Patient Interactions

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My favorite part of medicine is interacting with patients. My second favorite part is fitting the puzzle together, piecing all of the various bits of data from history, exam, labs and the literature to form a coherent image. For some providers, I suppose, that is the most exciting part. Dr. House comes to mind as an example of that disease oriented provider. Others are all about the procedures. They just enjoy getting hands on the patients, physically manipulating the diseased part, and providing healing that way. I suppose that category would include most surgeons. I find, however, that most patient encounters do not require much puzzling. Most are actually quite straightforward. Hardly of my patient encounters require procedures, although they are fun when they happen. However, every patient encounter includes an encounter with another human being. Sometimes these encounters are memorable, sometimes not. Sometimes they are fun, and sometimes they are not. Sometimes there is good rapport, and sometimes it seems that you are speaking totally different languages. Regardless, the encounter is always an encounter with the ineffable other of a human being who is not myself.

Tacoma is known for having a very high percentage of Asian populations. In fact, South Tacoma Way, one of my favorite strips for Asian cuisine, is informally called “South Korea Way.” Street signs are even labeled in Korean. Being a Special Forces soldier, my training includes a foreign language, which, in my case, is Korean. I would not say that I am fluent. I can order food, exchange pleasantries, and maybe chat a little bit about C. S. Lewis’ book “The Four Loves,” (I memorized a good deal of vocabulary for that book when I was preparing for my Korean speaking and listening test). It is not, however, to allow me to hold a conversation with ease with a native Korean speaker.

Several of my patients over the last two weeks were older Korean ladies, wives of Korean war veterans. I usually enjoy chatting with them a little, enough to say “Hello, how are you doing, where does it hurt?” One patient, in particular, was a very sad looking Korean lady who complained of fatigue, tiredness, pain, and heartburn. We talked with her for quite some time trying to come up with a list of her complaints and prioritize them, but she was a very listless and haphazard historian and she complained of confusion. Finally I asked, in Korean, “Sunsengnim (term of respect), do you get confused talking in Korean?” Her eyes widened and she repeated my question back to me in more correct vocabulary. I asked about her Korean friends, and she shook her head sadly.

“I not trusting Hanguk (Korean) peoples, they not sharing feeling. They nod yes, yes, when talk but later they like this behind you back,” she made a blabbing gesture with her hand. I asked if she had any American friends and she said, “I no likey Miguk (Americans) either. They just talking talking saying whatever come in they head. I not like that.”

While the doctor typed his note we chatted about this and that, and she slowly became more and more at ease. It was more “konglish” than either Korean or English. I learned that she was very lonely, and almost always sad. Her house had been broken into (she lived alone) and she just felt nervous and unsafe. She gave me an impromptu lesson in Korean language, history and folklore, and explained why the Korean number 4 “sa” is considered unlucky. I very much doubt we were able to provide any lasting relief for her symptoms, as I strongly suspect most of them had a behavioral or social health basis. She was a sad, lonely old lady, and she needed a friend and a hug more than she needed pain medications, but her fears and isolation kept her from those, so pain medication was all she could understand. However, she seemed to be put at ease by my broken attempts to speak and listen to her in her own language, and there was even something like a half ghost of a smile on her face when we shook hands goodbye.

Was that a good interaction? A positive one? I would not classify it as such, objectively. We learned very little to point our way to a treatment plan, and I do not have much hope that her symptoms will ever be resolved strictly by medicine. However, the attempt to reach out to her was just a little less negative than it otherwise would have been, and I think therefore it was more than worth it.

Another Korean lady the same day came in for coughing and post nasal drip, but she refused to believe that she had allergies. She was very upset at not being able to see her regular doctor (who was on maternity leave) and she denied ever having taken allergy medicine that her doctor had prescribed her. “I throw that medicine away, because I not like takey the pills!” It was hard not to laugh. She was about four feet tall and about two inches in diameter and bound and determined that something was wrong with her, because she could not stop coughing or sneezing, but it was NOT allergies! Bless her heart!

No amount of cajoling in English or Korean could convince her that, yes, in fact she very likely did have allergies, and it was perfectly normal and treatable. We tried to get her to promise at least to try the allergy medicine. When she would not we tried to sneak it into her medicine list without telling her what it was for! We said, “Oh, that’s to make you sniffles stop,” which was true, but she would have none of it. “I not takey the pills.”

Finally when the visit was over she stood up and said, “Thisa better working. You not makey me better I go to Korean doctor!” I felt like saying, “Fine! Go to a Korean doctor! What sense does it make to come to a western doctor and then refuse to take western medicines?” She never got angry, she just laughed at us like we were too ridiculous for believing that she was so weak that things like allergies and pills could apply to her. She did, however, tell us most emphatically that kimchi was going to keep us young and healthy and that I was going to live longer than the doctor because I loved kimchi and he “only likey the pizza!” He had never said that he didn’t like kimchi, he simply had never tried it, but in her mind that lumped him in with all the other pizza eating Miguks!

I cannot get angry at patients like that. I love their eccentricity, and I respect their autonomy. God bless them, if they want to grow old and cantankerous and get their kicks out of making fun of western medicine, more power to them. I hope I have enough spark left in me when I am old to be grumpy and funny like that.

The patients I feel sorry for are like the 60 year old man who came in for a regular checkup. In the course of the interview he mentioned having a new feeling of shortness of breath whenever he walked up hill. This prompted a deeper interview, a physical exam, an EKG, and the end result was that he was going home with a bottle of nitro, a bottle of baby aspirin, and a follow up appointment for an exercise stress test. As the appointment progressed and the diagnosis took shape, I could see the growing possibility reflected in his face and posture. His shoulders sank, more and more, his face became more and more bewildered, distant, afraid. It was a relief when the doctor finally said the word: “Heart disease.”

“We need to make sure you don’t have heart disease.” Amazing how we all knew that was what we were talking about, but we were reluctant to say it.

“Are you doing okay?” I asked.

He looked up at me. “I guess. It’s just I have a lot going on at home. I have family troubles, and my dad is not doing too well, and now this.”

“A hell of a thing,” I said.

