“Notes from a Healer” — Triple Digits

I have cared for Jonathan since he was a newborn; I can recite his medical history like my street address, bank account and social security number. Jonathan was born with a pedunculated tumor attached to the wall of his left ventricle. So far the mushroom-like growth has given him no problems. His cardiologist and I keep our fingers crossed each time we see him.

My latest installment of Notes from a HealerTriple Digits — 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.

Boxing Day

When snow falls, the driveway beckons to be cleaned; and no matter what the weather, dogs must be walked, even on Boxing Day.

Boxing Day, the day after Christmas, is not celebrated in the states.  Traditionally, this was the day when gifts were given by the British upper classes to their servants and to the poor.  Servants were free to spend the day with their families, and cold cuts were the order of the day on the tables of the rich.

I awoke in the early morning darkness to the sound of a snowplow skirting the street, then drifted off again until the alarm sounded.  In the darkness I dressed, pulling my clothes from the bedside chair.  Outside, a wet white frosting lay on the driveway, not quite frozen.  I started the car and let it warm up while I scraped off the coating of snow.

Mid morning I set out with the dog under a still grey sky.  No one else had ventured out in the slushy snow.  Coming back, I passed the remnants of a snowman standing in someone’s front yard.  The head was no where to be found—only a torso and belly remained, draped with a long flowing multicolored scarf.  One black branch stuck out precariously from the side of the torso—an arm previously raised in greeting now bade farewell.

I imagined the mind of the maker when catching the first morning glimpse of this creation, and reflected on Richard Wilbur’s poem, Boy at the Window, in which a 5-year-old child finds himself in a similar situation.  In an ironic twist, the poet turns the tables in the second stanza:

Seeing the snowman standing all alone
In dusk and cold is more than he can bear.
The small boy weeps to hear the wind prepare
A night of gnashings and enormous moan.
His tearful sight can hardly reach to where
The pale-faced figure with bitumen eyes
Returns him such a god-forsaken stare
As outcast Adam gave to Paradise.

The man of snow is, nonetheless, content,
Having no wish to go inside and die.
Still, he is moved to see the youngster cry.
Though frozen water is his element,
He melts enough to drop from one soft eye
A trickle of the purest rain, a tear
For the child at the bright pane surrounded by
Such warmth, such light, such love, and so much fear.

And so I received my Boxing Day gift.  The dog seemed quite content as well.

A Winter Walk with Jackie

“Please take the dog out before you go to work,” my wife says.

I look up from the book I’m reading in bed.  “I thought you just took her out?”

“I did.  But if you take her out for a walk before you go into work at noon, I won’t have to take her out again when I get back.”

My eyes drift down to the book in my lap.

“Such a hard life you have—the life of Riley,” she says, pulling on her coat.

I hear my wife’s feet pad down the stairs.  Below, the dog barks in a frenzied fit when the back door closes.  Soon she appears at the side of the bed, leaps up onto the covers beside me and buries her nose under my book.

“Okay, okay,” I laugh, stroking her pink belly.  “Let me get dressed.”

Head cocked slightly to one side, she watches as I shed my pajamas and pull on my heavy pants, fleece and vest.  I hunt for a pair of woolen socks in the chest of drawers.  Judging from the movement of the branches in the tall pines behind our house, the wind is up.  The clear blue sky portends a biting cold.

The puppy precedes my step on the stairs; she bounds through the parlor to the kitchen door where, tail drumming, she waits.  “Okay, okay,” I say, pulling on my heavy gloves and reaching for the leash, “let’s go.”

We step outside into a cold so sharp that it burns the nostrils.  The wind has blown bits of recyclables from the back porch, scattering them about the yard.  I retrieve the items and hurriedly toss them back into the bin before heading out.

The snow has hardened in banks by the side of the street.  We push ahead, the dog straining at the leash into the wind which cuts at my throat.  Instinctively, I reach for the zipper at my neck and close the collar of my vest.  Soon we are off at a trot down the tarmac.  At the end of the street we turn the corner and don’t stop running until the end of the block.

Microscopic windswept pins prick the skin of my thighs through my corduroy trousers and sting my face.  Despite the gloves, my fingertips tingle.  We cross the intersection and head down the street.

At the bottom of the hill two crows rise up from a snow bank and pull their wings like black oars against the oncoming wind.  The puppy pauses to sniff the air.  Shortly, we are off again, running down the road.

We make our traditional loop in record time and ascend the hill, past the stand of grey maples sparsely clothed in remnants of bittersweet.  The dog stops abruptly at the row of pines behind the church, nose to the ground.  “Come on, Jackie,” I say, tugging at the leash.  “Let’s go.”  Thankfully, she responds, and we race back down the street to our driveway.

