A Wounded Healer

A November 2, 2006, New York Times article, “Tending a Fallen Marine, With Skill, Prayer and Fury,” documented the story of Petty Officer Third Class Dustin E. Kirby, age 22, a trauma medic assigned to the Second Mobile Assault Platoon of Weapons Company, Second Battalion, Eighth Marines, as he tended to Lance Cpl. Colin Smith, age 19, a fellow soldier who had been shot in the head by an Iraqi sniper just outside Karma, a city near Falluja in Anbar Province, Iraq. “Doc” Kirby stabilized the wounded marine, who was transported to the nearest medical facility by helicopter within 12 minutes of being shot.

The Times reporter described Kirby’s emotional response: “He held his bloody hands before his face to examine them. They were shaking. He made fists so tight his veins bulged. His forearms started to bounce.… ‘In situations and times like this, I am bound to start yelling and shouting furiously,’ he said.”

Kirby himself was later wounded by another Iraqi sniper eight weeks later, on an otherwise quiet Christmas afternoon. His jaw and upper palate were damaged extensively by the sniper’s bullet that struck the left side of his face. Sometime later, after several operations and on ventilator support, Kirby was still alive, although he could not speak. He subsequently returned stateside to Bethesda Naval Medical Center in Maryland for further care.

In his book, The Living Reminder, Henri J. M. Nouwen states that those who minister are called to heal by reminding people of their wounded past and by connecting their wounds with the wounds of all humanity.

Petty Officer Dustin E. Kirby, a trauma medic, is now a wounded healer. As such, his wounds are connected with the wounds of Lance Cpl. Colin Smith, and with the wounds of all humanity.

In his novel, A Farewell to Arms, Ernest Hemingway, commenting on those wounded in war, notes that “finally only the names of places had dignity. Certain numbers were the same way and certain dates and these with the names of the places were all you could say and have them mean anything. Abstract words such as glory, honor, courage, or hallow were obscene beside the concrete names of villages, the number of roads, the names of rivers, the number of regiments and the dates.”

A rural settlement on the western edge of Karma, a city near Falluja in Anbar Province, Iraq. Second Mobile Assault Platoon of Weapons Company, Second Battalion, Eighth Marines. October 30th, 2006; December 25th, 2006.

A Life Well-Lived

Today’s New York Times (January 30, 2007) carries an article announcing the passing of Emma Faust Tillman, the world’s oldest woman: In Connecticut, World’s Oldest Woman Dies at 114.

Ms. Tillman was one of 23 children born to former slaves in North Carolina. Four siblings who moved north with Ms. Tillman at the turn of the 20th century all lived past age 100. Emma Tillman cast her ballot in the first election when women were allowed to vote, and ran a catering service, baking cakes for notables such as Kathryn Hepburn’s father and Jackie Robinson.

The Times reports that in the last month the title of the world’s oldest person has changed hands three times. “The Guinness Book of World Records will not be able to keep up,” said Dr. L. Stephen Coles, executive director of the Gerontology Research Group, based at the University of California, Los Angeles.

With all due respect to Ms. Tillman and her extended family, I can’t help wondering at the arbitrary legacy that has been assigned to her by our modern American record-keeping system.

In “The Grapes of Wrath,” John Steinbeck noted that “the gov’ment’s got more interest in a dead man than in a live one.” Ultimately, how important is the number of our days in this life compared to how we spend our allotted time?

During Henry Thoreau’s final days, one friend, as if by way of consolation, said to him, “Well, Mr. Thoreau, we must all go.” Henry replied, “When I was a very little boy I learned that I must die, and I set that down, so of course I am not disappointed now. Death is as near to you as it is to me.” Thoreau died two months shy of his 45th birthday.

Do we have to wait until the day of an individual’s passing to celebrate a life well-lived? John Stewart Jr., one of Emma Tillman’s great-nephews, had this to say about his great aunt: “She has served the good Lord, she has served the church, she has served us. What better legacy can she leave?”