“A hell of a thing” He agreed. His dad’s brothers had died in their early sixties of heart attacks. His face fell even further when he found that he could not work out until after the stress test, because of the risk of having another incident. “I can’t go to the gym?” His build spoke for itself. Despite his slight beer gut, his shoulders and arms were thick and powerful. He had been lifting his entire life. Now he would have to give it up, perhaps for a very long time, perhaps forever. Not only that, but because Viagra reacts synergistically with nitroglycerin, and can cause a catastrophic drop in blood pressure, he could not take Viagra until after the stress test, when we would have a better plan.

He looked at the doctor. He looked at me. “No weight lifting? And now you tell me no sex? Doc, what’s the point?”

At times like this you feel guilty about the clock, ticking away, reminding us that his appointment was only supposed to last twenty minutes, and that is long since up. How do you kick him out the door so the next patient can come in and tell us all about his acne and how it is affecting his social life?

I might be getting old, or maybe my parents were just poor and backwards (poor they certainly were) but it never would have occurred to them to take us to the doctor for acne, especially not acne so mild as to be invisible under long, thick black hair. There were a dozen or so cystic comadones around the hairline on his forehead, and another dozen along his hairline in the back. This rates a trip to the doctor?

And yet, it is a big deal to him. It never was to me, (I could have cared less for popularity at that age) and that may make it difficult to relate. One hopes that he grows to be a little less concerned about such things as he gets older and gains perspective, but he is not older. He is a teenager. This is where he is, this is important, and in its own way it is as devastating to him as a tumor would be to me. Why should I allow my age and experience to deprive me of empathy for his lack of age and experience? Would not that be shallow mindedness without even the excuse of youth and ignorance? And how difficult is it to prescribe some erythromycin face wash and an exfoliant? We sympathize with many, many older patients who are just as silly, and with less excuse. Certainly in my life many, many older and wiser people have put up with my ignorance and silliness. Shall I refuse to do the same for him?

So I resisted the urge to write him a script for “soap and water” or “a nice cup of man the heck up!” and provided one for face wash instead. I wish him well at his next high school social function. He was a nice kid, after all.

In reviewing these patient encounters I find it very difficult to classify them as “positive” or “negative.” That is more or less to be expected. Any encounter with another human being is essentially an encounter with the unknown. We do not hear the other perfectly, we do not communicate perfectly. The best I think we may expect of ourselves is the continual effort to be present; beyond all filters, preconceptions, contexts and languages, present for the other to be the other. Is it possible? Probably not. It is a worthy effort, I think, for only thus is any real meeting possible between humans. So, in any encounter, there is always more that could have been achieved, or less that could have been said badly, or some aspect that could have been improved. It is never perfect. The mistake, I think, is to try to reduce it to a technique. Technique is a tool, body language, active listening, participatory conversation techniques, or what have you. The essence, however, is goodwill towards the other. It is goodwill that will overcome all barriers, and hopefully shine through our clumsy, inept attempts at using our various languages, to communicate with something essential in the other person. On that level, perhaps we may even hope that some kind of real healing might occur.

Les Miserables: A Movie Review

So the movie version of Les Miserables has finally arrived! I am not as huge a Les Mis fanatic as some people I know, (my little sister is completely obsessed with the score) but I do know the story quite well. I listened to most of the book on audio as a kid, and vaguely leafed through the massive tome at least once. I own two movie versions (non-musical) and I have spent my fair share of time watching segments of the anniversary concerts on youtube, so I was pretty excited to see it. I was skeptical about the leads. I knew that Hugh Jackman had gotten his start in musical theater, but I didn’t know that Russel Crowe could even sing, and thus far I had not liked Anne Hathaway in any movie I had seen her in. Not that I couldn’t stand her, I just was completely unimpressed.

I did not see the movie right away. I watched it about a week after it came out, and then again less than a week later, and I must say, I thoroughly enjoyed the movie.

I am not going to provide a synopsis of the story, only say that it follows the life and redemption of an ex-con and parole-breaker named Jean Valjean, as he struggles to live a good life in mid-revolutionary France, relentlessly pursued by his ex-guard Javert.

First, the actors:

Hugh Jackman, in my opinion, was a complete and total failure. His acting is fair to middling, unequal to the depth of character required to do justice to that part, his pitch is terrible, and he sings through his nose with a terrible faux vibrato throughout. The sung-dialogue sounds stilted and artificial, and the large musical numbers lack any semblance of vocal control. So the leading man was a huge strike against the movie. Fortunately the story is so beautiful and the rest of the acting and storytelling was so well done that they managed to carry a mediocre performance and in the end it did no harm.

Russel Crowe, as Valjean’s nemesis Javert, did slightly better. Again, acting and singing at the same time is not really his forte, so the sung dialogue was often painful to listen to. Javert’s biggest musical number is “Stars” in which he describes his vision of justice and vows to follow Valjean to the death if necessary to bring him back to prison. The director chose an interesting vehicle for the song, having him pacing back and forth on the edge of a balcony next to a giant stone eagle, overlooking the city of Paris, which was a powerful visual metaphor for his vision of law. There is no room in his worldview for deviation, sin, or human weakness. There is only the straight and narrow. Russel Crowe’s physical acting was perfect for the part, giving the impression of a bitter, dedicated, driven man, with a strong undercurrent of aggression. He is potentially a violent man, willing to kill without hesitation or remorse, simply because he believes so unflinchingly in the rightness of his cause. Unfortunately, Russel Crowe seemed to lack the fire the song seems to call for, and instead softly crooned most of it to the rooftops of a sleeping city. Other than that, I thought his performance was excellent and only got better as the movie continued.

I admit that I had very low expectations of Anne Hathaway as the prostitute Fantine. Honestly, I was pretty sure she would fall flat on her face. To my surprise and utter delight, she not only did not flop, she carried the part with perfect vocal and emotional pitch, from desperate factory worker, to destitute selling her hair and teeth to pay for her daughter’s medicine, to unwilling prostitute, to a woman on her deathbed, half crazy, delirious and emotionally shattered. Her reprise at the end (which I will not describe, if you haven’t seen it) was the most amazing and triumphant moment I have seen in a movie in a long time. Well done!

