“Notes from a Healer” — By the Numbers

Numbers are the words of mathematics; mathematics is the language of science; science forms the basis of modern medical practice. Yet sometimes we can get caught up in the numbers to the extent that they cloud our outlook of the larger picture. We calculate the milligrams of medication, but fail to look at the patient.

My latest installment of Notes from a HealerBy the Numbers — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online clearinghouse for manuscripts dealing with the humanities and medicine. Interested readers can access a list of editorial board members and regular contributors here.

Casting pearls

“Should I have my daughter get the swine flu vaccine?” this mother asks.  She stands next to her toddler who sits on the exam table.  The little girl has had difficulty gaining weight.  Now two years of age, she barely tips the scale at 23 pounds.  Otherwise, she’s been a healthy child.

“The vaccine is available and indicated for her age group,” I say, attempting to disseminate the information in a non-biased way.

“I know, but should I do it?  What are the risks?  It’s so new.  You hear so much about problems with vaccines these days.”

“It will protect her against the swine flu.  The vaccine is manufactured by the same companies that have been formulating flu vaccines for years.  It’s been field tested and found to be safe.  Apart from some minor side effects, it’s a good vaccine.”

The look on this mother’s face tells me she’s not convinced.  “What will happen if she doesn’t get the vaccine and comes down with swine flu?  Will she die from it?”

I take a deep breath and recite my litany:  “She’ll get sick with fever and feel lousy for a few days, but she’ll most likely recover.  Of course, there are no guarantees; but chances are good that she’ll make it through fine.”

“So I’m not a bad mother if I don’t have her get the vaccine?”

“No, you’re not a bad mother if you decide not to have her immunized.”

The mother averts her eyes and reaches for her little girl’s shoes.  “I guess I’ll hold off for now,” she says.  “If I change my mind, can I have her get it later?”

“Of course—assuming the vaccine supply lasts.”

I step out of the room, toss the child’s medical record on my desk, reach for the next chart in the bin and step into the adjacent room to greet an adolescent boy.  His mother has brought him in with complaints of a sore throat.

I glance at the vital signs:  no fever.  I ask a few questions and proceed with the examination.  As I expected, he exhibits signs of a mild scratchy throat.  There are no significant swollen glands in his neck.  I prescribe a course of saline gargles, acetaminophen, throat lozenges and warm fluids.  Afterwards, I ask if there are any questions.  “Can he get the swine flu shot today?” his mother asks.

“Right now he isn’t eligible for the vaccine.  He doesn’t fall into one of the high-risk priority groups.”

I can see the look of disappointment on her face.  “Can he get the regular flu shot?  I heard that that might give some protection.  Is that true?”

“The regular flu shot will protect him against seasonal flu, but it won’t be effective against the swine flu,” I tell her.  “And at this juncture we’ve exhausted our current supply.  We should have some additional vaccine next month.  If you call the office, we can have him come back for the shot.”

“I can’t believe that there’s not enough vaccine to go around.  Everyone says to get the flu shot this year.  What are we supposed to do?”

I shrug my shoulders.  “I share your frustration.  We’re at the mercy of the vaccine suppliers.  Unfortunately, there’s been a shortage this year.  We can only work with what we’ve got.”

I step out of the room and walk to the front office.  All of the telephone lines are busy.  Each time one of the receptionists hangs up a phone, it rings again.  Everyone is exasperated.  “We don’t know what to tell the patients any more,” one medical assistant says.  “Everyone asks if we’re recommending the swine flu vaccine.  When we tell them that there’s not enough to go around, they go off on us.  One lady used such foul language, I told her that I was going to hang up!  I’ve never done that before in fifteen years.”

My third patient of the morning is a 12-year-old girl who has come in for her annual physical examination with her mother.  At this age the child is due for a number of inoculations:  booster shots for tetanus and chickenpox, as well as the meningitis vaccine.  I review the chart and note that the girl has a history of asthma.  “She should also get a flu shot today.  With her asthma, she’s high risk.”

“She’s never had a flu shot in her life,” her mother tells me.  “I haven’t either.  We don’t get the flu in our family.  Besides, three shots are enough.  Aren’t they going to tax her immune system too much?”

Once again I explain the reasoning for my recommendation.  The child has a history of asthma.  If she contracts swine flu, she would be more likely to develop a secondary pneumonia, further compromising her respiratory status.  The vaccine is available; it makes sense to give it to her today.  And in answer to her last question, no—one more vaccine won’t compromise her immune system.

“Can’t she have the vaccine that you squirt up the nose?  At least that would save her a shot.”

“The nasal vaccine is formulated with live virus.  It shouldn’t be given to someone with asthma.  And right now we’re only authorized to administer the nasal preparation to children below six years of age.”

The mother looks at her daughter, who pleads silently with her mouth:  No, not another shot!

