Russell

Our family cat Russell died this week.  He was eighteen years old.

My brother and I adopted Rus from a city animal shelter in the aftermath of the May 3rd 1999 tornado in Oklahoma City.  At the time, we were 9 and 12 years old, respectively.  Russ was three weeks old.  Over the ensuing two decades, we three boys grew up together.

When we adopted him, Rus weighed less than a pound and didn’t know how to drink water from a bowl.  My brother and I took turns dipping our fingers in water and letting Rus lick the drops.  For the remainder of his life, he “drank” by putting his paws in the water bowl and then licking them dry.  We build giant Lego houses for him in our bedroom.  We dressed him up as the Pope for one Halloween.  He was the reliable constant during our turbulent adolescent years.  He was fearless, intelligent, and fiercely loyal to his two boys.  He once chased a neighborhood kid into a bathroom because the kid had pantomimed punching my brother.  He slept in our beds at night, keeping some sort of internal schedule by which he rotated between my brother and me.  His favorite toys were rabbit foot tchotchkes.  We trained him to walk on a leash, and he loved going for long explorations outside.  He was the third son of our family.  We nicknamed him “Tubbs.”

By the time I was in medical school, Rus had developed diabetes.  Because he was otherwise healthy, we chose to treat him with insulin, and he thrived for another four wonderful years.  This week, the inexorable hand of age caught up with him, and he passed peacefully of kidney failure.  He fell asleep for the last time on his favorite blanket: a red Christmas tree skirt with white fringe.

It is hard to believe that you’re not here anymore, Russell; you were a constant for so many years.  I know you loved us as much as we loved you.  Thank you for everything.

I’ll miss you, Tubbs.

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Hold a Child

I lost a kid in the ER today.  Only the second one in my career.  Nothing in medicine or in life is more devastating.

I wept as I drove home.  I wept for the girl.  I wept for her parents.  I wept for a fucked up universe in which children die.

Whoever you are, wherever you live or work, whatever your family situation, hold a child today.  Your son or daughter, sullen teen or ebullient toddler, little brother or sister, baby niece or nephew: it doesn’t matter.  If there exists a child in your life who means something to you, tell them so.  Wrap them in your arms, hug them tightly, sit in the sunlight with them.  Say you love them.

Please.  Hold them.

ICU – Inhumane Care Unit

Patients go the ICU to die.  And the deaths they die are truly horrific.  We as doctors and we as society must rethink goals of medicine and goals of life in the modern era.  When we can keep patients “alive” indefinitely on machines, should we?

–♦–

Patient 1.  Her name was Charlotte.  She was an award-winning landscaper and lifelong gardener from Georgia.  Well into her eighties, she had a gentle southern drawl, piercing blue eyes, ramrod straight posture, and a sincere smile.  She loved to read biographies.  Her favorite flower was the British lady orchid.  Prior to developing colon cancer, she had only ever had hypothyroidism; no other medical problems.  When she had originally been diagnosed with cancer 6 months ago, she resisted any treatments, arguing that she had lived a solid life and wished to spend her remaining time outside, in the gardens, where she had lived her entire life.  Her grown children, unable to cope with the prospect of losing their mother, convinced her to undergo chemo, then radiation, and finally surgery.  She was in and out of the hospital environment for months, and I cared for her during her final month–which she spent exclusively in the ICU.  Her surgery went poorly, and she developed respiratory failure, requiring her to be intubated.  No matter what we tried, we could not wean her from the ventilator; her lungs had simply become too weak to function on their own.  This woman, who had spent eight decades breathing deeply the lush fragrances of her parks and gardens, spent her last moments with sterilized oxygen being forced into her lungs by a machine.  On the day before she died, she wrote something on a piece of paper and handed it to me.  It read, “I want to go outside.”  I looked back into her brilliant blue eyes, and nodded.  It took bribery, threats, pleas with her family, and calls to the hospital chief medical officer, but we managed to get her transferred to a chair and wheeled to a private courtyard in the back of the hospital.  She still had the breathing tube in place, and her oxygen levels were continuing to drop, but she could smell the fresh rain-soaked earth and pine needles.  I’ll never forget her face.  Ineffable.  Tears rolled down her cheeks as she squeezed my hand.  She stayed outside until nightfall, until her oxygen levels had fallen so far that she was barely conscious.  We brought her back to the ICU, and she died within an hour.  As I watched her breaths come to an end, I felt such anger at her medical course.  All she had wanted was to be in her gardens at home.  Instead, she got six months of hospitals and one, final evening in a dingy hospital courtyard.