The odd thing is that the farther down the list of actors we go, the better they get. Samantha Barks appeared in the movie, reprising her stage role as Eponine, a street urchin who tragically falls in love with a revolutionary who barely notices that she exists. There is a definite incongruity between her look and the part. At one point in the movie her revolutionary love interest grips her arm with his hand, and the visual contrast is almost comical. That is a woman who works out! Not that her bicep is grotesquely huge, or even remotely masculine. She is, and looks like, a very fit woman in her mid to late twenties (I have no idea how old she actually is) not at all like a half starved street waif. Apart from that physical disparity, she played the role beautifully, constantly watching from the shadows, moving things behind the scenes, very much in love and totally unnoticed.

Eddie Redmayne (I have no idea who he is apart from this movie) played an excellent Marius. He captured perfectly the character of a naïve, idealistic, passionate and ultimately stupid revolutionary student. Likewise his friend and ringleader Enjolras was perfectly done. All fire and hot headed idealism, no patience and no common sense. Most of the best musical moments in the movie involved these two and their band of young idealists.

Sacha Baron Cohen and Helena Bonham Carter as the criminal innkeepers, the Thenardiers, were equal parts revolting and comical, nauseating and hilarious. On the one hand they portray the vice, greed, and criminality endemic in the underworld of society. On the other hand they provide some much needed comic relief to what would otherwise be an overly emotional and dramatic story.

And of course, no character list would be complete without Gavroche. Played with childish bravado by Daniel Huttlestone, the little street boy with some serious mojo hangs out with the university students and becomes all too willingly sucked into their revolutionary plans.

Visually the movie was stunning. The sets were amazing, the physical acting and storytelling was thoughtful and meaningful throughout. I thought the editing was a little rushed at the very beginning, but there is a difference between a movie musical and a theater musical. In theater the audience is composed of either die hard musical fans or die hard Les Mis fans, and they will give you the time to tell the story. In a movie time is on a budget, and they had to get the story going before the audience lost interest, and at 157 minutes it is already pushing the attention span of many movie-goers. The pace was ironed out by the second half of the movie as the scope of the story unfolds and comes to its conclusion.

There has been some furor over moral content among Christian movie reviewers, particularly the immodesty and sexual content. Some have even gone so far as to say that Christians should not see it because of this. That, of course is too broad a topic for a movie review. Instead, let’s just talk about the movie itself.

Let’s be frank, here. This is a story about mid-19^th century France, and the evils of that society form a huge part of the moral content of the story. Valjean walks a thin line between the strict, unbending legalism of Javert on the one hand and the vice and squalor that Javert seeks to keep in check on the other hand. The movie portrays that vice in a bit more gritty a fashion than we are used to see in a musical. (Oklahoma! this ain’t!) In the “Lovely Ladies” sequence prostitutes advertise their wares for the sailors on the docks, wearing low cut bodices and some suggestive movements. The lyrics of the song are suggestive, full of euphemism, but never explicit. Fantine, after being wrongfully fired from her job at a factory and struggling to make enough money to buy medicine for her daughter, sells her locket, then her hair, and then her teeth (the song represents the passage of days or even weeks in the book), and finally, with no other recourse allows the pimp and prostitutes to talk her into accepting a “customer.” No nudity is shown, and the scene is mercifully cut short but it still leaves the viewer feeling almost as sick and violated as Fantine herself feels; and that is the point. It is most certainly not appropriate for children, or even teenagers, but for adults I think it is great storytelling. It is an invitation to enter imaginatively (and in a very insulated fashion) into someone else’s pain and degradation. Instead of condemning her, as Javert does, or dragging her deeper as the other prostitutes do, or simply ignoring her as most of the world does, the story invites us to look at her as Valjean does, with mercy. He never minimizes the evil of her situation, but refuses to let her be taken to jail, and instead takes her to the hospital and pays for her care and pledges himself to protect her daughter as well.

This is in many ways the central moral decision of the story. It could have been hinted at, or glossed over in any number of ways, but that would have been to rob the story of its power and humanity.

The other major kerfuffle is about the “Master of the House,” scene, which depicts an inn full of dissolutes cavorting through their miserable existence aided by drink, sex and thievery. There is some cleavage and some suggestive movements, and a prostitute is briefly shown with a customer, (no nudity), all the while Sacha Baron Cohen and Helena Bonham Carter sing and dance and rob their customers hand over fist. Is it grotesque? Yes. Is it funny? Yes. Again, this is a little bit grittier than you might expect from a musical, but still far, far from being a realistic portrayal of that kind of life. Perhaps the conservative viewers would prefer to see the degenerate low-life scum portrayed as being miserable, sick and reaping the just rewards of their sin, but that would be unrealistic. Criminals and degenerates are human too. They joke and sing, if only as a way to deal with the reality of their lives, and this is, above all, a story about human beings.

The story is a Christological one. Valjean, having himself been saved from hatred and misery by the mercy of one man, spends his life trying to live up to that burden by spending his time, energy, fortune, and ultimately his life for love of his neighbor. At the end of the movie, having paid a hundred times over for his petty crime and his neglect which indirectly contributed to Fantine being fired, still prays, “Forgive me my trespasses.” Other characters are shown leading him through his final moments and interceding for him before God. The overall message of the movie is overwhelmingly beautiful and redemptive and not only justifies, but even in some sense beatifies the ugliness that Valjean had to overcome. “To love another person, is to see the face of God.”

So in conclusion, despite the lead (realizing that that is big exception to make in a musical) and Russel Crowe’s rendition of “Stars,” the movie gets four out of five stars. I will definitely watch it again, probably when it comes out on DVD.

Death in Children's Stories

*Note, this post was first written, but not published, well over a week before the events in Newton, CT. Bear that in mind when reading it, but I am already beginning to think about how it applies to that event and especially to the children affected by knowledge of that event.

