The Unfallen Yellow Leaf

Age, with his stealing steps, hath clawed me in his clutch,’ as the gravedigger in Hamlet says. I’m not so sure I agree –he was speaking about a skull, after all- but I have to admit there are times when I do feel old, and shipped ‘into the land as if I had never been such’; when I do wonder if whatever I have done has gone as unappreciated as a shadow from the moon, as unnoticed as an owl in the night.

I used to think that ‘Aged’ was just a word –but an adjective, not a noun; a descriptor rather than a described -somebody else, in other words… And that makes a difference, even when it is not mentioned in your CV but, rather, implied in the later stages of your career. I prefer to see the years as a kind of parliament where habits, and opinions and experience, all cohabit equitably, calmly debating the memories they were each elected to serve, sifting through them, perhaps, to decide if any merit publication.

And I’m sure there are some memories out there where my face is almost discernible in the background; where at least my voice was recognizable at the time. ‘What you lose as you age is witnesses, the ones that watched from early on and cared, like your own little grandstand’, John Updike wrote in one of his ‘Rabbit’ novels. He’s right, of course –and yet… Sometimes it can happen that you forget the very ones that watched from early on; you forget they cared.

Janice sat giggling in the corner of the waiting room, watching a little child toddle across the room towards her, his legs bowed around bulging diapers, his progress uncertain but determined. I could see her eyes from the reception desk; they glowed with excitement and her head seemed to bob in time to every tottering step. Her entire face became a smile, an expectation living vicariously as the little boy approached, followed closely by his beaming mother.

The consultation request from her GP said she had been referred for antenatal care -as if the rapture in her eyes, and the glow on her cheeks could be mistaken for anything else. Some people wear their pregnancies like jewels. It’s why I love obstetrics.

As I walked across the floor to greet her, she suddenly jumped up and extended her hand. For some reason I had the impression that she wanted to hug me, and would have under different circumstances. Not that I don’t enjoy being hugged, but it did seem unusual from someone I’d never met before. Pregnancy can be an unpredictable gem, though, and I have learned to appreciate its various rewards over the years.

“I’m so happy to finally meet you, doctor!” she bubbled as we headed down the little corridor to my office. “Pregnancy opens so many doors,” she added, smiling at nothing in particular with her eyes.

Indeed, she spoke as much with her eyes as with her mouth as she glanced around the room like a tourist in Paris. They pointed like children in front of each picture hanging on the walls, flitting from pictures to plants and back to pictures again -excited hummingbirds. They finally came to rest on a little terracotta begging lady I’d placed on an oak table in the corner. Pennies dripped from her little bowl, mute testaments to her longevity in the office.

“Where on earth did you get the pennies?” Janice whispered, this time rolling her eyes.

I had to shrug; it was a long story.

“I Googled you before I came, of course, and all your patients seem to mention the begging bowl… Now I see why,” she added shaking her head with what I took to be admiring disbelief.

“And there’s the carving of the woman holding the child and hiding behind the leaves!” she said, excitedly pointing to the little, pot-bound Areca plant on my desk. I was beginning to feel a bit like an employee at a Disney resort.

But then she calmed a little and instructed her eyes to leave the office thermals they soared and perch on my face. I could actually feel them, heavy on my skin, their prey firmly captured. It was almost as if I should understand that they had come back to roost; that mine was the aerie they had once called home. And throughout that first visit, I thought I felt her disappointment –a father finally seen after many years away, that no longer recognizes his child. I could sense a hope for reminiscence, a need for demonstrating familiarity, sharing secrets I couldn’t possibly possess.

Indeed, I got to know her quite well in that pregnancy, and the initial expectation of acknowledgment she had worn, soon blended imperceptibly into an easy friendship. Who once were strangers, now were allies in the weeks, then days, before delivery. But there was always something in the background that I sensed she was disappointed I hadn’t recognized. Something she was now holding as a surprise; something I should have known from the start.

And then, a week before her dates predicted she should deliver, I saw her sitting in the waiting room with an older woman. She’d told me her mother was flying in for the delivery and seemed excited that I was finally going to meet her. I could even feel the italics in the word.

I saw the two of them whispering excitedly in the corner seats Janice always chose, glancing secretly at me as I greeted other patients with earlier appointments. I thought I heard them snickering once or twice, but sometimes people do that when they’re nervous.

