Thursday, December 25, 2014

Hula Dancer on a Square of Flesh: Scene from my Father's Medical Education


" . . . dismiss whatever insults your own soul"
                                               --Walt Whitman

I often hear people mention that "a lot of doctors are poets." The list begins confidently with William Carlos Williams. It often ends there. My interest in Narrative Medicine moves from another list, the list of doctors who never wrote poems. At the top of this list is my father, an endocrinologist, a Fellow of The Royal College of Physicians and Surgeons. My father is a brilliant physician. His patients adore him. Though he is retired a decade now, his patients friend me on Facebook to ask me how he is feeling. We don't often ask how doctors are feeling. More often we accuse them of not feeling.

While my father is in assisted living in Sedona, we talk often about Narrative Medicine, me as the poet, he as the doctor. To summarily arc his career: he started in research and was happy there, teaching and discovering insulin's effect on adipose tissue under varying circumstances. Publishing ceased in the late 1970s, at which time he decided to move to the U.S. and enter private practice. He grew his success to multiple locations and real estate holdings and lost it over two decades, leaving the U.S. in 1992 and opening a single-examining-room office in Hamilton, Bermuda.

He wanted me to be a doctor. I knew I could not. We fought about it. In that argument I threw a Royal Doulton coffee cup at his head. I missed by a centimeter. Ten years later I reconsidered and told him I would leave my MFA in Poetry program to study Medicine. This time, he argued:
"Don't do it. Poetry is the superior means of finding the truth."

I didn't withdraw from the MFA program. Another fifteen years later, I am developing the field of Narrative Medicine, a practice whereby doctors are trained to develop empathy by engaging literature. My father is my greatest ally. For years, I felt that I needed to justify poetry to him. Now, though, we justify medicine to poetry.

Poetry and Medicine both heal, one the soul, the other the body. Our fields have always connected by an obscure parallax. How far apart we were can only be perceived by blinding oneself in one eye momentarily, but we are connected. Now I talk with him to learn how he learned to be a doctor then I follow up with an email asking him about the story he has told.  He told me the other day the story about his first day at University of Toronto College of Physicians and Surgeons when one of the more advanced students stood in the hall stretching a "square shape" which as my father got closer he realized was a large piece of flesh cut from a dead person's stomach featuring a tattoo of a Hulu dancer, making it "dance." I wrote after:




Hi Dad,

I'm excited about our writing project. I'm going to ask you questions about your medical school experience to begin. I know the story of the tattooed flesh cut from the cadaver's belly. But I don't know how you felt as you walked down that hall. It was your first day. You see a more-senior student, or just a person down the hall . . .

Can you tell me your thoughts as you discovered what this was?
What did seeing this "do" to your ideas about medical school. It's a bit horrific to someone who hasn't been in medical school.

Love,
Laura

When we spoke today he told me he had never thought about this. He referred to John Irving's Door in the Floor, paraphrasing the writer's task as being one of paying attention. He said that a physician's task is to get information and "get out of there." He told me he was astonished by my three-dimensional thinking. I had to check the email I had sent to see if we were talking about the same thing. I wasn't aware I was being three-dimensional or astonishing. I was asking how he felt
"I mean, wouldn't seeing something like that insult your soul?"
"Insult your soul. That's Whitman, isn't it?"

I remember the first time I heard my father deliver an order to disconnect a patient's life support. We the family were gathered for supper when his beeper beeped. He dialed the hospital using the phone on the kitchen wall. I could hear him.

"Is the family gathered?"
Silence as person at hospital replies.
"Okay, then. Go ahead."

Then, he sat down and continued eating. I knew what had just happened. I stood and walked to my room. He followed.

"How could you just sit down after that?"

He told me the story of the first patient he "lost." He was devastated. His attending physician told him that he could choose to either be devastated each time a patient died or he could choose to be a doctor. That was the lesson. My father chose the latter. Hearing the story helped somewhat. We both returned to supper.

"Yes, Dad, it's Whitman."

"Did it insult my soul? If it did I never thought about it."
  
I told him I didn't think my questions were that astounding, that I thought they were the most obvious questions to ask. 

"No, don't sell yourself short, kid."

I have always sold myself a little bit short. It started the night the coffee cup shattered against the plaster of the dining room wall. It started when I chose to be a poet instead of a doctor. 