 

 

At Bible Study on Monday night, or rather in the pre-Bible study man talk (the ladies having either not arrived or gone off to procure refreshments) one of the guys mentioned a comic book inspired cartoon he had seen as a kid, and mentioned an episode in which Superman had had his dreams invaded by his arch-nemesis, and in the ensuing nightmare had accidentally killed his friend. The guy reminiscing about this episode pointed out, "You know, some of those cartoons were pretty dark. I mean those were kid shows, but they were really dark for kids."

I mused that I didn't particularly see a problem with death and violence in kid's stories or movies, necessarily, as long as it was done right. Some of the guys agreed, some disagreed, but we didn't really get into a conversation about it.

A couple of things went through my mind when I heard that comment. The first was all the parents I know who try so hard to keep their children from seeing certain movies because they are afraid they will scare them or give them nightmares (and by parents I mean mothers. I don't think I have ever seen a father censor a movie on that argument.) Parents who won't let their children watch "Lord of the Rings" because they think the orcs are too scary, or who won't let their children read the Chronicles of Narnia because of all the fighting. (This is a much smaller subset.)

There were a couple of movies that my parents wouldn't let us see when we were kids because they were afraid we would have nightmares. I don't remember any of them, but I think my parents, on the whole, were pretty sensible about it. They did their best but predicting what would or would not frighten each of us was an impossible task. I remember being frightened out of my wits by the flying monkeys in Wizard of Oz; crying at the dressed up White Rabbit in a live action version of Alice in Wonderland; having nightmares about the ghosts in Tevye's dream in Fiddler on the Roof; and lying awake for what felt like years, mulling over the haunted wood scene in Anne of Green Gables. The things my Mom expected to scare me, (Star Wars, for instance) were not scary at all. In fact, Star Wars was hands down my favorite movie for most of my childhood.

What this indicates to me is that it is impossible to predict with certainty what will or will not frighten any given child. The child himself decides, subconsciously and without understanding the reasons, what he will be afraid of and how he will be afraid of it.

On a deeper level, the whole idea that children must be protected at all costs from frightening ideas and images is counter-intuitive to me. (You will note that 1: I am a man and 2: I have no children of my own.) I do not think that movies that are frightening simply for the sake of being frightening, (i.e. horror movies) are good for children. On the other hand, I think that violence, fear and death are absolutely necessary in children’s literature and movies.

Grownups who do not want these elements in children’s stories do not understand the purpose of stories in a child’s life. Grownups think of stories as merely entertainment, but this is a stunted two-dimensional way of looking at it. Children know better. To a child a story is another life, no different in perceived reality or importance from the child’s own real life. Stories are a way of learning, perhaps the most powerful way in which children learn. Grownups worry sometimes about children entering so completely into their imaginary worlds. I know a lot of grownups were disturbed by how seriously I took my imaginary world as a kid but that is precisely how we learn. By investing the imaginary world with such depth, the lessons we learn there stick deep. To this day I still learn things in the same way. I imagine things and live them in my mind before they happen and learn prudence. I listen to other peoples’ experiences and try to enter into them, and I learn empathy. I live various possible solutions to problems and anticipate complications. None of this would be possible without that early childhood training in allowing my imagination full rein.

More importantly, stories change who we are. They allow us to grow up.

One of my young second cousins is 4 ½ years old. His parents have been showing him the animated Redwall series (based on the truly outstanding books by British author Brian Jacques.) Now, in the Redwall series there are many bad guys. In the first season there is the vicious rat Cluny the Scourge, and his vast horde of bloodthirsty vermin, weasels, stoats, ferrets and such. However, more sinister still is the serpent, Asmodeus. The brave warrior mouse Matthias has to fight with this serpent who is a hundred times his size and overcome it in order to achieve the sword of Martin the Warrior and fulfill his destiny. (Ha Ha! Just remembering the story is getting me pumped. I loved that series and read dozens of those books out loud to younger kids when I was a teenager. Good times!)

My cousin’s mom told me that the little boy was so scared of the snake that he was standing up on the couch as he watched it, ready to run away at a moment’s notice. But then his dad showed him how Matthias killed the snake, and now it is the little boy’s favorite part of the movie. He role-plays “Matthias and the Snake” over and over again with his dad, or whoever else will play it with him. Sometimes he is Matthias and sometimes he is the snake, and both are deeply significant from a psychological point of view, but the main point is that that he has looked the snake in the eye, and slain it.

G. K. Chesterton said, “Fairy stories are important, not because they tell us that dragons exist, but because they tell us that dragons can be defeated.” There should be a sign over the entrance to this world to warn us, “Here there be dragons!” Like it or not, dragons roam the byways of this earth and sooner or later every child will meet his dragon. When he does he should do so already knowing that dragons can be slain.

I am not talking about head knowledge either. I memorized my Baltimore Catechism with the best of them when I was a fuzzy headed altar-boy. I could quote from memory about the theological virtue of hope, God’s promise to grant me the “salvation of my soul and the means necessary to obtain it,” but I was fully twenty-five years old before that formula meant anything to me more than the words that made it up. I had long since encountered dragons aplenty and had long since had need of the hope in my heart that would give me the courage to fight them without rest or quarter, certain that in the end victory would be mine. The rational understanding of that hope came from my formal education, the training in writing, logic, philosophy, catechism and other such arts of the mind, but the habit of hope had been formed at a much earlier age by much humbler influences. Long before I knew how to read about serpents I already knew that they ought to be defeated, and that they could be defeated, and that I was born to fight them.

The grownups who refuse to allow anything frightening in the stories their children hear, watch and read, may be providing them with better entertainment, (or maybe not. After all, what is a story without a conflict?) However, they deprive them of so much more. They assume that all fear comes from outside of the child, but this is not the case. This is a fallen world. The shadow of Original Sin is cast from within and the fears are already there. Frightening things frighten because they echo in the dark places of our own souls. In depriving the child of an imaginary bad guy to be afraid of, you deprive him of any way of focusing on the internal fears. In depriving him of imaginary heroes you deprive him of any way to face his fears and defeat them.

