Sunday, May 21, 2017

Sunday Poem


So many smiles are gaping wounds
Deftly slashed into faces.
The spaces between what we mean
And how we hope to seem
Are the distances between parted lips.
Our false visages belie skittishness
And those shameful resistances
That compel us to embellish
With garish grins and rictal expressions.
Curtains will drop, facades like a solar eclipse

Your eyes have never lied.
A glinting of light
That breaks through the crinkled cracks in the corners of your eyes,
Lingers, then slowly fades without a fight
Skin smoothing to stillness like snack wrappers uncrumpling on the ground
A smile is an absence of flesh,
An aperture always in flux.
It is a wound, it is not a wound.
It is a mask of obfuscation, it is a life force that erupts

Wounds reveal or conceal
A smile can be real
A smile ought to be real



A few weeks ago I was awakened by a 2 a.m. call from the ED regarding a case of pneumoperitoneum.  I barely recall the specifics of the conversation, but I vaguely remember snippets of phrases, words that light the fires and compel immediate action: "free air, tender all over, hypotension".  I donned some old scrubs and quickly drove in to the hospital.

The patient wasn't much older than me.  He looked healthy, had a robust build.  No other medical problems.  But his vitals were perilously unstable.  Heart rate 120's.  Blood pressure 70 systolic despite several liters of fluid.  The CT showed air under the diaphragm and inflammatory changes in the pelvis consistent with acute perforated diverticulitis.  And he certainly had peritonitis on exam.  I didn't have much of a choice.  He needed an emergency operation.

An hour later I had washed him out, resected the colon with the gaping hole, and fashioned an end colostomy.  Primary anastomosis was not a consideration given the degree of contamination and pressor sustained systolics in the 80's.  We call it the Hartmann's procedure; an old school operation that is not used as often as it once was.  We found that it isn't always so easy to reverse a colostomy (70% success rate) and the procedure itself can result in significant morbidity.  Nowadays we find we can treat many cases of perforated diverticulitis medically with antibiotics alone.  Primary anastomosis is performed even on unprepped bowel in cases of mild contamination and hemodynamic stability.  Sometimes you can even get away with just laparoscopically washing out the pelvis, placing some drains, and bringing the patient back later on, for definitive one stage surgery, once the sepsis clears.  Lots of options.  But there is still a role for the Hartmann's procedure.  Four or five times a year I find myself resorting to it, even still.

The guy did well.  Got better, cleared the sepsis, started eating.  Right before discharge, I received a call from the case manager.  She told me she would not be able to arrange for a wound vac or home health care assistance, as I had requested, because the patient lacked any health insurance.

I must say, I have received far fewer phone calls of this nature since 2008.  Obamacare (in all its iterations, not just the exchanges but the Medicaid expansion as well) has certainly reduced the number of "self pay" cases I have seen.   And this simply makes statistical sense.  The number of uninsured since the passage of the ACA has fallen from 50 million to around 20 million (which is still embarrassingly too high!)

I told them to discharge the guy home with wound care and colostomy instructions and some bags of extra dressing supplies and to see me in the office in a week.  There isn't much else you can do in this situation.

The first thing he asked me in the office was, as expected: "doc, when can you put me back together again?"  Well, it's complicated, I told him.  I had been dreading this moment because it inevitably casts me in the role of villain--- the predatory quid pro quo shyster who financializes the doctor/patient relationship.  You gotta get some insurance, man, I told him.  I do plenty of uncompensated emergency surgery.  I'll be damned if I willingly perform complex elective surgeries without the guarantee I will be remunerated for my services.  In addition, it isn't just about me--- there is an anesthesiologist and the hospital facility that will want to bill for services.  I could do the procedure gratis, but he would still get a bill for 20 grand or more.

And the guy was not some street urchin or derelict.  He owned his own landscaping business.  He worked 60 or so hours a week.  He was married and had children.  By all metrics, he was an upstanding, contributory member of his community.  But he didn't have any health insurance.  And the reason is because he was able to choose not to have health insurance.

There is a mandate built into Obamacare, but it is a fairly weak one.  The cost of not having insurance often was cheaper than the cost of purchasing a plan on the open market.  Furthermore, the Trump administration, via executive orders, has enacted changes at the IRS that make it easier for people to get away with not paying anything at all.

Outside of government-run, single payer health care systems like the NHS in the UK (i.e., the rest of Western Europe and many countries in Asia), everything hinges on universal participation.  Universal coverage directly correlates with universal participation.  If the pool of patients buying health insurance are only the sick, the critically ill, and those with chronic illnesses, a health care fund will need to pump up premiums in order to ensure financial viability.  You need the young and the healthy on those health care roles in order to justify enforcement of "community rating".

Sadly, I see us starting to slip back into old ways.  AHCA probably has no chance of passing in the Senate.  But there are other ways of eroding the incremental reform brought to Americans under the imperfect auspices of Obamacare.  Executive orders to "decrease regulations" are one such seemingly anodyne way of accomplishing this.  Simple administrative incompetence and mismanagement is another way to sow doubt in the minds of private insurance companies and impel them to withdraw from markets.

