Winter advisory

"Winter Window" 2012 © Brian T. Maurer

Since acquiring an iPad, I’ve gotten used to checking the Weather Channel app every night before retiring. Most times the predictions are humdrum, but every once in a while I’m brought up short by an unanticipated forecast.

Last night the app carried a winter weather advisory. A major storm would strike our area shortly before noon today. The advisory called for 3 – 5 inches of snow over the course of the afternoon and night, ending in sleet and freezing rain.

I got up early this morning to run several errands before the storm. I topped off the tank in my car and brought back additional gasoline in a 2-gallon container for the snow blower, should the need arise. I pulled the snow shovels out of the garage and cleared extraneous debris from the driveway. Last night my wife had made a big pot of chicken soup for dinner. I turned on the burner and let it simmer. After working outside in the cold, there’s nothing like coming in to a bowl of steaming soup .

I gave myself a pat on the back, pleased that I had been able to prepare for the weather in advance. But even the best laid plans can’t anticipate everything.

Mid-morning I stared at a reply that popped up shortly after I e-mailed the editor at one of the medical journals I write for. Entitled “Away,” the automated message informed me that the editor would be indisposed for an undetermined period of time. Several personal contacts were listed, among them his spouse and granddaughter—not the sort of contacts that you would typically find in an automated e-mail.

Immediately, I shot off a couple of messages to some friends, asking whether they’d heard anything recently about the state of this editor’s health. I’m probably jumping to conclusions, I muttered under my breath as I pounded the keyboard; but I couldn’t help it—my clinical nose was twitching. I feared something was up.

The snow started to fall shortly before noon. Within an hour the yard was blanketed white. Snow lay on the bare branches of the maples in back of the house and accumulated on the cars parked in the street. Outside the window of my office it continued to come down steadily. This was certainly no ordinary snow, I mused, recalling the advisory. Such a rate of descent portended more than a mere dusting.

Another message popped into my Inbox. This one was from the editorial assistant. She confirmed my fears: the editor was indeed in the hospital. She didn’t know the particulars. She imagined that he wanted to keep things quiet—no fanfare, no fuss. She admitted that she was worried too. She would let me know as soon as she heard anything more. Meanwhile, outside the snow continued to fall.

Soup—piping hot, chocked full of fine noodles with bits of celery, carrots and corn. I lifted a spoonful from the edge of the shallow bowl to my lips and blew softly to cool it off. The dog perched at my side, eyeing the spoon and begging for cracker crumbs.

Years ago a friend and I had visited the editor at his townhouse. For lunch he had warmed up some homemade soup on the stove.

How different the hospital must have looked through his eyes from the bed. This esteemed professor emeritus who had attended so many patients over the course of his lengthy career was now at the mercy of his own attending physicians, a patient himself.

A thick layer of heavy wet snow accumulated on the driveway. I downed a cup of fresh brewed coffee, pulled on my cap and coat and stepped outside into the winter whiteness. I grabbed the shovel on the back porch and started pushing the snow off the driveway, herring-boning my way down the long expanse of macadam to the street. As I worked the snow continued to descend. The wet snow stuck to my woolen cap and my coat; soon I was blanketed with the wet whiteness.

“Do you tip your barber?” the editor had written after reading the manuscript of my piece Haircut. “I still do, though people tell me it’s no longer done.”

“When I read your latest, I was reminded of the stout cigars I used to love when I was stationed overseas.”

“Crafted with your characteristic twist, served up with a touch of grace—imprimatur!

Imprimatur!—that was his stamp of approval: Let it be printed! I learned a bit of Latin phraseology through our casual correspondence. He was a wonderful mentor, even when he wasn’t aware that he was teaching.

By the time I reached the street the upper driveway was once again covered in snow. I shouldered my shovel and trudged back to the top. For the second time that morning I threw myself into my work.

Afterwards, I pulled the car into the driveway off the street. My wife let our little white terrier out and handed me the leash. We took a short walk around the block. Several times the dog stopped to shake the snow from her rough coat. She bounded through the snow like a miniature sheep, tugging at her leash.

Back home I brushed the snow from my cap and coat in the mud room. I dried the dog with an old towel, kicked off my boots and stepped into the warm kitchen. The soup still simmered on the back burner of the stove.

I hurried upstairs to check my e-mail. A new message from the editorial assistant informed me that the editor had suffered a stroke during cardiac catheterization. No one knew anything more at that point. I dashed off a quick reply, thanking her for the timely update.

Outside the snow continues to descend. The bare maple branches bend precariously under the weight of the wet snow. It will only be a matter of time until one of the weaker ones snaps.

Haiku dog walk

White terrier stands
Head tilted, one brown ear cocked—
Eyeing the black leash.

Ski cap tight, warm gloves
Bulky fleece coat collar zipped—
Door creaks, biting wind!

Titmice perch and peck
Feeder spills, swings to and fro—
Grey squirrel attacks!