Children’s stories, therefore, should be realistic. This is not to suggest that dragons, hobbits, elves and dwarves are to be eschewed. The fairy stories are more realistic than the tamer stories could ever be, because the fairy stories get to the real root of the world, to goodness, truth and beauty; to evil, lies and ugliness; to the courage to stand up for the right and resist the wrong. In the end, fairy tales tell us the only things that really matter.

They tell us there is hope.

 

You are what you eat?

One evening I trained with a group of Thai policemen who were Muay Thai practitioners. Muay Thai, for those who don’t know, is the national martial art of Thailand, also referred to as Thai Boxing. It is a kickboxing form that relies on strikes with the fists, feet, knees and elbows, and even with the head. It is the Thai national sport and a large contributor to the repertoire of many Mixed Martial Arts (MMA) fighters. I have been training for years American style kickboxing. Sometimes I have been told that this was Muay Thai, but it turns out to be almost nothing like real Muay Thai, so I was thrilled to have the opportunity to train with a former competitive Thai boxer and his friends and in exchange shared some softer style combative and open hand fighting techniques.

After we were done training they invited me to go out to eat with them and about an hour later we ended up across the street at a restaurant that specializes in sumtam and dongnam. Sumtam is a dish of meat, seafood, fruit or vegetables, minced up together and sautéed in a spicy sauce. It is more a kind of dish than a dish in its own right and can be made with almost anything. One of the best sumtam’s I have had here was made with apple, grape, carrot, coconut, peanuts and hot Thai peppers. Dongnam is a soup made with meat and vegetables.

Since I don’t speak Thai, and the wait staff doesn’t speak English I usually do the pointy-talky thing with the menu. This time, however, I was with locals and the one RTP (Royal Thai Police) officer who did speak some English assured me that they had everything under control and proceeded to order all the food for me. When it arrived I quickly discovered two things: first I discovered why the Thai restaurants never seem to be able to split up the bill unless they are used to catering to Westerners. In Thai culture no one orders a separate dish. They all order the dishes which go on the center of the table and everyone serves themselves from them as they please. (That explains why some of the Thai’s thought we were rude for eating off the serving plate when we dined out.)

The second thing I discovered was why the RTP officers insisted on ordering for me. They had ordered the spiciest, rawest and creepiest dishes on the menu, and were all watching me with huge grins to see if I would eat them. We had a roasting hot spicy papaya and blue crab salad. The blue crabs were simply chopped in half raw and tossed in the dish. They ordered super spicy minced pork entrails and were more than happy to explain exactly what organ each piece came from. They had ordered a plate of deep-fried duck mouths (yes, you read that right), and to top it all off they had a plate of spicy raw minced beef with herbs. (They had also thoughtfully ordered some deep fried pork neck with ketchup and placed it within easy reach of me.)

So I started eating. I put some of my sticky rice on my plate and spooned some of the pork entrails onto it and ate that. They laughed at me and showed me how to eat it properly, by rolling the sticky rice up into little balls in my hand and dipping them into the dishes (the dipping is called jom and the popping into the mouth is called but. That’s what they taught me, but they may well have been teaching me dirty words for all I know. I certainly didn’t see any of the classier looking Thai families jomming or butting(the interpreters later explained that this was legit, but it was authentic north-eastern style dining, so not in vogue in my area)).

But I ate everything on that table. I ate the entrails, crunched the crabs and bit the beef and loved every bite of it (except the bite in which I mistook a green pepper for a green bean and ate it. That gave me the hiccups and left my mouth on fire. It was so hot that the snot running down my face was hissing and bubbling like molten lava, and it felt like it was melting my chin. Those green peppers are no joke.) After I had cleaned up all my sticky rice, ordered another basket of it and ate all of that too, and every scrap of food was gone, the guys all looked at each other and shook their heads. One of them said something in Thai and the English speaker translated for me, “They say, if you can eat this, this, this, this, you can marry Thai wife and live anywhere in Thailand.”

To which I laughed and said, “Sweet. Sounds good to me.”

The next day I told the story to one of our interpreters and he looked at me shocked, “What you want a Thai wife for, man, I thought you were the one who really loved your wife.”

I laughed and explained that I’m not married. My reasons for not chasing Thai girls every weekend are mostly religious.

He didn’t say anything for a little bit, and I thought the topic was over. But then I heard him muttering to himself under his breath, “Hmmm. Good job, good face, good personality.” Then he looked up at me and said, “Okay, man, if you want Thai wife you let me know, I hook you up with one.”

The Dutchman's Wife

Margaret awoke while it was still dark. Hans had coughed, and his wheezing breaths had paused, then stopped for too long and it had awakened her. He was breathing again now, and she allowed herself to relax. It wouldn't be long now, she knew. He could not hang on much longer, and it was better so. She reminded herself vehemently that it was better so, and looked over at the clock. Her vision was not what it once had been, but she could just make out by the light of the embers on the hearth that both hands were pointing nearly straight down and just a little to the left of the six. It was about six-thirty. She sighed and slowly eased her old feet onto the floor, finding her old worn slippers. Then she knelt painfully for her morning prayers, letting Hans sleep as she always did these days. There was work to be done and no one to help her with it so she prayed quickly, sure that the Lord would understand. The chickens needed to be let out into the yard and fed, the eggs needed to be gathered, the fire needed to be built up both on the hearth and in the stove, the dog, an ancient German shepherd named Fala, needed to be shooed up from her bed in front of the hearth and sent outdoors. By the time Margaret had breakfast heating on the stove the sun was up and she could see the mills swirling through the frosty air in the distance, on the other side of the canals. If it warmed up enough they would walk along the river for awhile, if he felt strong enough.


Hans was awake, sitting on the edge of the bed, his thinning, tousled hair looking like straw in the shafts of sunlight from the barred window. His eyes were curious today. He didn't know where he was, or who he was. In some ways that was better. On the days that his mind was blank he was easier to deal with, more pliant. Other times, when he fancied he was a little boy again he ran everywhere as fast as his old limbs would take him and she could never keep up. The few and far between times when he knew things were the most painful. Then he would reproach himself and beg her pardon for being such a burden all these years. Today he was a blank slate. Perhaps she would teach him his alphabet, later. For now she had to feed and bathe and dress him.