Now, to think that my consideration of seeing a human being holding another part of another human being (with a cartoon image of yet another human being inked upon it) in a joking, detached manner is unique or amazing, I would have to think that my father and I approach life from two extremes. Is it possible? Would others not be mortified by this image? Is poetic reasoning so different from clinical as to effectively render such a sight readable as two very separate texts?  One seeing it as okay and acceptable? The other seeing it as a horrendous and vile act?

The conversation ends with no judgment or even answers. And will continue.


Sunday, December 21, 2014

DENVER, a short story (wishing everyone a blessed holiday filled with kindness)




I arrived in Denver late at night, having flown across the U.S. losing hours along the way. Stella was four months. Her father and I had just ended it. I’d flown to Denver to spend Thanksgiving with my best high school friend, Audrey. Audrey’d said she’d leave the key under a flower pot on the front porch and would come back from Boulder in the morning, where she was presenting a paper on Kerouac. There was a snowstorm. She didn’t want to drive. The key, though, froze into the ice that gathers between the holes at the bottom of a flower pot so when I knelt (with my baby in a Snuggie inside my corduroy coat) to pick it up and feel around on the cold wood for the metal key I didn’t feel anything. I checked the flower pots on the steps and saw one at the far end of the front porch. When I lifted each of these, I moved my hand around on the snow planning to find that metal shape. I removed my gloves and felt the snow gathered under each one burn my fingertips.

I carried a lot with me that year everywhere I went. Having an infant was like being a bedouin burdened with brightly colored things. Part of this was out of necessity: I had to have a car seat for the shuttle, and I had to have a stroller because Audrey didn’t have a child, and I knew she’d want to show me all the places that Jack Kerouac and Neal Cassidy had hung out, got drunk, left one another behind. Maybe the Snuggie would have been enough, but sometimes I’d want to be able to do something without a baby strapped to my chest so I took the stroller. I also had to have a breast pump because once I’d breastfed on an airplane and forgotten to re-snap my nursing bra and pull down my shirt before getting up to get something out of the overhead. You only have to do that once to realize that milk-brain is a thing, a thing much more daunting than pregnancy brain which merely subtracts verbs from one’s vocabulary. Milk-brain subtracted minutes and hours from memory, a primal strategy no doubt to keep us always wondering if our offspring have fed, ceaselessly calling us back into the nursing rocker, the only furniture in the modern world other than a toilet wholly dedicated to one bodily function. Stella and I were still in that zone where when she was hungry my uterus contracted with all the tension of early labor. I needed a breast pump because if a pain is both unbearable and avoidable, one must do whatever it takes to serve the latter quality, even if it means toting a complicated bomb-resembling device cross-country. 

I had a four-day supply of Huggies Swaddler diapers because it does make a difference, two blanket sleepers, a pink snowsuit about four inches thick into which she was now safely stuffed, a week’s supply of onesies and “outfits” which I was into because I was a new, first-time mother willing to spend, if not fully in a financial position to do so, $50.00 on ensembles she’d outgrow in two weeks, and a peculiar contraption comprised of a brightly colored mat with two bendable bars that attach by arching over it much like the poles of a geodesic dome tent one might pitch on the side of Everest but without the nylon and instead with little clips from which hung a purple hippopotamus, a giraffe which had some kind of rattle inside it, a grey elephant, and a crinkly sort of zebra, and at the transept of these two bending bars attached a star with lights that flashed slowly in time to a little song that might not exist outside the realm of this one toy. 

My baby loved the star and the giraffe, and because Audrey didn’t have any children of her own, I doubted the presence of stars and giraffes in her home. I wanted to have something to keep Stella entertained. That’s the way I thought then, that the baby had to be entertained, as though the experience of being in a world for the first third of the earth’s cycle round the sun might not be stimulating enough. I had all this stuff divided between one suitcase for clothes and one very large duffle bag for Baby Things, including the stroller. Between these two objects I huddled on the floor of Audrey’s porch with my baby sleeping inside my coat and snow streaking the air. Where the fuck is the god-damned key, I swore at my scholarly friend.

I had a cell-phone, but the battery was dead. The houses on the street were all dark. It was after midnight. Families in Denver went to bed early. I regretted not telling the shuttle driver to wait until I was inside before driving off. Then I hated him for not thinking of it himself. The last hotel he’d dropped passengers at had been at least twenty minutes away, by vehicle. I wouldn’t be able to walk it. I pulled my hat down over my ears and double wrapped my wide wool scarf around my neck and shoulders, keeping the winter from Stella’s skin. 

