“Notes from a Healer” — Coup d’flu

A recent article in the New York Times caught my eye: Swine Flu Wave May Have Peaked in U.S. Thank God, I thought, heaving a sigh of relief as I scanned the text. According to the Centers for Disease Control, influenza activity is declining across the country. New cases of the flu dropped significantly during the week ending November 13th.

Anyone working in primary care medicine can tell you that the past two months have been a nightmare. Offices and clinics have been bombarded with phone calls and patients scrambling to secure a dose of the H1N1 vaccine for themselves and their children. Initially, no one wanted the vaccine because it was so new. When it became apparent that supplies were severely limited, everyone clamored for a dose.

My latest installment of Notes from a HealerCoup d’flu — 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.

“Medicine in the time of the EMR” posted in YJHM

The EMR, we are told, will help cut healthcare costs.  When medical records are converted into digital format, data will be instantaneously available to all providers caring for the patient.  Clinicians will have carte blanche access to previous laboratory and radiological studies, thus insuring that such investigations are not performed repeatedly or needlessly.  Data will be collated and scrutinized to insure that standards of care are met and that medical errors are eliminated.  Electronic billing will become the norm.  One day patients might even be able to schedule their own appointments online.  Somehow all this will serve to lower costs and improve the efficiency and quality of healthcare delivery.

Indeed it might.  But in my mind healthcare delivery is something different than the practice of medicine….>>more

My latest essay, Medicine in the time of the EMR, is now posted at the Yale Journal for Humanities in Medicine blog, a companion blog for the Yale Journal for Humanities in Medicine.

The Grace of Gratitude

In her book The Gift of Thanks:  The Roots and Rituals of Gratitude, Margaret Visser examines what gratitude is and how it functions in our lives.  “Gratitude is always a matter of paying attention,” Ms. Visser observes, “deliberately beholding and appreciating the other.”

Humility is a prerequisite to being genuinely grateful.  If we are to become humble, we must learn to esteem others more highly than ourselves.

One afternoon this past week three patients appeared on my schedule for physical examinations.  The first was a 10-year-old boy.  His father suffers from paragangliomatosis, a genetic condition in which tumors arise from neuroendocrine tissue in the body.  The father has already had several tumors surgically resected and has undergone extensive treatment with chemotherapy.

This boy—Norman is his name—and his two brothers underwent screening for the defective gene; Norman tested positive.  This past summer markers suggesting a developing tumor appeared in his urine and blood.  A scan demonstrated a pheochromocytoma in one of his adrenal glands.  The tumor was resected successfully.  His oncologist continues to watch him closely with periodic tests every three months.

Norman is a happy boy.  He’s put on some weight this fall.  His mother tells me that she didn’t sign him up for soccer this year.  “We’ve had too much going on at home.  My husband had a relapse and had to go on more medicine.  I’ve been sick with a cough for four weeks—they just can’t seem to find out what the problem is.  I’ve been through three courses of antibiotics, prednisone, other medicines—nothing seems to work.”

“You’ve had a lot on your plate,” I say as I begin to examine Norman.

“Well, what can you do?” she says.  “We just take it as it comes.  No sense worrying about the future—that will take care of itself.”

In the adjacent room a 6-month-old girl greets me with a huge smile.  Her mother holds her up so the baby can bounce on the exam table.  “Somebody seems happy today,” I remark.  “How’s she been doing?”

“Terrific!” her mother says.  “She’s been eating like a champ and putting on weight since you recommended she start cereal.  My breast milk just wasn’t enough to satisfy her.  And she’s doing all sorts of things now:  rolling over, sitting up, holding toys, drooling from a new tooth—she’s a great baby.”

I proceed with the exam, point out the child’s robust percentiles on the growth chart, share some anticipatory guidance and administer the shots.  Afterwards, the girl quickly quiets in her mother’s arms, returning to her happy disposition.

“We should see her back in three months,” I tell the mother.  Then I remember to ask:  “How is your housing situation working out?”

“We finally got the trailer.  It’s a little cramped for me and the four kids, but we manage.  They say our house won’t be rebuilt until next June.”

“Another eight months,” I say.

She shrugs her shoulders.  “I’m not complaining.  We’ve got a roof over our heads and food to eat.  More important than that—we’ve got our lives.  Sometimes I can’t believe that we all escaped from that fire without a scratch.  Every day I’m thankful that my kids are okay.”