He liked the food today, sometimes he didn't. The eggs and biscuits were warm and done perfectly, she still cooked as well as she ever had. He didn't want to bathe at first, until she convinced him, mostly by signs and gestures and the reassuring tone of her voice, that the water was warm and nice and wouldn't hurt him. Then she dressed him like a large baby in his old, old shirt and overalls, and the wooden shoes that no one ever wore anymore. She dressed him just like the children that they had never had, and in many ways he was very much her child. The innocence and trust of an infant looked out from his china blue eyes, or sometimes the petulance and weepiness of a two-year old, or the playfulness of a schoolboy.

"Aunty Lars," he said, suddenly.

She started. He was a child again, and in this particular fantasy he thought she was his long dead aunt. "Yes, Hans," she answered.

"Aunty, Captain Decker comes by today."

"Of course he does my love," she said. His eyes were the eyes of a little child, out of place in his gray stubbly face. There were only a few days in the month in which she could shave him without danger of him moving suddenly and cutting himself. He rocked back and forth and bounced a little, a potbelly he had never had as a boy jiggling as he did so.

"Can we go see him, Aunt? I want to wave him by."

"It is cold out today Hans," she said.

He laughed. "Silly Aunt, it is summer. See the tulips," he waved towards the window with a withered hand, blue splotches showing through the transparent skin.

"No dearest, that is snow."

"Yes Aunty, but the tulips are under the snow, of course."

"Asleep?" she asked.

"No Aunty. Tulips only sleep during the night. Don't you remember when you took me out into the garden at night and we watched the tulips go to sleep. But in the winter time they are awake beneath the snow."

"Maybe they are my love, maybe they are. But it is still cold out."

"I'll wear my muffler Aunt, and I will stay warm. Please let me go out and watch the boats."

She sighed. It was still cold out and would be until the afternoon, but he would not be kept indoors until then. She nodded and got his cap and coat off the pegs on the wall. He tried to put them on, as she wrapped up some cold biscuits and cheese for their lunch, but he couldn't remember what to do with the buttons. She buttoned them for him and let him carry the lunch because he begged her to. And they stepped out, a bent old man trying to run ahead of a gray haired old woman, she holding him by the hand and telling him to stay close. They walked across the fields, still covered with snow in some places, despite the warm April rain of the days before. The canals lay on the other side, and beyond them the Zuider Zee, and at the end of that, the dikes and the harbor, the ocean with all the ships that he used to build. A flat bottomed river boat drifted by, and Hans called out to them and waved. "Captain Decker, Captain Decker, it's me, Hans." The man in the striped shirt stared and then tried to pretend he couldn't hear. Hans continued to call, disappointment in his voice. He broke his hand out of Margaret's and tried to run after the boat for a few feet until he came up short of breath and had to stop, bent over and gasping. He cried and Margaret held him and told him it was all right, but he soon forgot all about it. A patch of tulip buds, breaking out through the snow caught his eye.

"Look, Sis, tulips. I'll pick some for you, pretty Betty." She was his older sister now and he scampered off to pull the tulips up by the roots and bring them back to her. He insisted on putting them in her hair and teased her about beaux that she never knew. They meandered down the banks of the canals into the village. Margaret pulled the tulip stalks out of her hair before they went in, but he didn't notice. He liked the town, it was so alive. He ran between the stalls in the busy market, calling merry greetings to long dead friends he fancied he saw. Most of the people were regulars, and they knew him and greeted him back. Hans begged Margaret to buy some ginger that she might make some ginger snaps, and she did, knowing that Alice, the pretty young girl who watched the stall, would let her give the ginger back as soon as Hans forgot about it, which he did in less than a minute.

He moved down by the shipyards, and she followed. She tried to turn him back, but for once he would not let her change his mind, though the day's outing was becoming longer and longer and very soon it would be too late for them to get back before dark. He would not listen, he wanted to go down to the shipyards. She remembered long ago, when he was a young man. She had first met him on her way home as she walked past the docks. Some sailors on shore leave had jeered and catcalled as she went by, and she had blushed bright red at their words, too frightened and embarrassed to do anything but put her head down and walk past, trembling and not daring to look right or left. And then, suddenly, a young man with broad shoulders and thick, calloused hands had stepped out from an alley and was walking beside her. He did not say a word to the group of jeering men, he just looked at them with his blue, blue eyes as cold as ice, and his hands clenched into fists. He had been a very tall man then, well over six feet and immensely strong from his work in the shipyards. The sailors shut their mouths and looked away. After that she had never walked home alone. He was always waiting for her at the end of the street, and he always walked with her, at least part of the way home. And she loved him for it.

Now he stared out into the dry docks, where men were building ships unfamiliar to him, new ships without sails that burned coal and put out a dreadful smoke. He didn't speak, but looked very hard as if he was trying to remember, but whatever thoughts and distant dreams that were dancing in his head, they faded and eluded him. She could almost see them like wisps of smoke curling away from his groping mind.

But perhaps they were not gone entirely. He took her hand in his and squeezed it with all his feeble strength and said. "Come on, little Meg, I'll walk you home. No one shall harm you while I'm around."

"I know they won't, Hans. I feel safe with you." She had always used to say that, as she leaned her head against his shoulder, and it had always made him beam with pride and happiness. It still did.

"You are safe with me, Meg. Pray God I am always around to keep you so." He walked with shuffling steps the length of the dock, going still further from the way home, following the streets that they had traveled so many times in their youth. He forgot his fancy before they made it to her father's old house, and they were now walking through narrow, deserted streets. He seemed no longer able to feel her hand in his and he began to tremble with fear. He hated to be alone. It was the worst when he got lost in his own mind, no longer able to see, hear or feel her. He called out to her, "Margaret, Margaret." He didn't hear her answer and kept calling, "Where are you Margaret?" There was nothing she could do but put her arms around him and hold him until the fit passed. Sure enough, he suddenly forgot about it as if it had never been, the evil of loneliness swallowed up in the childlike purity of his withered mind, like a drop of poison dripped into the ocean. Gone, erased from his memory.

