurs of conversation from the campsites. Later, the rocks leaving sharp-edged shadows in the moonlight, and coyotes prowling the desert's edges. Desert silence, and rest after hard climbing.

5. Topping out after leading a climb on Devil's Tower. Way up high, looking over the Wyoming plains, having cheated a thunderstorm which headed for the rock, then veered. Still tingling with the tension of doing the crux move; still half-scared, but moving into the amazement of having done it. Body sweaty, dirty, and perfectly tired; brain at peace. Down below, tourists circumambulating the Tower's footpaths. When you climb down they will look at your group, your gear, and your Golden Retriever and say one of three things: "Did you get to the top?" "Does the dog climb too?" "Did you see any aliens up there?"

6. Christmas Day in Nanyuki, Kenya. A mock-Tudor farmhouse built by the British, now occupied by "my" Kenyan family's grandparents. In the morning, Turkana tribeswomen who work the farm come to collect their Christmas bonus of sacks of salt and maize flour. When they receive them, they dance: in a circle, horny bare feet shuffling and stamping out a primal rhythm, voices chanting a song which sounds like gospel from before the flood. Their cheeks are stitched and folded with age; they have blue tattoos on their foreheads. They are cooler and have more rhythm than all the rock bands in the world put together.

7. Mingun, on the Irawaddy, a few miles from Mandalay. A brick pagoda, crumbling, with a monk inside who takes our chyaat (Burmese money, worth, like, nothing) so we can climb the steps to the top of what was going to be the world's biggest pagoda except nobody finished it. The monk trades us a banana for some prayer beads. On top, the bricks are fiery hot, the river shimmers in heat haze, the Burmese plains stretch away. Ox carts beneath spreading, dusty trees down below, and at a monastery, lines of faded-burgundy monk robes fluttery in the hot wind: monk laundry day. It's eighteen hours by bone-rattling bus back to Yangon.

8. Going back to India after a two-year absence. Flying in low over the Ganges, seeing the familiar brown plumes of Patna pollution and the yellow bulk of the hospital. Deplaning to happy nun-faces peering at me over the barricades. Seeing Father Jack, the best Jesuit ever, putting up on his 1970 Honda motorcycle with a sarong wrapped around his ears to keep out the bugs. Watching my students in the hospital; shy, tongue-tied students no longer, now tri-lingual staff nurses. Drinking gin with my best friends, listening to their music, letting them listen to mine.

9. Mahabodhi Temple in Bodh Gaya. A celebration night with the whole structrue outlined in glowing butter-lamps. Monks out back by the peepul tree where the Buddha became enlightened; monks chanting with that deep bass boom. The stones cool beneath my bare feet. We find an odd little carving in a niche: some Buddhist goddess--Tara, maybe? My Muslim friends make an offering to the Buddhist goddess on behalf of Christian me. A group from Taiwan sits down behind us with a tape player and begins singing, "Ami fo fo" over and over. It's very soothing.

10. Finishing my first novel, which will never see the light of day, but oh, that moment when after three years I was done. Knowing I had it in me to write that much, even if it wasn't very good; knowing that even if it never got published (it never will be if I have anything to say about it!), the writing of it had given me joy. Knowing I write because I love it, not for any other reason. Knowing I had done this thing to the end.

Saturday, June 04, 2005

Down on the Floor, Kicking

The Rabbit has had a nasty virus for the last week, and as is his wont when he's sick, he has taken to throwing actual, boring, two year old tantrums, complete with Wicked-Witch-of-the-West meltdowns to the floor and fists beating a tattoo on the nearest object (usually the floor, sometimes me, which meets with no parental mirth at all). I greet these occasions with mixed emotions. I feel bad for the guy, because I know he doesn't do this unless HE feels dreadful; I feel brokenhearted, because I don't want him to have any sadness or hardship or disappointment in his life, ever; I feel furious, because where does he get off with this stuff; I feel embarrassed, because here I am, reduced to coaxing and hissing and dragging my screaming kid out of the library like every other parent I swore I'd never be; I feel very very tired in a here-we-go-again way. Also I feel bemused and bumfuzzled. I mean, I want to cut him some slack because he's sick, and I want to cuddle him when he needs it, and yet I also want to shut the whole production down when it needs to be shut down (for my own sanity and, more importantly, because he needs me to do the shutting down for him when he can't do it himself) and maintain some rules and order even if he is sick. And of course I want to do it all kindly, firmly, with detachment and wisdom and infinite patience. Odd how I don't seem to accomplish this with any regularity.

But we muddle on. Sometimes I stick to my guns and soldier through the meltdown without giving it much notice, sometimes I get creative with distractions, sometimes I sink to sweets and bribery, sometimes I throw my own tantrum, sometimes we both end up on the kitchen floor comforting each other and eating ice cream out of the box with our fingers. This was not how I envisioned myself as a parent. Hmmm.

On a brighter note, it's summer, which in Iowa City features green leaves tossing in the huge maples, vast expanses of green park to run in, and a freezing-cold public pool filled with clamorous small fry just around the corner from our house. Heaven if you're a Rabbit. There's an ice-cream truck which tootles around the neighborhood playing the opening bars to the theme from The Sting, and a tiny amusement park with miniature rides (carousel, airplanes, ferris wheel) for tots down by the river, and a empty-of-students town with no lines in the coffee houses and lots of parking on the street. At our house there are naked babies and very dirty toddlers, and there's much less brush in front of our house, because The Tall Doctor and I spent Memorial Day weekend hacking down overgrown laurel and I don't know what-all, and replacing it with hosta and cedar chips (the latter to make it look like we're trying). It's hotter than stink, and I am losing all ambition as my ankles swell, but it's kind of nice. We've planted corn in the back yard, kind of as a joke (Iowa, married to farm boy, etc) but it's actually starting to grow. A little. The Doctor maintains that it's too shady, that "we're raising corn in a forest," and that it will not be "knee high by the fourth of July," which apparently is some farmer dictum. I will keep you posted.

Wednesday, June 01, 2005

Young Ducks and Sad Moles

Any of you remember "Ping," the book about the little duck on the Yangtze River? I found it at the library the other day and have been reading it to The Rabbit, over and over because that's how one reads to a two year old. Today we were all tucked up doing the pre-nap reading, me with him under one arm and The Urplet balanced against the other shoulder so he could work up a really good belch, and I began: "Ping was a beautiful young duck who lived on the...." The Rabbit looked up at me, grinned, and announced, "I'M a beautiful young duck."

Well yes, he is. He's also taken to announcing, at regular intervals, "I want to be a girl." And he's started projecting his emotions onto you name it...moles, for instance. We saw one digging in the park the other day, actually got to watch it roto-rooter its way straight down into the earth until all that was left was one large, pink mole-foot waving around and flipping dirt an astonishing distance, and naturally The Rabbit was fascinated. Eventually said mole disappeared, and the afternoon continued, and about an hour later The Rabbit turned to me and announced, appropos of nothing, "The moles are sad, but they're not crying. The moles are sad, so Mama's hugging the moles."

I hope I always have the sense to tell when the moles are sad, so I can provide the appropriate hugs.