“Well, if you think it’s a good idea, I guess we’ll do it,” the mother says, avoiding her daughter’s misty eyes.

I scribble a note in the chart and think:  How will I ever get through this day, let alone the next five months?  At times like these I wonder whatever possessed me to opt for a career in primary care medicine.

My last patient of the day is a 6-year-old boy.  I’ve known his mother for years.  The boy has brittle asthma.  She knows how to treat it when he gets sick.  Today he has a fever, cough and runny nose; he looks ill.  “I have an appointment to have him get his flu shot day after tomorrow,” she tells me, with a concerned look in her eyes.

Thankfully, the boy’s lungs are clear.  I take a nasal swab specimen and test it for swine flu.  Ten minutes later the tell-tale red line appears on the test strip.  There won’t be any need to vaccinate him now.

I write a prescription for Tamiflu, a drug that will blunt the viral infection surging through his small body.  His mother remains calm while I explain the treatment.  At the end of the visit she thanks me with an easy smile.  “I’m glad you were able to see him today,” she says.  “It’s a comfort knowing you’re here when we need you.”

And suddenly once again I remember why I elected to practice primary care pediatrics.

Where a story begins

Remarks made by the father of the bride at a 2009 Columbus Day weekend wedding.

When I say that each one of you has journeyed a long way to come here today, I don’t necessarily refer to physical distance.  Of course, some of you have traveled a long way:  some have come from Florida, some from Cuba, some from England.  Others have journeyed from Iran, and from Galicia, that Celtic region on the northwest coast of Spain.  And there are those who have traveled from that far-off exotic land known as Pennsylvania.  Each one of you has made a conscious decision to meld your story into this story, the one we are celebrating today.

Where does a story begin?

It begins thirty-four years ago when a young man steps off a bus in a small village on the northwest coast of Spain, and a young woman emerges from the shadows of a doorway to meet him; and they walk arm in arm down a rain-drenched cobblestone street underneath an umbrella.

Where does a story begin?

It begins twenty-seven years ago when, after a month of working 100-hour weeks in the hospital, coming home only to eat and sleep, a man hears his wife tell him that she’s going to have a baby; and the only regret the husband has is that somehow he can’t seem to remember the moment of conception.

Where does a story begin?

It begins nine years ago when a father wakens his 18-year-old daughter before first light and the two of them drive six hours to visit a college nestled in the farmland of central Pennsylvania; when, after viewing the campus, the daughter says, “Dad, I think this might be the place for me.”

Where does a story begin?

It begins one year ago when a slightly anxious young woman accepts an offer by a slightly nervous young man to enter in to a partnership to try to make something good together in this life.

Fall is the best time of year, when the leaves show their true colors and drift down to blanket our roads and our pathways.  Fall is the best time of year, when the air turns crisp and the fields turn golden brown; and the apples are red and ripe and ready for picking.  And despite what the common folk might say, fall is the best time of year for a wedding, because of all the seasons it is the most poetic.

Yesterday the rain was falling.  A woman at work told me to hang a rosary on every window of our house to ward off the rain.  I didn’t take her up on the suggestion.

But earlier today, when I stood before the mirror to fasten the tie around my neck and tug at the edge of my vest, I noticed the raindrops on the window pane.  Two drops quivered next to one another, uncertain of their fate.  Then they melded into one and flowed effortlessly down the glass.

Like raindrops on a window, like rivulets in a brook that eventually make their way to the sea, our stories flow into one another until they become that one universal story that is told over and over, again and again.  In the end it doesn’t really matter whether you hail from Pennsylvania or Florida, Cuba or England, Iran or Spain—the story is the same.

Where does a story begin?

The answer is simple:  it begins here, it begins now.  For now is the moment when nothing remains of yesterday’s rain but an opening in the sky, a patch of blue and the promise of a new story—perhaps a poem—which my daughter and my son-in-law stand poised, ready to write together.

“One More Child Left Behind” published in “Pulse”

Making the diagnosis might be straightforward, but sometimes getting adequate medical care poses a more formidable challenge.

Readers can now access One More Child Left Behind, newly published in Pulse, voices from the heart of medicine.

A previous version of this piece appeared in the online journal Dermanities and was subsequently published in Patients Are a Virtue: Clinical Tales in the Art of Medicine.

Pulse is an online magazine that uses stories and poems from patients and health care professionals to talk honestly about giving and receiving medical care.

One of the Club

My daughter’s fiancé, who is now my new son-in-law, invited me to a golf outing the day before their wedding.  “Just a few guys in the wedding party—my dad, my best man, my college roommate—a chance to get away, hit a few balls and relax for a couple of hours—you’re more than welcome to join us.”