–♦–

Patient 2.  Her name was Margaret.  A 65-year-old smoker and obese diabetic, she predictably suffered a massive heart attack, and during the attempts to repair the arteries of her heart, she sustained a stroke–her fourth in the past year.  Her brain was devastated.  For a week, she lay intubated and sedated in the ICU; and even after she recovered enough neural activity for the breathing tube to be removed, she remained delirious and unable to form complete sentences.  She had wires going into her wrist arteries for continual blood pressure monitoring; she had lines going into the veins in her neck and under her collarbones to measure the pressures in her heart and lungs; she had urinary and fecal catheters placed; she had a feeding tube going into her nose; and she required a face mask for continual oxygen delivery.  Her skin was sallow and sunken, a patchwork of bruises and breakdown from repeated needle sticks for blood labs.  Her adult children watched for days as their mother tossed and turned in her bed and periodically cried out unintelligible monosyllables.  Physically and emotionally exhausted, the family left one afternoon for a quick respite, and in that hour of their absence, their mother died.  Alone, with tubing and IVs sticking in and out of every orifice of her body.  Her last words were a garbled childish plea for “more ginger ale.”  I stood at the foot of the bed and observed as her heart rate on the overhead monitor slowed from 50 to 30 to 10 to 5 to 0–a flat line.  Her head fell slightly to the side, and her breathing, which for days had been labored and coarse, finally ceased.  I placed my stethoscope on her chest.  Silence.

–♦–

These two women died within 24 hours of each other.  Driving home that evening after my shift, I compared them to the woman described in a BBC article who had been diagnosed with terminal cancer and who had chosen to spend the last year of her life not receiving chemotherapy but instead traveling widely throughout the US.  During her travels, she fulfilled many of her personal dreams and wishes, and her final days were filled with memories and friendships and kindness, not with medications and laboratory testing and invasive procedures.  She died well.

I failed my patients.  The US healthcare system, with its blinkered focus on life saving rather than life enrichening, failed them.  Surely they and their families would have preferred a few peaceful and meaningful days, or even hours, at home over their protracted weeks of ICU hell.  Reflecting on these two cases has caused me to reconsider my own end-of-life wishes and those of my patients.  Above all else, I do not want to die in a hospital.  I’d rather live my death fully than die and be artificially sustained in some travesty of “life.”

Elegy for Stephanie

Late at night, silence and snowflakes fill corners of windowpanes.  Phone call.
On your sled, hit by a truck.  Time and breath slow to a crawl.
Hearing but not understanding, I sit on the couch in the darkness.
Fuck god or infinite space, this is supposed to be justice?
There are no tears
for pain beyond a certain deep.
This I discover
on the day you sleep.

Brilliant, industrious, brave, and compassionate, you were my best friend.
Greater than I were you, though: seeking our world to mend.
Founder of medical clinics, staunch steward of Earth, leader.  You cared,
Never gave up on your dreams, accomplishing more than most dare.
A passing light,
what did you leave
but kindness, health,
and joie de vivre?

Springtime has come, but within my heart, snow remains. How do I move on?
Formerly, I would ask you.  Where do I turn with you gone?
Distance and wisdom will show me one day that the truth is plain: you stayed
Endless, immortal, and here, alive in the lives you have changed.
So, half as good as thou
I’ll try to be,
For I love you,
Stephanie.

Martha

The last time I saw Martha was on a blustery November afternoon, when her eighty-year-old emaciated body lay bedridden, wheezing, and curled in the fetal position, a tiny sickly lump of human flesh with wiry unwashed grey hair, eyes squeezed tightly shut, and a wrinkled face contorted in pain or despair or both.  A few days later, she died, and a then second-year medical student was forced to cope with the first real loss in his life.