Had I been alone, only me, I might have stayed there through the night. In the same way that before I found out I was pregnant I smoked cigarettes, I would have done something stupid. But as much as breastfeeding and the actual process of growing a baby inside of you make your brain a little slow, it makes you really smart in matters of life and death. There was no way I was going to let my baby stay outside all night a mile above sea level. I gripped the bannister and slipped down the steps and along the sidewalk and knocked on the un-illuminated next door. 

And waited.

Booking the flight to see Audrey was an automatic response to suddenly being alone, like turning on the lights when entering a room or buckling a seatbelt when entering a car. I hadn’t seen her in years, but it was the only thing that made sense. I had a baby. I wanted my best friend to see her. Then I’d arrived on the porch of a stranger’s house about to beg to be let inside, like the Virgin Mary begging to be able to give birth in the barn. Not for me. For the baby. I was alone and vulnerable and part of a story in humanity that aligned me with the one no one could deny assisting on a winter night. If no one answered, I’d make my way to the next house, and the next, and the night would go like that. Me, the woman in the snow with the baby’s heavy head against her breast inside layers of corduroy and wool. 

The porchlight came on, and a man in red Royal Stewart plaid flannel pajama pants and a cream-colored long john shirt and great thick hiking socks and a kind, long, pale and unshaven face answered. I didn’t have to say anything once he saw the little brown haired head emerging from my coat. I was a story that didn’t have to talk. He opened the door wide. Come in Come in.

The door opened into a universe of Family. The wooden floors peeked up through archipelagoes of toys, sweaters, coats, textbooks, notepaper, and wool socks of varying sizes. Sheet music lay on the floor around the piano, with one sturdy page standing straight in the place sheet music belongs. How long have you been outside?  The man’s wife, wearing also a cream-colored long john shirt and plaid flannel pajama pants and wooly socks , poured hot chocolate from a well-used saucepan into a dark blue mug with the word “LOVE” engraved some sunny summer camp afternoon. I was sure if I peeked at the bottom I’d see the name of the pilot of the plastic helicopter on the fireplace mantle or the hockey player whose black skates hung from a hook screwed into a two-by-four nailed to the wall by the front door. Worn blankets lay across the backs and arms of worn sofas to the degree where it was impossible to tell what was upholstery and what was adornment. A cuckoo clock on the wall had two little doors above the place the bird came out at 1 a.m. and out of which popped a little man who danced to a little song with a little woman then cheerily went back inside their instrument of time. I took Stella out of my coat and the Snuggie as I sat down, not long, just a few minutes. 

Here, I’ll hold her, she said, holding her arms out the way women hold their arms out to infants, this ancient thing, this “oh-please-give-her-to-me” favor, the desire of love itself. I didn’t hesitate. Stella was deep in the sleep infants can access in times of stress and extremely cold weather. She was moving her lips in a gentle pulse. Soon she’d want to nurse, but I’d have time to drink hot chocolate first. The marshmallows released their form. The warmth from the heating vent wrapped my legs under the long wooden table.

Wade and Leslie were my hosts’ names. They had two sons and a daughter, Jim, Drew, and Alice. all sleeping upstairs in their rooms, rooms I could picture as they told me about each one. Alice, it turned out, was the hockey player. Drew was the pilot at age 7, and Jim preferred improvising jazz to learning classical on the piano. Alice was 11. Jim 13. Nobody said anything about the way everything was everywhere the way other people always apologized for “such a mess” when their homes were almost spotless. 

When Stella unsettled and started to mouth the air like she was seeing angels, Leslie showed me to the room where I’d be sleeping. I sat on the bed and started to nurse while she simply swept a pile of unfolded laundry back into its blue plastic oval laundry basket and kicked it toward the corner of the room where already an ironing board stood with a pile of un-ironed shirts on top of it. I didn’t imagine the shirts would ever get ironed or that Wade was a man who would require them to be. 

We have this. 

Leslie opened the closet and wheeled out a white lacy bassinet with a pale blue star, a pink moon, and a golden mysterious other figure from the solar system bobbing from a musical device that also spun these around when Leslie pressed a white almost-invisible button on the side of the basket. The song was a lullaby I knew the words to, “slowly the big silver moon rises and peeks in the room . . . . “ It was the prettiest bassinet I’d seen. I was almost jealous I hadn’t found it myself. Leslie reached up to the shelf in the magical closet of baby things and brought down a silk blanket printed with pink sailboats and blue sheep. 