Inside I push the door to, hang up the leash, pull off my gloves and stocking cap and pour a cup of hot coffee from the carafe.  The heat from the cup permeates my hands; the coffee percolates down my throat.

Garrison Keillor once remarked that winter is the only season of the year that is actually trying to kill you.  Not that I have beaten Death—but only once more succeeded in postponing that final inevitable rendezvous.

Sufficient Depth

As a young man, Samuel Clemens spent two years learning the lay of the Mississippi River to become a licensed riverboat pilot.  No sooner had he completed his apprenticeship than he realized that the topography of the river had changed.  In order to maintain his proficiency as a pilot, he would have to continue to study the waterway, which remained in a constant state of flux.

Rivers are not the only things that change over the course of time.  Medical knowledge also morphs with each new piece of data that is discovered.  Just when we think we’ve got it figured out, voilà—a piece of information gleaned from the latest research hints that we’re probably off the mark; and so we set off, chasing a new lead.

Consider the influenza virus.  These small packets of RNA mutate every year, changing just enough to keep ahead of our immune responses.  We get exposed, we become ill; and, most of the time, we recover.  Yet history has shown that once in a great while a strain of virus surfaces which most of us have not encountered before.  At these times influenza pandemics have the potential to wipe out large segments of the human population.  Those of us who survive carry the immunity to prevent illness when next we are exposed to the same or a similar viral strain.  But just because we survive doesn’t mean that we can become complacent.  It’s only a matter of time until the next mutant arrives on the scene, courtesy of random genetic drift.

Thirty years ago conventional wisdom had it that peptic ulcers were produced by hyperacidity of the stomach, brought on by stress.  Patients were treated with medicines designed to neutralize or decrease the production of gastric acid and advised to seek productive ways to reduce stress in their lives.  Then, in 1979, Dr. Robin Warren, an Australian pathologist, discovered a type of bacteria prevalent in the lining of stomachs of patients who suffered from ulcer disease.  Eventually, Warren and his colleague Dr. Barry J. Marshall were able to prove that Helicobacter pylori was the causative agent of peptic ulcer disease.  Treatment plans were devised to eradicate the organism from the stomach, which led to a cure for this common malady.

So it is with medical science.  Many times what we think we know for certain turns out to be nebulous at best.  Still we beat on against the current of conventional wisdom, ever learning in fits and starts, never quite nailing down the truth.

Thirty years ago when I was a young student of medicine, our professors told us that fifty percent of what we were taught would ultimately turn out to be erroneous.  Their dilemma of course was that they couldn’t tell us which half was wrong.  We were forced to digest as much information as we could, hoping for the best.  The study of medicine, like the study of a river, is a life-long process.

As a riverboat pilot, Samuel Clemens would bark orders from the bridge to periodically sound the depth of the river to avoid running aground.  Soundings were taken by heaving a weighted line over the gunwale of the boat to measure the depth of the water in fathoms, indicated by knots in the line:  two fathoms marked sufficient depth for safe passage.

Like riverboat pilots, we must periodically sound our medical knowledge.  Sometimes we drift into shallow water and come up short; but so far the depth has been sufficient to avoid running aground.

A kind, big-hearted, gentle person

Daniel Mongiardo, a physician in Perry County, Kentucky, and also Lieutenant Governor of that state, recently described his colleague Dr. Dennis Sandlin as “a kind, big-hearted, gentle person.”  Dr. Sandlin had been in practice for over thirty years at the Leatherwood-Blackey Medical Clinic in southeastern Kentucky when a disgruntled patient showed up with a gun and shot him dead.  The dispute was reportedly over a prescription for narcotic drugs.

I was amazed at the vehement responses submitted as online comments to a recent editorial in the Journal of the American Academy of Physician Assistants which advocated that healthcare professionals counsel their patients on firearm safety.  Here are a few choice reader remarks:

Cars, swimming pools and tobacco can certainly be blamed for far more deaths than firearms. Quit being a nanny and do your job.

Since you seem to know nothing about firearms or their owners, I suggest you stick to practicing medicine.

You’re trotting out all the tired old anti-gun arguments in your text and you advocate disarmament.

Doctors should really advise us not to exhale, as the EPA has listed carbon dioxide as a dangerous pollutant. It certainly would cut down on all the hot bags of wind that try telling us in crappy little articles that they know better than I do when it comes to my safety.

The most amazing thing about every one of these emotionally charged comments is that their authors seem to have missed the entire point of the editorial, which advocated counseling patients on gun safety in the interests of keeping a safe environment in the home.  (Note:  All of these comments have been deleted by JAAPA editors because they did not adhere to comment guidelines and were deemed to be outside the scope of professional discourse expected on the journal’s website.  As of this writing, comment posting on this editorial has been closed to discourage members of the public from pursuing private agendas at this site.)