Hound dog approaches
Straining at the taut choker—
Vicious snarls exchanged!

Rough coat buries nose
Beneath cinnamon needles—
Organic treasures!

Starlings sit on wires,
A bar of slurred sixteenth notes—
Bird’s eye notation.

Photo eye captures
Afternoon winter debris—
Frozen artifacts.

Stark limbs stretch skyward
Broken branches snapped in two—
Matchsticks on cobalt.

Sudden shot echoes
At wood duck and white water—
Turning tail, dog yaps!

Silver skillet rests
Over open orange flame—
Welcome kitchen warmth.

Copyright 2012 © Brian T. Maurer

"Two Take Flight" 2004 © Barry H. Penchansky, M.D.

Omens are made by men

"Streetlights" copyright 2012 © Emily B. Maurer

Three nights ago
The sentinel streetlamp
In front of our house
Extinguished itself.
Our dim porch light struggled
To keep the darkness
At bay.

The next morning
My daughter called the power company
To report the outage.
The cordial woman who answered
Gave her a confirmation number
And no time frame for repair.

That night the street
Remained in darkness.

This ashen afternoon
A turkey vulture lighted
Atop the cross
On the village church spire.
The buzzard spread
Its black wings
In horaltic pose
And raised the hackles
On its crimson neck.

“Look!” I pointed, “an omen!”
“Omens are made by men,”
My wife said,
And resumed her needle point
In silence on the veranda.

When next I looked
The bird was gone.
The spire shone golden
In late afternoon sun.

This evening
Before our house
Above the cars parked
In the snow-covered street
The sentinel streetlamp
Once again casts its yellow cone.

Copyright 2012 © Brian T. Maurer

We’ve come a long way, baby!

PA: a post-modern acronym devised to denote a select group of highly trained top-notch healthcare professionals groomed to provide state-of-the-art compassionate care in collaboration with practicing physicians, upholding the vision to restore the practice of medicine to its prior place of unselfish service to humankind.

The January 2012 issue of AAP News (Volume 33, No. 1) carries a front-page article about PAs as key members of the team model of care in pediatric offices.  Chris Barry, PA-C, is highlighted as the medical liaison from the AAPA to the AAP.  Jack Percelay, M.D., AAP liaison to the Accreditation Review Commission of Education for the Physician Assistant, describes PAs as having “a collaborative working relationship with physicians.”

Like their pediatric patients, PAs have demonstrated tremendous growth and development over the past three decades.  As bona fide clinicians now recognized and welcomed by the American Academy of Pediatrics, we’ve come a long way, baby.  more»

a sous bois

Undergrowth with two figures, 1890

The window frames a wood in spring.
Betwixt rows of sentinel tulip trees
An equally vertical couple stands
Side by side, hand in hand,
Amidst daffodilled undergrowth.

I keep my distance with arms crossed
To shield a harrowed heart and ponder:
Were these two figures casually caught
Between the purpled trunks,
Two tares among the wheat;
Or caged behind pale prison posts,
Seeking a silent escape?

Copyright 2012 © Brian T. Maurer

Focal Points

As cancer, that insidious conniving guest,
Silently invades the body,
Making no pretense in devouring its host,
It focuses the mind.

From morning’s waking moment,
In lieu of schedules and daily schemes—
Early aerobics, a suitable outfit,
Slipstreaming down the interstate,
Lunch, enjoying a chapter in early afternoon,
Home for dinner, an evening walk, bed—

She now hears the clear notes of chickadees.
Morning light unfolds, revealing
Ruby red carnations potted by the backyard fence.
The bedroom fan cools her sallow skin.

Ultimately, such moments are all she has—
Has it always been thus?—
Just so, just enough.

Copyright 2012 © Brian T. Maurer

Farewell, My Lovely

Not all old friends die hard. For some it’s as easy as a cough, a sputter, a sudden surge in temperature, a brief episode of cheyne-stoking, and then the end. The body is cleaned and dressed; the final appointment is made. Papers are duly signed and dated. The hearse arrives to collect the body, now spent; a eulogy forms in the mind, a hand raised in final salute.

In this case the friend to which I refer is an old lovely, a vintage legacy no longer manufactured in this country. She appeared before my house one morning eight and a half years ago with a shout from the street: “Isn’t she a beauty? I saw the color and I thought of you.”

The speaker was my auto mechanic. The beauty under discussion was a 2000 Subaru Legacy GT AWD wagon, standard transmission, grey upholstered seats, console cassette player, AM/FM radio, dual moon roofs: a second-hand dreamboat from Florida. The golden pearl exterior reminded me of the lining of seashells cast upon the shore. I took it for a spin and fell in love; this was the car I had waited for, now dropped fortuitously at my doorstep.

And so began a relationship that lasted nearly nine years. We traveled everywhere together: back and forth to work, the daily mundane commute; several long treks to the wilderness regions of Pennsylvania; a semiannual rendezvous on the porch of an inn at the square of an old town in the northeast. Periodically, we ferried family to Logan Airport outside Boston and JFK in New York. She ran like a charm in overdrive across the long stretch of interstate highway from Brewster to Port Jarvis. Altogether we logged over 177,000 miles with barely a complaint along the way.