At 18 years of age, my next patient is technically an adult.  At least, he is classified as such according to the ICD-9 codes.  Although he’s been coming to our group practice for regular exams over the past four years, this is the first time I’ve seen him.  He’s here with his father.  Wes is a soft-spoken boy with a pleasant disposition; he’s got a light growth of downy hair on his chin.  When I introduce myself and offer my hand in greeting, Wes can barely lift his hand from the arm rest of the wheelchair in which he is confined.

The chart tells me that Wes was diagnosed with Duchenne muscular dystrophy at age 5.  He has gotten progressively worse over the past six years.  He has no strength to speak of in his proximal muscles; he is unable to straighten his legs due to contractures.  He has had spinal fusion surgery, and recently a pacemaker defibrillator was implanted in his chest.  His respiratory status is compromised:  due to extensive muscular atrophy, Wes is unable to use his accessory muscles to take a deep breath.

I ask Wes how he spends his days.  He tells me he likes to listen to music.  “What kind?” I ask him.

“Any kind,” he says, “classical, rock, country—heavy metal.”

His father rolls his eyes.

“What else do you do?”

“I play video games, read books, watch some TV, spend time with my family,” he tells me.

“Any plans for the future?” I ask him.

Wes looks at his father.  His father tells me that right now Wes is residing at home.  “My wife is a stay-at-home mom,” he says.  “Wes has talked about going to college, but right now he’s taking a break from his studies.  He just graduated high school last spring—cum laude.”

I examine Wes as best I can, given the constraints of the wheelchair.  Afterwards I comment that the physical exam is normal—normal apart from the obvious muscle wasting, contractures and inability to move his limbs.  “He’s due for two shots today,” I explain to his father.

“I’m good with that,” Wes says.

I administer the shots, and Wes thanks me for taking care of him.  I take a deep breath and say:  “You know, Wes, I think it is I who should be thanking you.  I’ve learned a lot from you during our time together today.”

Wes regards my face with silent eyes of innocence.

“Wes has taught us a lot—quite a lot—over the years,” his father says.

“I’ll bet he has,” I say.

Wes smiles.  “I’m no one special,” he says.  “I just try to do the best I can with what I’ve got—you know, take it one day at a time.”

That’s the grace of gratitude for you—lived out better than even the best author is capable of putting into words.

Streets of Philadelphia

I walked the avenue till my legs felt like stone
I heard the voices of friends vanished and gone
At night I could hear the blood in my veins
Black and whispering as the rain
On the streets of Philadelphia.

—Bruce Springsteen

This past weekend I did something I hadn’t done in thirty years:  I took the train to Philadelphia.

The occasion for my excursion was an editorial board meeting for a national medical journal.  Such meetings are held twice a year.  Six months ago I flew out to San Diego for the previous one.  This time round I took the train.

Friday morning I boarded a two-car commuter rail just north of Hartford, rode it to New Haven, and connected with the northeast regional to Philadelphia.  In thirty years I had forgotten that trains in the northeast corridor pass through rough stretches of country—past litter strewn ravines, boarded up brick buildings, scrap yards filled with piles of junked cars, graveyards populated by the dead.

Those of us on the train—the living—sit by the windows and watch graffiti covered walls stream by or read the morning paper, listen to an iPod shuffle or text message a friend.  Occasionally we rise to our feet and stagger down the central aisle to the john before picking up a coffee or a bottle of water in the café car and return to our seats.

I arrived at 30th Street station in Philadelphia that afternoon and walked thirteen blocks to the Westin Hotel on 17th Street and checked in.  The remainder of the afternoon I spent exploring the city on foot.  I sauntered down Chestnut Street to Independence Hall, glimpsed the Liberty Bell through the massive window, paused at the memorial in Washington Square and picked up Walnut Street on the return leg.  Near Jefferson Hospital I cut up to Chestnut again and stopped at a medical bookstore to browse the titles.

My first medical mentor had attended Jefferson Medical College in the 1960s.  Shortly after I got to know him in the late 1970s, he developed Hodgkin’s lymphoma.

I in turn took my medical studies at Hahnemann at Vine and Broad Streets, where I cemented a life-long friendship with another student who now practices family medicine in Arizona.  At the time we both roomed on north 15th Street, although he and his wife later took another apartment ten blocks south near Spruce.  My wife and I sublet from them when they were out of town for a month that second summer.