They both stood up and glanced mischievously at each other when I approached them. Her mother was a short matronly woman with greying hair that was precariously balanced on top of her head like a silver hay-stack. Her face, though wrinkled, held a pair of familiar eyes that strained at their cage doors just waiting for liberation.

It’s an interesting thing about faces: no matter how much they change, they stay the same… Or is it just the eyes –roses by any other name…?

The waiting room by then was empty, and there was nothing to stop Denise from hugging me, followed, as if on cue, by her daughter.

“So now do you recognize my daughter?” she said, her face an imp, her eyes laughing silently as they flew towards me.

“She’s changed a bit…” I stammered, still flustered by the secret, and admittedly a little embarrassed at being old enough to deliver a patient I had already delivered so many years before…

 

 

 

Leave Me Alone

I have lived in a hospital as an on-call obstetrician on more days –and nights- than I can count over the years; hospitals were the grudging homes for me ever since medical school and the subsequent ages of specialty training that fell upon me like unbidden hats. And despite the palimpsest of colours I was forced to wear, hospitals have been the lodestars in my ever-changing world.

They weren’t all pleasant, although each beckoned with what seemed, from a distance at least, to be tempting endowments of knowledge and experience. Gifts are gifts, no matter the source, and I accepted each with gratitude, if not a little experientially-acquired caution. But although one must often stride boldly into the unknown to arrive at a destination, adaptation follows close behind. And then comes a fondness for what seemed, initially, to be strange. Chaotic. Frightening. And yet the utility of the situation breeds an eventual reconciliation. The disturbing, becomes assimilated into the quest for advantage. The hope for reward.

At least, that’s how an employee –a doctor or a nurse, especially- might rationalize the initial anxiety in a hospital: ‘short term pain for long term gain’, as the trite political aphorism would have it. But one can only wonder how the experience might strike a person who, travelling along the avenue of illness or accident, is forced to endure the unexpected and probably unwelcome distress.

There was an interesting article in an old BBC News article that questioned whether going into hospital might actually make you sick: http://www.bbc.com/news/magazine-35131678

A Dr. Harlan Krumholz at the Yale School of Medicine became interested in in the statistic that ‘about a fifth of patients who leave US hospitals are back within a month.’ At first glance, this may seem obvious and uninteresting –the original cause for their admission may not have been completely dealt with, or perhaps there were complications from it that only surfaced after their discharge. Indeed, in many countries ‘re-admission rates are taken as a measure of the quality of care a hospital provides.’ But Krumholz realized that ‘only about a third of patient readmissions were related to the original cause of hospitalization. Patients’ reasons for returning to hospital were diverse and linked to their immune systems, balance, cognitive functioning, strength, metabolism and respiratory systems.’ He felt this was an entity unto itself and called it PHS (Post Hospital Syndrome): http://www.nejm.org/doi/full/10.1056/NEJMp1212324

Basically, it assumes that hospitals unwittingly engender stress in patients by imposing disruptive and often intrusive regimes –some of which could safely be postponed or modified at night, for example. Patients already feel vulnerable and powerless in the face of illness or accident, and few would dare complain for fear of alienating those who are the providers of their badly-needed succour.

*

Vesna was not one of those. From the moment I saw her in the Emergency department with a severe and unresponsive pelvic infection, it was obvious she did not intend to relinquish control. Indeed, it was something of a diplomatic coup that one of the ER docs was able to convince her to allow an intravenous catheter to be inserted into her arm. She had to point out one of the only remaining veins –she knew her arm well- and direct his hands when he tried, unsuccessfully, to enter the tiny vessel that was hidden under a tattoo on the skin above her elbow.

It was around 2 A.M. when my resident called me about her, and just as I entered the little cubicle, someone dropped a large metal pan by the door. Before I could introduce myself she yelled at me. “I’m not gonna use one of those f– things, doc!” and she pointed to the bedpan on the floor.

The nurse looked up apologetically. “No, I’m just taking it out of the room, Vesna. It’s not for you.”

“Do I have to stay down here all night, doctor? It’s too f– noisy!” She said this all too loudly, ostensibly so her voice would be audible above the noise, but despite the outburst, despite the angry expression on her face, for a fleeting moment her eyes seemed to betray her when she glanced at me: they twinkled contritely, as if trying to excuse the behaviour of their owner.

My resident shook his head. There was apparently a bed available for her up on the ward so she’d be moved up shortly.