Although it pained me deeply to admit it, the last time I had played golf was twenty-some years ago—and that was the miniature variety.  With the exception of one disastrous afternoon attempt at chip and putt as an adolescent, the only other time I had ever set foot on a conventional golf course was in high school when I ran cross country.  “Sure,” I choked.  “I’d be happy to come.”

“Good,” he said.  “And don’t worry—we aren’t professionals.  It’s just to have a good time.”

I nodded my head with fear and trepidation in the pit of my stomach.  I believe the operative term is performance anxiety.

Although my two sons had been invited as well, at the last minute they bowed out.  Both had been out partying the night before; one had class that morning.  When the group of four swung by our house, I was the only one available.

It was drizzling—a cool, wet autumn morning; just right for getting soaked to the skin and chilled to the bone.  But I grabbed my slicker and pulled on my cap: a promise is a promise.

We took two vehicles.  The best man rode with me.  A sports management major in undergraduate school, this fellow now ran a country club in the Pittsburgh area.  Their club had just finished sponsoring a regional women’s open event.  He had a professional demeanor about him.

“I suppose you play quite a bit of golf,” I said nonchalantly, as we tooled down the country road.

“Not as much as you’d think,” he said.  “These days I spend most of my time in the clubhouse putting out fires.  It’s been a while since I’ve played.”

“How long?”

“Four months.”

I swallowed hard and inched the accelerator a little further toward the floor.

The parking lot at the public course was deserted.  My son-in-law’s father pulled his minivan in beside my station wagon.  We all stepped out and looked at the grey clouds overhead.  “There won’t be many players out today—we’ll have the run of the place.”

“How many holes are we playing?” I asked.

“Eighteen,” my son-in-law said.

“Eighteen?  How long will it take to finish?”

“It depends—probably a couple of hours.”

I looked at my watch:  8:45 AM.  “You’d better put me down for nine only,” I said.

“Sure—whatever you’d like,” my son-in-law said.

His father opened the back of the minivan and proceeded to parcel out bags of clubs.  “I brought these along for you,” he said.  “They’re old, but functional.  My son said you didn’t have a set of your own.”

I swung the bag over my shoulder and hunched forward as we walked up to the clubhouse.  By the time we paid at the desk, it had started to drizzle again.

“Now, when you place the ball on the tee, half of it should rest above the top of the head of the club,” my son-in-law explained.  “That way, when you swing, you’ll get a good piece of the ball.”

We were on the first tee.  I pushed the ball and tee down into the soft grass and straightened up.

“Take a few practice swings,” he said.  “Here, let me show you how to hold the club.  Now pick out a leaf on the ground, and try to brush it off with your swing.”

I gripped the club, eyed a fallen leaf, swung the club back and powered forward, clipping the leaf dead center.  Unfortunately, I took a hefty piece of sod with it.

“That’s okay—give it another try.”

I stepped up to the ball, squared my stance, drew back the club above my head and swung, striking the ball with a nice follow through.  Had we been playing baseball, it would have been a beautiful line drive to third; although in my estimation, the ball hadn’t traveled quite as far as third base.

The score card listed the hole as 331 yards long.  Methodically, I chipped my way down the green.  It only took eight strokes to reach it, and four more to putt out.

I picked the ball out of the hole and looked at my watch.  I wondered if you could sign up for three holes instead of nine—you know, a special dispensation of sorts for the meek.  After all, we’re supposed to be the ones inheriting these golf courses along with the rest of the earth; although I can’t imagine of what use any of them they might be.

As we approached the third hole it became apparent that some landscaper had made a big mistake.  There before the tee stood a small pond.  The flag that marked the hole on the green stood directly opposite, 163 yards away.  I couldn’t fathom why anyone would have designed a fairway with a body of water smack dab in the middle.  A player could easily lose a ball in that mess, I mused; and then where would he be?

One of the young men in our party hit first:  a beautiful shot directly over the pond.  Way off in the distance you could see the tiny white ball bounce by the green.  The country club manager was up next:  another lovely send off, three-quarters of the way down the fairway.

Now it was my turn.  I pushed the tee into the sod as I had been taught and slapped the ball with a #1 driver.  The ball struck the surface of the pond and skipped six times before submerging into the murky depths.  I wondered secretly if it weren’t a record of sorts.  My second shot made it safely to the other side.

By the fourth hole I had learned quite a bit about the use of the various weights of irons.  On the advice of my son-in-law’s father, I started with a #1 driver, then switched to a #3 hybrid, followed up with a #7 and finally a #9 iron to chip onto the green.  It was only 437 yards.  Twenty minutes later, after five attempts, I putted out.

At the fifth hole I was introduced to three additional essential pieces of equipment in the game of golf:  a free standing scrubbing unit analogous to a small churn to clean the balls, a fixed set of brushes to wipe the mud off your cleats, and a portable john, inside which the fatigued golfer can find momentary rest and relief.