Time went on, as they continued to walk, and afternoon found them on the dikes overlooking the sea. The sunsets they had watched from there, the starry skies, the moonrises. She dared not stay long enough to watch another one, and at last he was getting tired, and allowed her to turn him homewards. It was a long walk, but she was not worried. It would do him good, he would sleep well tonight with no pesky dreams to disturb his slumber, and the memories that flooded over her were very strong, very beautiful. It would not hurt to take some time to turn them over in her mind, to thank God for them. She had long ago learned to live without bitterness, not like the first few years of loneliness after the terrible war had taken its toll on his mind and body. She had often thought it would have been easier to be a widow, rather than losing him while he was still alive. It had been especially hard when she was younger, for his mind had gone long before her beauty had faded into its present comfortable grayness. She had learned since then, painfully over long years, but she had learned. Now she lived to care for her husband and her love for him was so strong that he seemed to be more a part of her than a separate person. When it was time for him to go, she would feel the loss terribly, as if she had lost her right arm and right leg, but it was not time to think about that yet. The day had warmed up beautifully, and he took off his jacket and made a show of flexing his arms, fancying they still had the muscle of his younger days. She wasn't sure where his mind was then, but it didn't last long and then he was quiet again as they walked home together through the fields, following along the wagon trails. They still had a mile to go as the sun set blazing behind the windmills, washing the sky in red and orange, purple streaked with pink and bordered by the deepest of deep blues, rapidly fading to a satin black. There was one bright star with the temerity to shine out while the sun was still over the horizon as if impatient to start the night's festivities. It was alone at first, but as the sun sank and surrendered more and more of the sky the one star was joined first by a few, then a dozen of its stronger brothers and sisters, and then by hundreds more, and finally, all at once, a million of the smallest and youngest in the family appeared, twinkling diamond bright in the black. Sometimes he used to say the stars had voices and they sang, like a choir of very high, sharp chimes, voices that no human could ever understand, but with a beauty that would kill anyone who once heard it, or break their heart and drive them mad. She looked into his eyes, small dark circles with an entire galaxy mirrored in them, and she believed him.

When they reached their door, the wind was just picking up with a little hint of frost, reminding her that it was not yet May. He was in a quiet, melancholy mood, and she left him to sit quietly as she hastily did the chores and warmed up the leftover breakfast. She made him some tea, with a drop of whiskey and they ate quietly, and he sat still and listened to her as she said her evening prayers.

As she said "Amen" she heard his voice whisper, "Margaret?"

Her heart beat fast, and she met his eyes, realizing that he was having one of his rare moments of clarity. "Hans?"

"Thank-you, Margaret," he said, his voice trembling with age, but his eyes clear and steady. "I love you.”

"I love you," she said, but the moment was gone. His eyes were vacant again.

She began to hum through her tears as she dressed him for bed and rolled the covers back. It was an old song, one that had been popular when she was a little girl, but he recognized it as she tucked him in, and he hummed it with her, until his eyelids drooped, and he fell asleep. Margaret brushed two gray hairs away from his forehead, and then with a sigh, she leaned over and softly blew the candle out.



Written by Ryan Kraeger, June 2007: inspired by the 1968 song “The Dutchman” by Michael Peter Smith.

The Smile

In response to this writing challenge on lkjslain's site, I wrote this poem. I had no idea where I was going with it, I just started it and kept writing down what came to me. Then I liked it so much that I recorded myself reading it:

Enjoy!

The Smile

I walked alone at night, through streets of gray,
Content to be alone, chasing tales
Hidden, obscure, in corners of crooked paths.
Secrets of those who passed that way before.

The walls and stones see all, and plain as day

Reveal the stories to me, their long lost friend.

For years I wandered thus, full well content
To slip unnoticed around the edge of life
Untouched by the swirling blizzard of human flakes,
I watched, and listened; marveled and passed on.

Then one day a new tale came to me,

Borne on a breeze of ice from the blackest heart

Of the shadowy ways of the City of Dreadful Night

The darkness at the center of that tangled wild.

Somewhere in the labyrinth a woman walks,

Or so the black breeze whispered in my ear,
Pale and tall, fragile and great of heart,
Mighty in soul, shrouded in hood of black,
Walking the city, weeping for her child,
And then, with tears used up, she still walks on
Through dark, dry, hopeless aching night.

I loved her then. It is not too strong a word.
Her grief scored deep my heart, my spirit shrank
At the deadening weight of pain that crushed her soul.

I shrank away in fear, but could not run

For awesome fascination at her strength,
For even yet, (the breezes sighed) she hopes.
The candle is all but snuffed, and yet one spark
One pitiful, stubborn, glorious, relentless spark,
Will not be quenched. She will not fade away.
She loves. There it is. Even still she dares to love.

Just a tale, passed on the fickle wind, and yet,
The weight of its fantasy shocked my sleeping soul
All my actions, pale, transparent and flimsy
Vanished in the shadow of such a love,
Such pain. I slowly turned my trembling steps
Into the night. The darksome labyrinth
Loomed before me, moaned and sucked me in
Into the whirl of pain, despair and hate
Harpies like a pack of howling wolves
Tore at my ears and shivered my resolve,
But yet it held. By ever so little, it held.
I sought her. Through narrow, devious ways I searched
Peeked through cracks in walls and peered through bars
In cellar windows. I kept an eye for her,
And the other looking back, always aware
Of the way out. For I purposed when she was found
That I would take her hand, and gently lead the way

Back, through treacherous paths and hateful looks

And clutching, clawing keepers, to freer air
To a place where light and music, silence and peace
Can still exist, and stories all end well.
Once in those early days I saw a glimpse
Of her face across a crowded, sullen street.
She stepped through a sickly yellow pool of light
From the streetlamp, but she never even paused.
When I crossed and looked again, she was long gone.
I redoubled my efforts, and vowed oneday to bring
A smile to those fair, set, determined lips.