What better legacy indeed than a life of service, no matter the span of its years?

The Iraqi Children’s Relief Fund

Fellow Physician Assistant Jeremy Orr, Captain, Vermont Army National Guard, has founded the Iraqi Children’s Relief Fund, a non-profit organization dedicated to securing medical aid for needy Iraqi children.

While serving with US forces in Iraq, Captain Orr contacted the Palestine Children’s Relief Fund to ask for help in securing the services of a pediatric urologist for Zaynab, a six-year-old Iraqi girl born with congenital exstrophy of the urinary bladder. (In utero, her bladder had developed outside the abdomen and leaked continuously.)

Dr. John Gearhart, a pediatric urologist from Johns Hopkins, performed the successful surgery pro-bono at Children’s Memorial Hospital, Columbus, Ohio. Zaynab is now safely back home with her family in Iraq.

Many more Iraqi children are still in need. Interested readers can contact the Iraqi Children’s Relief Fund via the postal service at ICRF, PO Box 1148, Barre, VT 05641 (Telephone: 802-476-5452).

After combing through tales about the myriad of children disaffected by armed conflict posted at the Palestine Children’s Relief Fund site, readers may wish to peruse my Cell2Soul essay The Butterfly and the Dump Truck.

The Cognitive Dimension

In his recently published New Yorker (January 29, 2007) article, “What’s the Trouble?”, Dr. Jerome Groopman explores the issue of how doctors think.

Groopman quotes Dr. Pat Croskerry, a emergency medicine physician at Dartmouth General Hospital, Halifax, Nova Scotia, stating that, as a medical student, Croskerry was surprised at “how little attention was paid to the ‘cognitive dimension’ of clinical decision-making—the process by which doctors interpret their patients’ symptoms and weigh test results in order to arrive at a diagnosis and a plan of treatment.”

Croskerry opines that many medical misdiagnoses result from identifiable—and often preventable—errors in thinking.

In making diagnoses, most doctors rely on “shortcuts or rules of thumb,” known as “heuristics.”

Although heuristic principles help doctors diagnose patients, they can sometimes lead to serious errors.

One type of mistake physicians often make is called a “representativeness” error. According to Groopman, this happens when doctors base their judgments on what is “typically true,”—failing to consider other diagnostic possibilities—and attribute symptoms to the wrong cause.

Doctors also make mistakes when they allow their judgments about a patient’s condition to be influenced by the symptoms of other patients they have just seen, as is often the case during disease epidemics.

Another type of error, dubbed “availability,” refers to the tendency to consider a patient’s symptom complex to be relevant as similar examples—“templates of disease”— come to mind.

Sometimes a doctor’s impulse to protect a patient he admires can adversely affect his judgment. Croskerry terms this tendency an “affective” error.

When physicians are confronted with diagnostic uncertainty, they are susceptible to underlying emotions and personal biases that can cloud their ability to make sound decisions.

Croskerry believes that the first step toward developing an awareness of these issues in medical practice is to recognize that “how doctors think can affect their success as much as how much they know, or how much experience they have.”

As clinicians, it behooves us to approach the patient with an attitude of humility and respect. Both Groopman and Croskerry should remember that, at core, the diagnostician’s ego plays a large role in errors of medical judgment as well.

Dr. Robert Paeglow: mentor and model of humane medical care

Today I received an e-mail from a good friend with a link to a CBS news article about Dr. Robert Paeglow, who may be the least-successful doctor in America.

Dr. Paeglow, who operates the Koinonia Primary Care clinic in Albany, New York, takes no salary and survives mostly on donations. He channels every penny he makes “back to his patients in one way or another.”

According to Dr. Paeglow’s Compassion in Action mission statement: “Each patient is treated with the dignity and respect that recognizes their value as a unique and special creation.”