Regular oil changes and servicing helped maintain her health. A leak in the moon roof resulted in a sizeable payment for what turned out to be unnecessary repairs suggested by an unscrupulous dealer no longer in business. She ran well on a diet of regular unleaded gasoline during a decade when gas prices were relatively cheap. All told, we had a good run.

Even good runs eventually wind down. I knew there was a problem when the needle on the temperature gauge began to fluctuate and the coolant levels dropped. The thermostat was replaced; the radiator fluid replenished. The water pump was changed along with the timing belt. Still the problem persisted.

One morning the engine overheated on the way to work. By that time I had learned to carry a jug of diluted antifreeze in the car. Quickly, I pulled off to the side of the road and shut the engine down. I waited a few minutes before I cracked the radiator cap to allow the steam to escape. She ended up taking nearly two quarts of fluid to complete the resuscitation.

“If the lines are soft when the engine is running, it’s most likely not the head gasket.” “If there’s no white smoke from the tailpipe at startup, it’s not the head gasket.” “A good number of those 2.5L engines go over 300,000 miles without a head gasket leak.” That’s what I read in the forums online; those were the words of trusted friends. I’m sure they meant well. In the end it was my auto mechanic who pegged the telltale sign: “Check the oil. If it looks like a milkshake, it’s the head gasket.”

She overheated again one Sunday morning on the way home from the filling station. I had just topped off the fuel tank in preparation for another week. Once again I pulled off to the side of the road; once again I checked the fluids. The coolant was down a quart from the previous day. The oil on the dipstick looked like a chocolate milkshake.

In the end I elected not to trade her in on a newer model. I donated her to charity instead. Early one morning I cleaned her out and placed the title and the keys in the glove box, running my hand over the dashboard one last time.

When I returned home from work that evening, she was gone.

The days were golden, the nights were dim and strange. I still recall with trembling those loud, nocturnal crises when you drew up to a signpost and raced the engine so the lights would be bright enough to read destinations by. I have never been really planetary since. I suppose it’s time to say goodbye. Farewell, my lovely!    —E. B. White

Humane Medicine — When difficult decisions must be made

Moral distress: when clinicians feel they cannot do the ethically appropriate thing. Midnight medicine: when difficult decisions must be made with no time for consultation and critique. more»

Interested readers can now access my latest Humane Medicine column — Midnight Medicine: A time when difficult decisions must be made — recently published in the Journal of the American Academy of Physician Assistants.

Great performances, poor players

Medicine is a learned profession, but clinical practice is above all a matter of performance, in the best and deepest sense of the word. —Frank Davidoff, M.D.

Years ago I recall watching a television documentary on Arthur Fiedler, the conductor of the Boston Pops orchestra.

The camera caught Fiedler backstage, stooped and shuffling slowly about as he struggled with his tux in preparation for the evening performance at Symphony Hall. He looked like the old man he had become—tired, fatigued, worn out. But then, as he stepped out onto the stage, a miracle happened. Fiedler’s frame straightened, his head lifted squarely onto his shoulders, a big smile flashed across his face. Proudly, he assumed his position at the head of the orchestra, pumped up by the thunderous applause.

We are what we are; we become what circumstances require of us.

Fiedler’s transition occasionally flashes through my mind as I step across the threshold into an exam room to meet a patient. Almost always I offer a big smile and extend a hand in greeting. I attempt to hold my composure throughout the interview, adjusting my demeanor to reflect the emotional state of the patient. I become, as it were, a player on stage where the art of medicine is performed countless times in daily rounds.

I might move from an encounter with a new mother, freshly primed by a healthy, thriving infant to a silent teenager, subdued in the throes of a depression. In each case I’m cast as best supporting actor, called to muster my emotive repertoire at a moment’s notice.

Sometimes I don’t feel up to the task; I’m drained, exhausted, spent. Sometimes I want to turn tail and run as fast and as far as possible to distance myself from the suffering I witness daily. I want to cover my ears, shut out the woes, the aches and complaints, for I have more than enough of my own.

None of this is permissible, of course. The patient has come seeking expertise, care and compassion—what does it matter how I, the clinician, might feel?

Here Osler’s wise words of comfort seep into my mind:

Dealing as we do with poor suffering humanity, we see the man unmasked, exposed to all the frailties and weaknesses, and you have to keep your heart soft and tender lest you have too great a contempt for your fellow creatures…

Even I, a poor player who daily struts and frets his hours upon the stage of clinical medicine, am not one to wallow in self-pity. Ultimately, I can not run from the responsibility I have for those entrusted to my care.

I call to mind the image of Fiedler stepping out on stage. Once more I buck myself up, rap quickly on the exam room door and step into the limelight for my next performance.

It will be the best I have to offer.