I exited the bookstore with my hands thrust deep into the pockets of my trench coat.  It had started to rain; the wind was whipping up in cold wet gusts.  I passed by two musicians huddled in a stone archway playing a Michael Jackson tune on their saxophones.  I’ll be there, one horn soothed reassuringly, while shortly afterward its companion echoed the same soulful sentiment.  I tightened the collar of my trench coat against the wind and pulled the brim of my cap down tight.

That evening I met up with my fellow editorial board members for dinner at Upstares & Sotto Varalli on South Broad.  The remainder of the weekend flew by:  an all day meeting in the Director’s Room at the hotel on Saturday, dinner at the Raw sushi bar on Sansom Street, a late evening demitasse of melted chocolate at the Naked Chocolate Café on Walnut.

Back in my room on the 14th floor of the hotel I stood at the window and looked down on the gleaming streets of the city.  I thought about the man I had seen slumped over a makeshift cardboard sign on which was scrawled one word:  “Hungry.”  A tangled mass of black hair emanated from the back of his stocking cap, his coat was marred with grease stains, his ankles showed white between the tattered cuffs of his trousers and the tops of his dirty sneakers.  When I dropped a few coins into the plastic bowl in his lap, he barely stirred.  In thirty years the streets of Philadelphia haven’t changed much.

The cabbie I hired Sunday morning chatted in Arabic on his cell phone all the way down JFK Boulevard to 30th Street station.  I tipped him a dollar and stepped out onto the wet pavement in the early morning darkness.

As we gathered at Gate 3 to make our descent to the waiting train, I noticed a young couple standing off to the side, holding hands with their foreheads touching.  There are always young couples standing on station platforms, it seems; huddled together, oblivious to the rest of humanity.

Shortly after pulling out of the station we passed over the Schuylkill River.  I caught a glimpse of the macadam path that runs along the bank by the boat houses.  Another good friend and I attempted the Philadelphia marathon there when we were undergraduate students.  I logged 18 miles before I cramped up from dehydration and dropped out of the race.  Some things in life you never complete.

My mentor finally succumbed to his lymphoma this past year.  I still correspond regularly with my doctor friend in Arizona.  Once a year we get together for an afternoon saunter through another Pennsylvania town and catch up on our lives—far from the streets of Philadelphia.

Jabberwocky

Jabberwocky is perhaps the best nonsense poem written in the English language.  Author Lewis Carroll included it in his children’s book, Through the Looking Glass, and What Alice Found There.  In the poem Carroll makes liberal use of portmanteau, the blending of two or more words (and their meanings) into one.

Although nonsensical, the poem is structured using rules of classic English poetry.  It is written in rhymed quatrain format with iambic metered verse.

On an initial reading, many of Carroll’s words baffle the mind.  What actions, for instance, do the verbs “gyre” and “gimble” signify, or the adjective “frumious”?  Thankfully, Carroll himself offered a few definitions to enable readers to decipher various phrases.  For example, chortle is a blend of chuckle and snort. Armed with this knowledge, the studious reader is able to tease out the meaning of the lines of verse—to a point.  Through repetitive wrestling with the poem the reader begins to infer meaning, much in the same way that the student with a rudimentary knowledge of a foreign language garners the gist of a passage that he doesn’t fully comprehend.

One of the first books I purchased when I embarked on the study of medicine was a text of medical terminology.  Like most professions, medicine has a jargon all its own:  a vocabulary which must be mastered if one wishes to understand its basic concepts.  I quickly learned that the suffix –itis meant inflammation of, while –osis referred to the condition of.  Ectomy denoted an excision or cutting out; hence the treatment of an inflamed appendix—appendicitis—was the surgical excision of it—an appendectomy.  (Incidentally, it is the general surgeon who performs this operation, wielding his vorpal blade in snicker-snack fashion.)

At the outset these words seemed uffishly strange, almost otherworldly.  Initially, it was an arduous task to learn them.  Yet through constant use I gradually mastered their meanings as I grappled with my medical apprenticeship.

One danger all clinicians face is assuming that patients understand medical jargon.  We can be too quick to interject our professional vocabulary into explanations of medical conditions, procedures and treatment, burbling on about borborygmi; and find ourselves met with mimsy stares and vacant looks.  It is always best to explain medical concepts as though speaking to a child.  Even the most complex procedures can be broken down into simple steps.  Otherwise the patient is left groping in the dark, trying to comprehend the incomprehensible.  Sometimes the patient or a significant other might interject some manxome meaning on a par with that of Carroll’s poem.