So yeah, we can go back to those "good old days" when 50 million Americans lacked health insurance, when medical bills were the number cause of personal bankruptcy, when a person could be denied reasonably priced insurance due to pre-existing conditions.  It would be just as shameful and inexplicable in the future as it has always been.  The wealthiest, most hegemonic nation in the history of the world, unable to muster the means to care for its own citizens when illness strikes.

Wednesday, May 10, 2017

Wednesday Poem


For Easter dinner I sat next to a Buddhist who claimed to have no thoughts
What do you mean “no thoughts”? I asked him
Where did they go?
What happens instead
On the inside and what fills your head?
He only smiled at me.  
He smiled and nodded his slab of a head

But I was serious.  How is that done?
He looked at me like I was dumb

Later on, I watched him blankly chewing a piece of cake
An urge to smash his face into the plate
How do you fill the time---the space---between the bites?
How do you imbue a mind with pure silence?
It seemed an act of violence----
A forfeiture, at best a bluff.
Not even a whisper or a cough
Like church when we were asked to bow our heads and pray
And instead of a higher communion I could hear
Only the creaking of pews and the scuffling of shoes
The birds twittering outside, the wail of a passing siren.
Instead of warm peace I felt only cold fear.
The whirling tumult of my inside world gone speechless, silent.
Nothing to say, haltingly austere
When I most wanted to speak, when I most wanted to hear.


Sunday, May 7, 2017

Sunday Poem

Count to Ten

There are things I could do
But none of them will help you
I could excise that tumor with my knife
But it will not save your life.
It’s spread; you’re infested,
Surgery should not have been suggested.

I was called because they always call.
It is up to me to say things like “infested”
To tell you what the others cannot.
They defer to my judgment
Someone must do what cannot be said:
Snatch the terminus of an unwinding thread.

Now let us close the door
And dim the lights.
I’m going to take a seat right here.
Close our eyes and count to ten
And then count again

That was twenty from ten
Shall we carve out another block of time
Like initials into an old oak, a forgotten forest from youth?
Will we get closer to the truth?
What was her last name again?

The IV alarms
Tubing occluded
Sir, you must straighten your arm
Let us count one more time
I know it is hard
You need not speak, just listen to my voice:
One, two, three…
When I get to ten
You can open your eyes
Will I still be here?
Will the lights be on?
Will you still be trapped between dusk and dawn?


Tuesday, May 2, 2017

Noble Hearts Crack

Deep in the trenches of childhood memories I recall always being told I would be a doctor.  Birthday cards addressed to "Dr J", surgical scrubs as pajamas, a heavy dose of science-themed gifts (microscopes, insect dissection kits and the like).  The message was undeniably clear.  You will be a doctor.  You, child with the good grades, the quicksilver Jeopardy answers shall become a physician, the highest of the high, the one true and noble landing point for a child of your talents and gifts.  When you are a child you don't even think to question it.  I was a typical first born boy who aimed to please, to make my family proud.  At all the Easter, Thanksgiving, Christmas family gatherings I'd be peppered with questions (what kind of doctor? kids or adults?  surgery or medicine?) I couldn't even begin to try to answer.

 In retrospect it probably wasn't fair.  To thrust that sort of expectation and pressure upon a young boy.  But none of it was of malicious intent.  I know they were all proud of me.  My mom was a Child Life specialist in a hospital and my aunt worked as an ICU nurse.  For them, the all-powerful doctor represented the pinnacle of achievement.   I understand it all, of course.  I may not have chosen my path, it may have been thrust upon me, but no matter.  After my parents divorced, my dad moved to Arizona and started a new family.  We grew up in relative poverty.  We were on welfare for a time.  I was a latch key kid until I could drive.  Absent the realm of hunger and true squalor, you never realize relative paucity of material well being until you get older.  I may have represented something for the older women of my family, something beyond the hum-drum mediocrity they had known.  (What they didn't realize was that life can be hum-drum and drab and mediocre no matter your station, but that's another topic...)

A couple weeks ago I saw Hamlet again on stage.  It is a work I have always returned to over the years.  I'm a dork about Hamlet.  I memorized the famous "To be or not to be" soliloquy when I was 17 and haven't forgotten it since.  (From time to time, usually in the car, I'll randomly spout it out to no one, and usually, for some strange reason, end up veering into a bizarro Australo-Irish brogue by mid-speech)  Hamlet speaks to me, as the wise asses say.  The melancholic, brooding youth paralyzed by fear and time and inaction.  Knowing there is but one chance along the path of time, that every decision we make is fraught with loss, life as a series of paths untread.

The older I get the more Hamlet stops "speaking to me" and simply informs me of who I am.  It isn't a conversation, it's "here you are, take it or leave it".  And that's fine.  I keep coming back to it so there must be some good to be had.