When I was a boy growing up in Pennsylvania, adolescents were required to complete a rigorous hunter safety course as a prerequisite to obtaining a hunting license.  The state was not advocating gun control or restricting the use of firearms—it merely wanted to insure that those who used firearms would do so in a safe and responsible manner.

Outside of the first year of life, the number one cause of mortality in the pediatric age group is accidents—deaths related to automobile accidents, drowning in backyard swimming pools, accidental poisoning by mouth, falls, choking hazards, burns from hot liquids and house fires (including smoke inhalation), and accidental deaths from firearms.  A good part of primary care pediatrics is centered on prevention of morbidity and mortality.  Included in this armamentarium of preventive medicine are the timely administration of childhood vaccines, monitoring the growth and development of young children, and counseling parents on how to keep their children safe.

Although I am not an advocate of carte blanche gun control, as a practicing pediatric clinician I do spend time counseling parents about how to keep their children safe.  Firearm safety is one piece in the accident prevention paradigm, and counseling patients on how to stay safe—regardless whether the issue is sexual practice, drinking and driving, substance abuse or proper handling of firearms—should remain an integral part of preventive medical practice in primary care.  The American Academy of Pediatrics has issued a policy statement on office based counseling for unintentional injury prevention which includes firearm safety.

Could gun control have prevented the death of Dr. Dennis Sandlin, a kind, big-hearted, gentle clinician, revered by his patients and the members of his community?  Perhaps; perhaps not.  But regardless of how an act of violence is eventually carried out, it is first formulated in the psyche of the perpetrator.

While we can all agree that when it comes to divisive issues, spirited debate is healthy and perhaps even desirable; those who resort to the use of threatening, abusive and demeaning language should be granted no voice in professional forums.

Humane Medicine — A Measure of Equanimity

In Sir William Osler’s farewell address to his medical colleagues in the United States and Canada, L’Envoi, he enumerates his personal goals: to do the day’s work well, to practice the Golden Rule, to cultivate a measure of equanimity that would enable him to bear success with humility.

Over the span of my 30-year career, I have seen several hundred children for suspected abuse. Yet I can’t help but wonder why every time I evaluate such a child, instead of Osler’s measure of equanimity, I’m left with only a hollow feeling deep inside.

Interested readers can now access my latest Humane Medicine column, Evaluating the patient with a measure of equanimity, recently published in the Journal of the American Academy of Physician Assistants.

Rain on the Roof

Rain on the roof: midnight serenade.  I awaken to the sound of pounding droplets, keystrokes on the roof, drumming out the cadence of thoughts—letters, words, sentences, paragraphs—stories composed overhead in the night.

Cormac McCarthy’s typewriter is to be sold at auction, the Olivetti through which flowed five million words over the course of his literary life.  I recall Hemingway’s Royal, on which he banged out his early journalistic copy and later short stories and novels; and Don Marquis’ archy the cockroach, hopping from key to key, leaving behind his trail of thought.  Helen Miller, big bosomed, sitting at her desk, hair pinned up, writing copy in the 1930s for the West Schuylkill Press:  did she touch type or, like Hemingway, hunt and peck?

Eleventh grade: Mr. Shirk’s academic typing class.  I sit at my desk, eyes glued to the top bound open book, fingertips on the home row, and begin to strike the keys: a, s, d, f; j, k, l, ;—next the reaches: t, r, e, w, q; y, u, i, o, p.  Later the words will come: The quick brown fox jumps over the lazy dog.

Mr. Shirk saunters up and down the aisle, periodically pausing at each student’s desk to observe.  “Check to make sure your fingertips return to the home row,” he says in a quiet voice.

I look up from the open book to the piece of paper pressed against the platen.  Through a slight shift of hand, a lateral displacement of the fingertips, I find that I have translated the quick brown fox into yjr wiovl ntpem gpc/.  Embarrassed, I reposition my hands and try again.

Early morning rain beats down on the roof: myriad millions of droplets, pounding out a story.  Tender is the night.  For forty days the rains descended during the great flood; the waters rose, covering every mountain top.  A rising tide lifts all boats—unless there’s a leak somewhere.

Dickens left his manuscripts, trails of thoughts composed in ink with quill pen; likewise Thoreau; later Hemingway and McCarthy on the platens of their Schreibmaschinen.  Modern writers leave no such trails behind.  Tracks are covered with spellcheckers and cut and paste, insert and delete.  How will future literary hunters track our train of thought to learn the art of our composition?  For we leave nothing behind but finished copy.

Raindrops on the roof, keystrokes, pound out the words:  nature’s story.  Seated at my desk in the darkness, fingertips poised on the home row, I take a moment to listen to this fine immemorial oral tradition.  Presently, the skies will clear; the pounding will cease, these words will slip away.

But the written word remains for all time.