Here I am reminded of the historical information provided by the wife of a man who presented to the emergency room with an acute myocardial infarction (heart attack).  “Well, doc,” she explained, “it was like this.  First off, he got high blood.  They kept on checking him with the cuff, but it wouldn’t come down, so they put him on a water pill.  When that didn’t help, they x-rayed his chest, which showed he had a big heart.  He got worse and worser, and they took more and more x-rays; and they showed that his heart was getting bigger and bigger, until finally there just weren’t no more room in his chest for his lungs to breathe—and that’s when they put in a spacemaker.”

Later, she was overheard speaking on the telephone, imparting the sad news that her husband of forty years had passed away from a massive internal fart.

This might not be jabberwocky, but to my mind, it comes frabjously close.

A Pig in a Poke

I was tickled pink to learn that scientists have succeeded in sequencing the genome of the pig.

According to a recent NPR piece, the DNA sequence comes from a single Duroc pig, one of five major breeds used in pork production.  By comparing the genome of a domestic pig to that of wild ones, scientists hope to isolate and study regions of the genome that contribute to behavior and disease resistance.

One surprise thus far is that the structure and sequence of the porcine genome seem to be closely related to the human genome—similarities are much more apparent than scientists had previously suspected.

For me this information served to substantiate what I had intuited for quite some time—actually, since when I first read E. B. White’s Charlotte’s Web as a boy.  Wilbur, I thought, was truly some pig.  After all, he was capable of giving and receiving love through his friendship with Fern, the little girl who raised him from a runt.  He learned the lesson of ultimate sacrificial love from Charlotte, the common brown literate spider who inhabited the doorway of Zuckerman’s barn; and I in turn learned these same lessons through immersing myself in the book.

In a separate essay on the death of a pig, White comments:  “From the lustiness of a healthy pig a man derives a feeling of personal lustiness; the stuff that goes into the trough and is received with such enthusiasm is an earnest of some later feast of his own, and when this suddenly comes to an end and the food lies stale and untouched, souring in the sun, the pig’s imbalance becomes the man’s, vicariously, and life seems insecure, displaced, transitory.”

So you see, it isn’t surprising that pigs share similar physiological and behavioral traits with humans.  Until relatively recent breakthroughs gave us genetically engineered human insulin, diabetics formerly injected themselves with porcine insulin, the closest biochemical equivalent to our own.  And as is readily apparent this flu season, pigs and humans share a similar viral mutant, which is currently the cause of much consternation in the human camp, revolving around the decision of whether or not to get a pig in a poke.

Perhaps one day we will be able to tap into the pig’s brain and analyze its thoughts.  If so, we might be able to glimpse how pigs view us humans—in a pig’s eye, of course.

Requiem for a flower

Sixteen years ago on my desk it appeared:
A gift from my parents
To celebrate my new position,
A fresh chapter in my medical career—
A peace lily plant, young and tender,
With one newly formed white flower.

The plant continued to thrive,
Unfolding a white blossom once
Every three to five years.
Periodically I repotted the tangled roots
To accommodate its towering sedge-like stalks.

Just this month, a week before my daughter’s wedding,
It bloomed again—
The white flower unfurling like a flag,
Its cylindrical core dusting lush green languorous leaves
With powdered sugary seed.

I returned after my week away,
After attending wedding guests
And ferrying family from
Hostel to home and back again,
To find the listless brown-edged leaves of the peace lily
Draped across the carpet:
The white flower wilted, now edged in black.

Immediately I saturated the potted earth
With cup after overflowing cup
Until the water seeped through the soil
And percolated to the base of the pot.

Afterwards on my desk I found
A news clipping published the previous week,
Deposited there in my absence,
Bearing the obituary of the mother
Of two boys and a girl—three of my patients—
Deceased at age 42
From cancer of the colon.
Her face stared coyly out at me:
A black & white photograph
Depicting what I reckoned to be
A newly-wed young woman.

This morning the peace plant’s ragged leaves
Stand nearly erect,
Revived by living water;
While the wilted white & black flower,
Bowed in permanent prayer,
Has given up the Ghost.

Copyright©2009 by Brian T. Maurer