Also at the fifth hole I was introduced to another conundrum:  the sand trap.  This is a small amoebic depression in the earth filled with coarse crystallized silicon and placed precariously near the green.  Should you ever encounter one of these wastelands on a golf outing, I highly recommend that you avoid it at all costs.  They only lead to marked frustration and an acute deterioration in your verbal etiquette.

At the sixth hole, my son-in-law’s father suggested that I drive the golf cart.  “Just floor the pedal,” he said.  “They don’t go that fast.”  We took off down the fairway like a shot.  I wondered if that’s how Mario Andretti or Dale Earnhardt got his start.

I surveyed the ninth hole with thanksgiving in my heart.  For me, this would be the final fairway of the morning, which somehow had disintegrated into early afternoon.  Markedly fatigued, I became aware of the pain in my right shoulder and the small of my back; my thighs had turned to weighted jelly; my shoes and socks were soaked through.  Still I managed to muster the will to drive on, and drive on I did, searching for my ball under the fallen leaves halfway down the fairway in the little cart.

We putted out on the green, quietly removed our hats (I in a moment of reverential silence) and offered each other firm handshakes.  “Good round,” the country club manager said, looking me in the eye.  It was a genuine smile.

At that moment I felt as though I were truly one of the club.

Full Moon over Kitchen Creek

It was dark when we left the barn after the last lecture.  Outside, Jim’s wife waited for me with a flashlight.  I pulled my sleeping bag and duffle from the back of my Subaru and followed her across the meadow.  High above the barn where the haflingers were bedded down, a full moon broke through the clouds.

At the far end of the meadow we found the path that led down the hill to the hollow above the creek.  You could hear the water rushing down over the rocks in the night.  Off to the left I could make out the lines of a cabin in the moonlight.

Jim’s wife opened the door.  I followed her inside and threw my bag and duffle on the high bed.  She lit an electric lantern and held it up so I could survey the room.

“You’ll probably want a fire for the night.  Stoke the stove full and let it burn down to coals.  It’ll be nice and toasty inside.  I left a couple of heavy throws on the bed in case you need them.  Breakfast is at eight o’clock.  Good night.”

I looked about the room.  The cabin was perhaps fifteen by thirty feet, housing three windows, one on each side and another in front next to the door.  A writing desk stood opposite the double bed.  Another wooden desk stood at the far end near the wood stove.  The tinder box rested against the opposite wall.  A double bladed ax leaned up against the back wall, and a number of fishing poles lay cradled in a rack on the wall above the ax.  One of them—a fly rod—looked to be at least ten feet in length.

Three chairs rested between the desks and the bed.  I thought of the three chairs in Thoreau’s hut:  one for solitude, two for company, three for society.  This night only one would be necessary for me.

I set a lighted match to the kindling and stoked the stove with several split logs.  The dry wood caught quickly.  The fire made a whooshing sound as flames drew up the flue.

I rooted through my duffle and pulled out a set of long johns.  I undressed by the light of the electric lantern and hung my trousers and shirt on a nail by the window.  The thermometer on the wall read 52 degrees.

In the desk I found two books:  one on fly-fishing with an introduction by Jack Hemingway and another with watercolor prints of various species of trout.  I laid out my sleeping bag on the bed and crawled in and paged through the book on trout until the words fell out of focus.  Afterwards, I turned out the electric lantern and drifted off to sleep with the sound of the cascading brook in my ears.

Sometime during the night I got up to check the stove.  The fire had burned down to glowing embers.  I slipped on my boots and stepped outside.  Overhead the full moon burned in the night canopy.  This was Lorca’s luna, one and the same, sailing through a sea of smoky clouds.  A poem by e. e. cummings came to mind—

 !
O (rounD) moon, how
do
you(round
er
than roUnd) float;
who
lly & (rOunder than)
go
:ldenly (Round
est)
?

I returned to bed once more and awoke several hours later to find the full moon sitting on the edge of the silhouetted black mountain above the gorge.

I was up at first light.  The stove was cold.  Methodically, I stripped off my long johns and donned my clothing.  I gathered my gear and stowed it back into the duffle bag, rolled up the sleeping bag, stuffed it into the sack and cinched the drawstring tight.

I stepped out into the cool morning air.  For the first time I noticed that the maple leaves had turned a golden yellow; many had already fallen to the ground.  I hiked up the back hill to the pasture, carefully separating the hemlock branches now wet with dew.

The haflingers were out feeding on their flakes of hay.  They looked up when I stepped out through the trees, then resumed their breakfast.  I watched them eat before descending the hill back to the cabin.  Jim’s wife was calling from the path.  “Come up to the house.  You can get a hot shower before breakfast,” she said.

It was only when I turned to leave, my arms laden with gear, that I glimpsed the painting wedged on the shelf above the door below the beams.  A white-bearded man bowed his head over hands folded next to a crust of bread.