The bend in the great river

One generation passeth away, and another generation cometh, but the earth abideth forever. The sun also riseth, and the sun goeth down, and hasteth to its place where it rose. The wind goeth toward the south, and turneth about unto the north; it whirleth about continually, and the wind returneth again according to its circuits. All the rivers run into the sea; yet the sea is not full. Unto the place from whence the rivers come, thither they return again. Ecclesiastes 1:5-7

“He’s had fever for two days. He’s been so fussy, he won’t let me put him down.”

This mother looks exasperated, exhausted as well. And she’s not a new mother. This 7-month-old infant was her caboose. Up until today, she’s only brought him in for well-child care.

“Has he been eating?”

“Not well. I could only get him to take 4 ounces all day.”

“Vomiting?”

“No, no vomiting—just extreme fussiness.”

“How high has his fever been?”

“102 to 103.”

I study the infant in her arms while we talk. At this point he seems comfortable. He even smiles at me, always a good sign in my book of clinical diagnoses.

“Any one else at home sick?” I ask, reaching for my stethoscope.

“No, not at home. But we did take him to see my husband’s grandfather in the nursing home a week ago. He was bedridden with pneumonia.”

I nod and listen to the baby’s back and chest. Nothing but normal breath sounds greet my ears, another good sign.

“Let’s lay him down,” I say, standing at the head of the exam table with otoscope and tongue blade in hand. The mother pins her infant son’s arms at his sides while I peer into his ears and throat. The tympanic membranes appear pearly grey, but the throat is red and swollen with a small amount of exudate on the tonsils.

“He’s got a sore throat,” I announce. “Let me swab it and run a quick test.”

“I knew he had a sore throat from the way he was acting,” the mother muses. “He cried every time he tried to swallow.”

Even without running the test, I know that this infant has contracted a virus. It’s exceedingly rare to see strep throat in such a young child. But I need confirmatory evidence to prove it.

By the time I return with the news that the results show no strep, the baby has calmed down. Even his fever has dropped — another good sign. I tell this seasoned mother that in all likelihood her little boy will turn the corner in 24 hours. “Give him some acetaminophen, hang in there and call me tomorrow morning to let me know how he’s faring.”

“By the way,” I say, “what did his great-grandfather think of him?”

“He was pleased to see him. Could the baby have picked up pneumonia from him?”

I pause to ponder her question. “Do they know what sort of pneumonia he had?”

Tears fill the mother’s eyes. “Terminal,” she says. “He wanted to see his great-grandson before he died.”

Pneumonia, the dying man’s friend. It settles into the lungs of the exhausted aged bedridden patient and whisks him away in the night.

“When did he pass away?”

“Ten days ago.”

“I doubt that the baby contracted pneumonia from him,” I say. “The incubation period is too long, and there are no signs of a lung infection on exam.”

The mother seems reassured. She will follow my instructions and call me in morning.

One generation makes its entrance while a former one fades away. Standing at the bend in the great river, I look upstream and marvel at how the new white water cascades down over the smooth rocks as downstream the current meanders around the far oxbow and silently slips from sight.

“Pine Creek” 2011 © Brian T. Maurer

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Literary medical weblogs

Dear J.B.,

Your comment on my blog posting The stories we tell came in just as I was re-reading the first chapter of James Joyce’s Ulysses on the front porch.  Previously, I hadn’t run across the Joyce line you quoted about all novelists having only one story, which they tell again and again; but it certainly rings true.  Hemingway said that in crafting a piece of writing he could “cut the scrollwork or ornament out and throw it away and start with the first true simple declarative sentence” he had written. In my book, anyone who takes writing seriously has to start with a desire for truth and the stamina to pursue it, no matter where it might lead.

You also mentioned Dr. Robert Coles.  I too was fortunate to hear Dr. Coles speak two decades ago at a conference on medicine and the humanities.  I recently read Handing One Another Along, a collection of lectures from an undergraduate course which Coles taught at Harvard on literature and social reflection. (The title of the book comes from a line in Walker Percy’s The Moviegoer, one of Coles’ favorites.) Dr. Coles, of course, is an excellent resource for many good works on medicine and literature as well.

Decades ago I got interested in the idea of using story as a vehicle to explore the doctor-patient relationship.  Throughout my medical training (I am a practicing physician assistant) I was appalled at the insensitivity which many clinicians demonstrated in dealing with patients in their time of suffering.  I struggled to understand the source of this coarseness in bedside manner.  Had these clinicians always acted this way, or through years of training had their medical education squelched whatever empathy they might have once had?  Was this perhaps a defense mechanism they had developed over time to shield themselves from the suffering that they witnessed daily in practice?  If so, what could be done about it?  (It certainly wasn’t helping the patient to heal.)  Could empathy be taught, or was it an innate trait possessed by only a minority of individuals who opted for a career in medicine?

As I began to craft narratives of patient encounters, I discovered that the act of writing itself enhanced the way I related to patients.  Somehow writing the story down served to hone an empathetic response.  It also served to help me deal with my own emotions, guilt and grief which I experienced in encounters with patients.  As my perspective developed, I was fortunate to find several like-minded souls in the social ether along the way.  Over the years I worked with other colleagues to create several online sites which continue to function as forums for clinicians and patients alike, Cell2Soul and Dermanities among them.  After reviewing my book Patients Are a Virtue, Dr. Howard Spiro asked me to consider submitting a monthly piece—“Notes from a Healer”— for the Yale Journal for Humanities in Medicine; and I was also invited to write a bimonthly Humane Medicine column for the Journal of the American Academy of Physician Assistants.  I established this weblog to serve as a repository for my writings.

My hope has always been that with ongoing exposure to these sorts of narratives, more and more medical colleagues might come round to recognizing just how intimate and profound the doctor-patient relationship truly is, and come to an understanding that there is much more to the art of healing than just closing a surgical incision, dressing a wound or writing a prescription.  Medical practice is after all the stuff of life; and because literature historically has been an attempt to capture the essence of what it means to be alive, it is small wonder that the two complement each other so beautifully.  As you so aptly put it, medicine and storytelling go hand in hand.

None of us can be all things to all men; but we can certainly make some fumbling attempts to alleviate suffering in the world and bear one another’s burdens as best we can.  As Rilke so aptly put it, perhaps if we learn to love the questions themselves, we can one day live on into the answers.