It's nice to the touch. But you wouldn't put it in there with her.

I told her about the bags I had left on Audrey’s porch. We’d completely neglected them. By now they’d be covered with ice and snow. Don’t worry about it. But Leslie left and there was a conversation and soon Wade was bringing the duffle and my suitcase to my little guest room. He picked a towel out of the laundry basket and wiped off the melting snow. Stella was on a break from nursing. I pulled down my sweater before he saw. I found the key, he said, It was frozen to the bottom of the flower pot by the door. But your friend didn’t leave the heat on. I booted it up, but it won’t be warm enough for you and the baby for an hour or so. Sleep here. We’ll move you over in the morning.

He drew down one feather duvet and two heavy blankets from the magic shelf and placed them on my mattress. I’ll leave you two. Good night. Glad you’re safe. He looked at Leslie, Love you.

Leslie held out her arms to hold Stella again, Why don’t you take a shower. I put some pajamas next to the sink. They should fit just fine. I pulled a pale purple blanket sleeper from my suitcase and placed it on the bed. I didn’t understand how Leslie could think her pajamas could possibly fit me, but the ones she’d placed on the shelf did fit, large enough for a woman who’d eaten the world in order to produce a healthy baby. It didn't at all feel strange leaving Stella with this stranger. I felt that I was in a house that was made for keeping children safe. If anything ever went wrong here it would be the result not of human neglect or human action. It would have to be something of an eerily impossible and terrible chain of events. The hot water melted the last bit of winter from my body. I hadn't taken a long shower since before giving birth.

I returned to my room where Leslie held Stella close. She'd dressed her in the blanket sleeper from the suitcase, and rocked where she sat at the edge of the bed. She’d placed a bag of Pampers next to the bassinet, for 3-6 month infants. I climbed under the blankets and felt the feather duvet and blankets smother me into safety. I welcomed Leslie’s rocking. She might have done it all night as I slept. 


Wednesday, December 17, 2014

We Thank You Very Sweetly: My Father's Favorite Patient and the Wizard of Oz

In thinking about patient narratives in healthcare, I think of my father's patient who had played the munchkin who hands Dorothy flowers in Wizard of Oz. One of the few munchkins with speaking lines, he was also one of the few of my father's thousands of patients whose story flowed over into my life. I think of the countless others, the faces in the shadowy rooms he visited "on rounds," (I sometimes went with him when I went to the hospital instead of walking home.) If I think of hospitals as libraries of human stories, with some of the books with spines broken open and others barely browsed, then Mr. Cucksey was fully made into his own feature film.

He was practically a part of our family, a mysterious circus and movie star uncle,  though I only met him once.

Mr. Cucksey lived in a community for the retired performers in Ringling Brothers Barnum & Bailey Circus in Sarasota, Florida. His mobile home was connected by a small bridge with a bell on it to his wife's mobile home. According to my father, he and his wife lived separately but would ring the bell on the bridge when one wanted to see the other.

My father adored Mr. Cucksey and his wife. There were days he came home and told me he'd seen Mr. Cucksey and had shared with him various events from my own life.

Mr. Cucksey was a window in my father's medical practice, a world that otherwise dwelled behind the boundary of his white lab coat, tethered to strangeness by the yellow-rubber stethoscope cord around his neck. He is the evidence that my father loved his patients. On one occasion, my father cancelled a weekend trip we were scheduled to take: he was afraid Mr. Cucksey would die without him.

On one of those trips, Mr. Cucksey did. My father was heart-broken. We didn't take any more trips.

In designing a Narrative Medicine course entitled Patient as Hero / Doctor as Human, I often remember Mr. Cucksey as he stood in the dining room of our home tickling himself and cracking up, and cracking us up, a circus performer to the end. I also think often of my father and the sorrow he endured when Mr. Cucksey died. Looking at both sides of the chart that hangs at the end of the bed in the thousands of hospitals in the world, the shared vulnerability care invites us into comes to life, I am moved by the tensions story creates, the clinical ease its absence creates.

The course begins January 13.
And while I add, subtract, shift, and shape the syllabus, I think of Mr. Cucksey and my father, the doctor that loved him.

If you want to take the class, let me know. laura.hopegill@lr.edu or just register at www.lr.edu.
If you want to hear Mr. Cucksey singing "We thank you very sweetly. You killed her so completely," here is the link: https://www.youtube.com/watch?v=jlAOQKjoIaU