At hand-over rounds the next morning, the resident looked exhausted. Apparently Vesna had complained that the patient in the bed next to hers was snoring so she couldn’t sleep. And the nurses insisted on talking in the corridor whenever they walked by; the medicine carts they pushed were too noisy; or somebody kept coughing in the next room. So, Vesna demanded a sedative. That, of course, required the okay of a doctor first. And then, later, her IV stopped working –it had been inserted into a vein that would not ordinarily have been used- and the so the resident had been called to order the antibiotics to be given by some other route. The ones she needed were not available by mouth, so the only remaining way was by injection into her muscles. Vesna objected, of course, and so the resident had to go up to the ward again and explain things to her.

The hospital food was certainly not to Vesna’s liking –she said it made her sick- although, in fact, it was probably a side effect of her antibiotics. I’ve never liked institutional food either, but there seemed no end to her complaints while she was in hospital. We learned to tolerate her, of course, but I remember deciding to buy coffee for the resident staff when we discharged her.

I suppose I fell prey to the uncharitable assumption that Vesna was simply a grumpy person –someone whose circumstances had taught her to be suspicious of everything around her; someone who had learned to be tough and difficult to befriend. It was a wall she was forced to live behind -makeup she applied to protect the skin beneath.

She was supposed to come to my office for a follow-up visit a week or so after discharge but I have to admit that I wasn’t surprised when she didn’t show up for her appointment. My secretaries had actually double-booked me for her time, suspecting as much.

A few weeks later, I saw her name on my day sheet again but the woman who sat nervously in the waiting room pretending to be absorbed in a magazine was nothing like the Vesna I’d met in the hospital. This time she was dressed in slim black jeans with a frilly light blue cotton pullover. Her auburn hair was neatly combed and her ears adorned with enormous golden earrings that threatened to snag her curls every time she moved her head. When she saw me approaching, she smiled and stood up to extend her hand.

“I’m sorry I missed my last appointment, doctor,” she said, as soon as we were settled in my office, the embarrassment written in her eyes. “I had to be admitted to another hospital so I couldn’t make it…”

“The infection came back?” I said, concerned that we had discharged her too early.

She chuckled merrily at the thought and shook her head, making the earrings dodge in and out of her curls like it was a game of tag. Then the look of embarrassment returned. “Overdose.” She took a long breath and then shrugged. “Occupational hazard, I’m afraid.” She looked out of the window behind my seat for a moment. “Interesting, though…” she said slowly and deliberately, as if something had just occurred to her. “Same source, same amount… Never happened before and my boyfriend was okay so he couldn’t have cut it with bad shii…” She glanced at me and quickly corrected herself mid-word. “…ah, stuff… so I wonder how I could have overdosed.” She sat back in her chair and shrugged it off. “Maybe somebody’s trying to tell me to change my ways while I still can, eh?” She giggled like a school girl -and for a moment, she was.

Was she a victim of PHS or, in her case at least, the recipient of an opportunity? Were the two events even related, or in my rosy-eyed naiveté, am I projecting my own hopes on an otherwise indifferent world? I don’t know, of course, because I never saw Vesna again, but I’d like to think that something changed her. But for the better this time… Could PHS do that too?

I remembered the words of Emily Dickinson:

‘Hope’ is the thing with feathers that perches in the soul                                                                                    And sings the tune without the words and never stops at all.’

 

The Cleanse

Sometimes, if I have the chance, I like to review the list of referral letters before I see any patients for the day. It tells me what to expect; how to allocate the time for the consultations; whether any of them might be particularly interesting. Surprises happen. The other day, one letter about a patient caught my attention. It was short and to the point: Chronic yeast infection. Tried everything. Nothing worked!

Great. I noticed she was booked for the end of the day so there was always the chance that she wouldn’t show up. The thought sustained me all that morning.

But of course, she did.

Quite an confident looking young woman in her early thirties walked into the office accompanied by her partner. Tight jeans and a bulky grey tee shirt announced her presence on the chair, a too-loud voice from an un-makeupped face made it echo around the room.

“I’ve just done a cleanse, but I thought I’d keep the appointment anyway,” she shouted defiantly. I suppose it wasn’t technically a shout, but it made my ears vibrate nonetheless. She glanced at her partner to underline the proof of the assertion, and then they both glared at me, in case I dared to disagree.