Martha and I had first met four years earlier when, during a religious period in my life, I responded to a church bulletin asking for volunteers to visit this elderly, widowed German lady who was confined to nursing care and who could not attend worship services.  Nearly every Saturday afternoon thereafter, she and I would meet for an hour of snacks and pleasant conversation, and I grew to know her well.  In the late 1940s, after having lost her entire family to Nazi persecution, she had immigrated to the U.S. as the new bride of a dashing young Air Force captain.  Their marriage was long and happy, and after her husband died, she remained fiercely patriotic, decorating her nursing home bedroom with American flags, pictures of the Statue of Liberty, and “God Bless the USA” plaques.  Her two adult children, unfortunately, had little to do with her aside from managing her finances; and so, my weekly visits served as the key highlights of Martha’s last years of life.

On that chilly autumn day when I sat by her bedside for what would become the final occasion, thin nasal cannulae snaked out from her nostrils and across the grimy, long-unwashed sheets to a bedside oxygen machine whose noisy gurgling disturbed the room’s otherwise funereal silence.  Martha lived in a cheap, disreputable nursing facility; her small, poorly lit, dank apartment reminded me of a dungeon.  She had wrapped herself into her favorite blanket, a tattered fleece quilt with a pattern of little red cardinals hopping along tree branches against a background of forest green leaves.  Her bed had a stout wooden frame surmounted by an even stouter headboard that had built-in shelves and drawers decorated with innumerable USA-themed memorabilia, tiny plastic biblical figurines, and stacks of old greeting cards.  The giant structure engulfed Martha’s frail, dying body, and the mattress reeked of stale urine.  “Martha…it’s me. Martha, can you hear me?” I whispered loudly, cognizant of her poor hearing.  She responded to my greeting by turning a bleary-eyed ashen face to me, muttering something incoherent, and falling immediately back into a stupor.  She died four days later, before my next weekly visit.

For some time after Martha’s death, I felt haunted by our last moment together and how it hadn’t ended in cinematic fashion, with the dying character imparting a brilliant, life-altering message to the captivated audience.  According to popular lore, Martha should have awakened, turned lucid eyes to me one last time, and whispered some deep philosophical advice as her parting words.  Instead, she gave me a vacant, expressionless stare and an unintelligible mumble.  I felt as though she and I had in some way failed because we did not generate the necessary amount of profundity and significance during that final encounter.  This sense of failure threatened to eclipse the many fond memories I held from our preceding four years of friendship.  I kept wondering, was all of our time together meaningless simply because the last moments before death seemed so unsatisfactorily unremarkable?

The answer, I have eventually realized, is no.  Do not overemphasize the importance of “last words.”  Obsessing over a loved one’s departing words simply adds undue stress to an already tense moment.  The surviving kith and kin hover ’round their dying friend or family member and scour their final breaths for meaning, coming away disappointed and distraught if they uncover no timeless, breathtaking, everlasting truths.  Fixation on the perimortem period can cause us to overlook the day-to-day words and experiences of life, believing them to hold less importance than the words spoken on the deathbed.  This thinking is fallacy.  The opportunities for gaining wisdom, the chances for finding meaning and wonder and remembrance, come to us daily in our interactions with others.  Life is simply too rich a soil to bear fruit only on the eve of the harvest; instead, we should search daily for new growth.

I kept waiting for Martha to awaken and impart to me some penetrating, soul-shaking, sagacious insight that would shape evermore the direction of my destiny.  She didn’t.  She had already spoken those words, in the countless afternoons we spent talking with one another; in the shaky, scribbled lines of the letters she constantly mailed to me; and in the laughter we shared over hamburger and onion pizza–her favorite.  Her memory should not be relegated to a single, cold, November day out of the hundreds of beautiful, sun-filled, happy ones we enjoyed.  Her brilliance, her beauty, and her wisdom, they were found in her life, not in her death.