Robert J. Paeglow came to a career in medicine later in life. After an undistinguished undergraduate academic career, he matriculated in medical school at 36 years of age, graduating cum laude, and subsequently completed a residency in family medicine. In addition to founding Koinonia Primary Care, Dr. Paeglow has led 25 medical missions to serve the poor and destitute populations overseas, mostly in Africa.

Dr. Paeglow mentors medical students and residents in his practice, modeling compassionate care for the poor and underprivileged in the West Hill neighborhood of Albany, NY. He considers himself to be incredibly rich—not in material possessions, but in that richness that comes “from investing in the lives of others, not only of the poor, but also in those who will carry on his legacy of caring for and serving those less fortunate.”

For those interested, you can read Dr. Bob’s Blog or make a donation to his work through his web site.

Birthing a Book

Last fall, news of the arrival of the first child of Angelina Jolie and Brad Pitt flashed around the world. Everyone was happy for the couple, even overjoyed after hearing the announcement of this new little life recently added to the global register of live human births.

I suppose if Angelina had birthed a book, it would have shot immediately to the top of the best-seller lists. Within a week we would have been reading stunning reviews in the New York Review of Books and the New Yorker magazine. Conceivably, it could have made the top ten in the Amazon.com rankings.

Yet what of all those other babies born that same day; what of all those other books birthed after months of mental gestation? Is each one less significant? Are they inherently of less value? These questions are apropos for an author who also happens to practice pediatric medicine.

“How many a man has dated a new era in his life from the reading of a book?” Thoreau wrote in the pages of his masterpiece, Walden. Indeed, how many a person has dated such an era through the writing of one?

After several years of persistence, burning the midnight oil; writing, editing, rewriting, polishing the manuscript; periodically emboldened, like Mr. Thoreau, by some degree of success in quiet hours, I finally got a glimpse of my first literary creation.

I remember the day that I found the proof copy of my book resting comfortably inside a brown corrugated cardboard UPS package on my back porch when I returned home from work.

I slit the plastic packing tape with my penknife and pulled the book out, looking rather dumbfounded as I held it in my hands, like a father staring in disbelief at his first-born son.

I paged through it, amazed at how perfect the type looked; each page appeared just as I had painstakingly formatted it. It actually brought a tear to my eye (from the dust, you understand).

I turned on the A/C and the upstairs fan to cool the house off a bit, and then sat down to read through it. I discovered a few minor errors that were easily fixed. I marked them with a highlighter and later made the corrections in the manuscript document on my computer.

Back then, it seemed to me for all the world like a dream come true—something I had wanted to do my entire life. After fathering four children, I’d finally birthed a book of my own. Your fifties may be a fertile period after all.

What does a man do after writing a book? He hems and haws, not knowing exactly whom to share the news with; ponders and postulates, comes to a decision, only to retract it … then, in the end, he takes the leap and elects to publish it to the world.

In 1853, faced with a four-year record of poor sales even after receiving wide notice and favorable reviews of his first book, A Week on the Concord and Merrimack Rivers, Thoreau wrote in his journal: “I have now a library of nearly nine hundred volumes, over seven hundred of which I wrote myself.”

Too bad for Mr. Thoreau that Amazon.com wasn’t online in 1849.

“Notes from a Healer” column debuts in Yale Journal for Humanities in Medicine

Brian T. Maurer is pleased to announce the debut of his new column “Notes from a Healer” in the Yale Journal for Humanities in Medicine.

Readers can peruse the premier installment, “Rumblings in the Distance,” at the YJHM site.

After reading and reviewing Maurer’s recently published book, “Patients Are a Virtue,” Dr. Howard Spiro, Editor-in-Chief, invited Mr. Maurer to contribute a monthly piece to the Yale Journal.

The Yale Journal for Humanities in Medicine acts as an online clearinghouse for manuscripts dealing with the humanities and medicine.