I’d never actually knowingly talked with anybody who’d confessed to a cleanse, and to tell the truth, I was a little vague on what it entailed. I thought I’d ignore the gap, and ran my eyes over the referral paper to make sure I had the correct patient. “So…” I said, noisily unfolding the referral letter on my desk -I often start this way, to demonstrate beyond a doubt that I am in possession of their doctor’s opinion- “Your doctor tells me you’ve had a yeast inf…”

Both their eyebrows shot up in unified derision of whatever it was that the letter contained. “Oh, don’t listen to her!” the partner interrupted in a softer, angrier voice. “She had no idea what was going on with Marcie…”

“Was..?” There was hope in my tone.

“I told you I did a cleanse!” Marcie said, almost reverently. And slowly, as if she were spelling the word out in her head.

I must have looked puzzled, because she produced an overly-tolerant look on her face, and smiled at me, the only slow one in the room.

“Cleanse!” She said it so slowly she seemed to caress the sound on the way through her lips. “It’s a way of ridding your body of its built-up toxins.” When my expression didn’t change, she continued after a maudlin sigh that her partner obediantly repeated. “The colon contains all sorts of toxins that build up over the years and stop the body from fighting off things like yeasts…” She rolled her eyes at the need to explain it to a specialist like me.

“So it worked?” I had meant it as a tentative acceptance of her information at first, but by the time the sound made it out of my mouth it had turned upwards into a question.

Her partner, Grace, seemed offended. “Of course it worked!” she said indignantly. “We both tried it,” she added proudly and smiled broadly at Marcie.

“The theory makes sense, when you think about it,” Marcie bellowed at the picture on the wall behind me. I could almost feel it rattle.

“Oh? Why’s that?” I was trying to be polite –there’s absolutely no evidence for its benefit in the standard medical literature. In fact the fecal microbiome is important for proper immune functioning- but I’m afraid that, once again, my words came out suggesting I was doubtful at best.

Her eyes narrowed and her face tightened –both faces tightened, actually- and she straightened her tee shirt as shocked as if I had sworn in church.

“There’s evidence,” she said and crossed her arms defiantly, satisfied that she had bested me.

I tried to look neutral –neither judging, nor rejecting her statement. “I…” It was all I could get out before she launched into a tirade.

“You doctors,” she roared, somehow managing to make ‘doctors’ sound like a disease. “You restrict your information to narrow little unreadable journals. You never read anything that disagrees with what you already think you know… Or, if you happen on it, you never read the whole thing…” I used the opportunity between her breaths to think about that one. Maybe she had something there… Confirmation bias is something we all struggle with.

She quickly turned to Grace who nodded in support. “There was a website I saw just last week that proves it…” She hesitated momentarily when I picked up a pen to write it down. In fact, she lowered her voice to encourage me.  It’s  http://www.tylervigen.com/

And then she laboriously spelled out each letter, including the forward slashes -in case I got them backwards, I suppose. “I just looked at a couple of them, but they were stuff you’d never find in your medical journals –and all statistically proven.”

I must have raised my eyebrows, because she quoted an example. “Did you know, for example, that the per capita consumption of chicken in the USA is correlated with the total USA crude oil imports? Don’t you find that strange? I mean stuff like that is proven, but they don’t want us to know about it.” She crossed her arms again.

I just concentrated on keeping my expression neutral, all the while trying to figure out how oil imports had anything to do with cleansing.

“And what about the margarine one, Marcie?” Grace added to overwhelm me with evidence.

Marcie nodded, somewhat annoyed she had chosen the chicken example, I thought. “Anyway, I’m betting it’s the same with colon toxins!”

And with that, they both rose in unison and thanked me for listening, all the while glancing furtively at each other. “We’ll come back if it doesn’t work out, though,” Marcie added as a sop to my dignity as she left the room.

As for my part, I felt disappointment at my inability to defend myself. Sometimes naivete is attractive, but usually it is just annoying. Incapacitating…

Out of curiosity, I looked up the website that night. Marcie must have skipped over the title, though -it was called Spurious Correlations. Or maybe she read it as ‘Curious’ Correlations… Anyway, I managed to find an article on it in the BBC News Magazine  http://www.bbc.co.uk/news/magazine-27537142

Somehow, I think they both missed the point of the website -written by a student at Harvard- that correlation does not equal causation. But maybe it wouldn’t have mattered: I didn’t read the whole thing…

 

 

 

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