Hamlet, as per Harold Bloom, is the only character in Shakespeare we can conceive writing any of the actual plays of Shakespeare.  He is human in a way that most flesh and blood, most of the quick can only hope to aspire to.  He speaks and acts his way into existence.  He is the sort of character that, as Holden Caulfield says, we wish were a friend of ours, someone we could call up on the phone and talk when we wanted or needed to.  He has been my friend for an awful long time.   Sad as that is to say.  (I never "mixed" well).

The transformation that occurs in Hamlet from the time he sees his father's ghost to the final duel with Laertes at Elsinore is really quite astounding.  I never noticed it in younger days.  We too easily deposit Hamlet into the bin of "moody adolescent anti-heroes" without paying attention to what happens to the young Dane, the maturation that erupts forth, the flesh and blood human who rises from the pages by Act 5.  Too often we over-focus on the woe-is-me ninny in the first couple of acts who yearns that his "too, too solid flesh would thaw and melt itself into a dew" without recognizing the new man emerging at the end who stoically accepts the dictum of "let it all be".

In the beginning Hamlet is wracked by indecision and guilt and rage.  His father, the noble warrior King Hamlet, has been murdered, it is revealed, by the jealous scheming Uncle Claudius, who then seduces the grieving widow Gertrude; she, "with such dexterity to incestuous sheets", brings the mourning son of a king shame beyond description.  The ghost appears to Hamlet, reveals all and demands vengeance.  It is incumbent upon Hamlet alone to right the wrongs of a foul, foul murder.  None of these events are caused by any act or idea of Hamlet himself.  He is appropriated by filial duty, obligation, social and cultural pressure and urged into action.  He must exact revenge for his murder, but in doing so, risk losing his soul.  His manhood hangs in the balance.  Hamlet swears in writing "adieu, adieu, remember me!" as his ghost father passes into oblivion.  And then we get 3 acts of  equivocation.  To be or not to be.  The anguish that an actor could weep over fictional Hecuba with such volcanic emotional range while Hamlet himself is frozen despite having the "motive and cue for passion" to carry out his dead father's final plea.

In the end he never initiates, just reacts to events as they occur.  He forces Claudius to ignite the fuse with endless schemes and walks into traps willingly.  He stops giving a damn about what others might expect.  He stops trying to manifest the ideal foisted upon him by the Other.   He finds himself in predicaments of the moment and begins to face them with a newfound dignity.  The transformation is completed when he holds the skull of Yorick aloft:
Alas, poor Yorick! I knew him, Horatio: a fellow 
of infinite jest, of most excellent fancy: he hath 
borne me on his back a thousand times; and now, how 
abhorred in my imagination it is! my gorge rims at 
it. Here hung those lips that I have kissed I know 
not how oft. Where be your gibes now? your 
gambols? your songs? your flashes of merriment, 
that were wont to set the table on a roar? Not one 
now, to mock your own grinning? quite chap-fallen?

Memento mori.  All shall pass into dust.  The clay of the remains of even Alexander the Great could be used to plug up a hole in a beer barrel.  All pass into nothingness.  The cat will mew and dog will have his day.  Death becomes a tangible inevitability for the young Dane, not something abstract to theatrically fret and shed tears over.  Life will go on until it stops; whether we act or abstain, whether we lash out or hide behind ramparts, the end will come, far into the future or prematurely.  Life will end.  The path we have trod cannot be retraced and we find that the reasons for our steps assume less and less importance as the years elapse.  All reasons are forgotten in time.  There is only the moment of the eternally recurrent present in which you reside, briefly, before you die.

We find ourselves in places chosen by others.  We never had a chance to weigh in.  But a moment arrives and we make the best of it.  We choose to be, we embrace our fate with indifference, with what Harold Bloom calls a "noble disinterestedness".  By the time Hamlet kills Claudius, he has forgotten all about the ghost of his father.  The events that have driven him to the precipice no longer matter.  He has transcended the boy, become a man, by turning away from filial and social expectation.  His duty is to himself.  Once his fate has been sealed by the sharp tip of Laertes' rapier, he acts, fully in control of himself, for himself.

I still have those envelopes addressed to "Dr J" from years ago.  I keep them in a chest in the attic.  They remain a part of who I was but no longer impact the choices I make, no longer feel woven into my being.  I make my rounds not for those lost whispered promises from my youth, but for the sick, for mine own ends.  I have become the compilation of the days I have lived.  No longer am I an animated projection of the dreams of others.  And each dawn will bring the opportunity to add fresh material to the narrative of a life.

Hamlet walks knowingly into the final trap, despite Horatio's protestations:
We defy augury. There’s a special providence in the fall of a sparrow. If it be now, ’tis not to come. If it be not to come, it will be now. If it be not now, yet it will come—the readiness is all. Since no man of aught he leaves knows, what is ’t to leave betimes? Let be.
Yes, let be.  We shall be ready.  Hamlet learns that the question of "to be or not to be" is no longer a question about living versus dying; at some point along a lifespan it becomes about taking ownership of your own being.  Let it all come rumbling down from the mountain tops and let us rejoice in our transient freedom of the now, to choose to be our own best version of ourselves. Doctor, husband, father, citizen, son....