Across the Threshold

Once, when I was a teenager waiting in a hospital hallway, I chanced to see a white-coated woman doctor pull a medical chart from a box mounted on the wall outside an exam room door. She leafed through its pages before she knocked briefly on the door and stepped into the room. I saw her face brighten, and heard her voice croon a greeting before the door closed behind her, sealing doctor and patient inside. Although I could hear muffled voices, I couldn’t make out the words. But I was certain that whatever they were talking about carried great significance, like the words of a penitent to his priest in the confessional.

Decades later, now trained in clinical medicine, I find myself in the same position as that doctor countless times a day: reviewing a medical record, rapping gently on an exam room door, and stepping across the threshold into another person’s world.

Patients say things behind closed doors that they would never think of divulging in other settings. Most times (not always) the patient sheds his mask, lowers his guard, allows himself to become vulnerable to the extent that he feels he can safely tell his story. Over the years I have counted it a privilege to listen to the stories of my patients. I know that when they tell me their stories, they have a chance to experience some degree of healing, of being made whole again.

We are all vulnerable at core; we all fear rejection by others. Each one of us has a deep-seated need to be understood, and it is in telling our stories that we begin to understand this need. We all desire acceptance: we want others to see us and embrace us for who we are, warts and all. As Victor Hugo wrote: “The greatest happiness in life is to be loved for ourselves—or rather, loved in spite of ourselves.”

I have listened to many stories over the years—stories of illness, stories of addictions; tales of misdiagnoses, tales of treatments turned worse than disease. I have heard hope straining to rise above despair; I have witnessed love struggling to triumph over hate, apathy and indifference; I have watched pain pour out of old hidden wounds.

Once, an elderly man stopped by the clinic where I worked. He sat in the chair opposite my desk and proceeded to tell me about his wife when the two of them were young. She had a problem and sought guidance from a deacon in their church. After months of counseling, his lovely young wife announced one day that she was leaving him. He later found out that she ran off with the deacon. At seventy-six years of age he told me that he still loved her deeply, and still carried the pain of her betrayal in his heart.

It takes a bit of nerve to step across that threshold into another’s world. You never know what awaits you there. You never know what stories might be poised, ready to spring off the tip of the tongue, until you acknowledge the patient as person, and listen.

Author signing day at upcoming PAAV conference

Brian T. Maurer will be on hand at the Equinox Resort and Spa in Manchester Village, Vermont, Saturday, January 20, 2007, to offer autographed and inscribed copies of his book “Patients Are a Virtue” at the 25th Anniversary Winter Continuing Medical Education Conference sponsored by the Physician Assistant Academy of Vermont.

“Patients Are a Virtue” has been highlighted under the “Book and Media Received” section in the January 3, 2007 issue of the Journal of the American Medical Association Vol. 297, No. 1, p. 98 and reviewed in the Yale Journal for Humanities in Medicine.

Craving Reality

In a recent e-mail a friend asks: “Every story you create makes it seem like you are experiencing life on a different plane, feeling and observing the small details that make everyday life more than ordinary. Is this how you experience life, or is it merely reflection and embellishment for the sake of the story? I’m curious how your mind is wired.”

I’m not certain that I experience life on a different plane, but I do write about it as I experience it. Obviously, recording your thoughts forces you to organize them in a coherent fashion, and I do try to polish the prose up a bit so it reads better; but the underlying thoughts are there just the same.

Perhaps a better way of putting it—sometimes I can center myself in the moment, taking in the picture with all its details before my eyes, running with it for as long as it lasts; and then later at some point I can recall how it felt as I write it down. If I’ve done a good job with the writing, and if I’m lucky, the reader will experience those same feelings that I had at the time the event took place.

It’s hard to live in the moment, to create a sense of awareness, but it’s at such times that I feel most alive.

Perhaps that’s one reason why I find the natural world so attractive. Out in the woods you can center your attention on the sights and sounds you encounter. You get pulled into the experience as it is occurring; you live along with it. At such times you don’t think about the bills that are due or problems at work or issues with relationships—you just exist in the continuous present moment. It cleanses your soul somehow—at least, it does mine.

See the final paragraph of my piece Craving Reality.