Then one day I saw a fallen child,

With broken wings and tangled dirty hair
Caught in a pit, thrown in an abandoned crypt.
Worn out dreams lay wasted ‘round her feet,
Scornfully plucked in the bud, never to bloom.
Dirty hands tossed cold hard cash her way
To make her dance, or sing, or play to please her crowd.
So ugly, she was. Not the Lady’s child.
That child was long since dead, I know, but still
Once that child had suffered, as now this girl
Suffers. “It won’t take long,” I thought.
“I’ll show her out, and then return to the search.”
I did. I returned to her late at night and broke the lock
And guided her through the well-known maze of streets
To the tangle’s edge, and set her free. She ran
And never once looked back. I turned back in.

I went back to my quest, but once again,
I came upon a child, and once more paused
My dogged search long enough to get him out.
Another glimpse of her, but when I arrived,
Not her, instead two more of these pitiable urchins.
By now the keepers had learned I knew the way.
This time I had to fight to make it through
To the edge, and then frantic I rushed back in.
These distractions had to stop, or I would never find
The Lady; but now whichever way I turned
Were pitiful faces, children, women, the old
The lame, the sick, the hungry and the weak.
I walked with them. One or two at a time I got them out.
I couldn’t turn them away. They told their tales

And I listened, and wept and fought to clear the way.

Every time was harder than the last,
These middle years were years of many scars.
The Keepers scarred my body, the children my heart
And both bled freely, but each time I went back.

And now I am old and tired, and winding down.
My back is bent, my beard is gray and wild
And my hands are crooked, gnarled and lined with scars.
My heart looks much the same, or so I’d guess,
Inscribed as it is with so many tales of pain.
I have not seen the Lady these many years,
Perhaps she lives no more, perhaps never did.
I might have made her up, a silly dream
That will not go away, but holds more firm
Than the rocks I hide behind. Pitiless is hope!
Weariness covers my soul like a hood of black.
I am dying. That’s how it is. I’m glad to go.
Even though there are still so many more,
But I am full of other people’s pains.
I’ve drained to the dregs that goblet of human sorrow.
From the first to the last the stories stay with me,
Of kept and keeper alike, and scars of both.
And now I’m done. Right now, this trip, my last.

I know this one is my last, because I fell,
Just like that, my face hits the city street.
I cannot rise to my feet, my breath is short,
My chest sinks like an anvil on my heart,
As it finally breaks.
                               I have never seen her smile.

But what is this? The falling darkness breaks

The sky goes gray, then teal, then blue, then gold
And light falls on my head with searing heat
And all the weight of gold, poured liquid hot.
Intolerable for one brief hellish breath, far worse
Than life itself, and then a gasp of air;
Only not air. Or rather, this is at last is air.
Before this moment I’ve never tasted air.
I’ve never yet known light before this day.
The brightest day of life was shades of gray,
And air before a vacuum next to this.
This air could make a meal, this light a bath,
A shower, an ocean of curling waves of gold
Washing over and through my broken frame
‘Til Every scar shines out with borrowed light
A gift, a jewel, a royal diadem.
I draw this joy up from the very grass
And a laugh rings from my chest, the very first
I ever truly laughed. Mirth pours out,
Sounding a mad, triumphant organ fugue,
Answered in kind, in brave bright jubilee
In the Lady’s eyes; for there, at last, she stands.

Beautiful as the glowing moon, radiant with light

Over, around, with and by and through

The Light is pleased to shine, and even thus
Lovingly tempered still it is too much.
She smiles.

                   Too much!


                                        I could almost die again.

She stands amid a joyful throng, a Queen
A Mother. Her children, whose stories now are mine
Keeper and kept alike, now whole and free.

Thus I lived and all my life was this.
Was bliss, for I have made my Lady smile.

Patients are More Fun when they Aren't Drama Queens

One evening a little girl came into the ER. She was about nine years old, and she had fallen on her outstretched hand while roller-blading. Her right arm was in a sling and she had abrasions on both her knees, but what really struck me when I walked in the room was the fact that she was sitting contentedly and quietly on the edge of the gurney, kicking her legs and looking around with interest. She was little and cute in the way that only little girls are, with messy brown hair done up in a sort of pigtail. She was still wearing shorts and a t-shirt, although someone had thrown a man’s zipper jacket over her shoulders, because the room was cold. Her parents were standing on either side of her, looking anxious, but she had a bright, intent, wide awake look. Her eyes were open all the way and a little extra as if she was perpetually amazed that there was so much in the world to see. She grinned at me as I walked into the room in my scrubs with my beard and that reminded me just how awesome my job was.


“Hello,” I said cheerfully. “What brings you in here tonight?”

“Oh,” she said casually, as if it had just suddenly occurred to her, “I fell while I was roller blading.” Her voice was cute too, very high pitched and squeaky. She said it with a perky attitude like, “Oh, if you must know. It’s probably not even worth mentioning, but you asked.”

I knelt down in front of her and examined her knees very carefully. “Hmmm, yes, I see. Wow. Well, you know, I think we can take care of this. I can call a surgeon and well get you scheduled in. We’ll probably take them off right about here.” I made a slashing motion across her legs right above her knees.

She laughed and squealed, “No!”

“What? You don’t want us to take off your legs? Really? Then why are you here?”

“This!” she laughed and held out her arm in the sling.

“Ohhhhhhhhhh!” I nodded, because it was all so clear now. “So that’s why your arm is in a sling. Oh, I get it. Okay, so what happened to that?”

“I fell on it,” she giggled.

I got her to describe how she had landed, and to point out exactly where it hurt, but she assured me that it didn’t hurt very much at all. I made her go through all her ranges of movement with her wrist and elbow, and then poked and prodded and pinched and squeezed. “Does it hurt here?”

“Nope.”

“Does it hurt here?”

“Nope.”

“Does it hurt here?”

“Nope.”

“How about here?”

“Not really.”

“You know what? I’m not even going to ask you any more questions, because you’re too tough. You could probably be lying on the floor with your hand cut off and I’d ask, ‘Does it hurt’ and you’d say, “No, not really’.” I said the last part in a high, squeaky voice to illustrate how she would say it.

She just laughed at me. Her parents relaxed a little bit when I explained to them that she might have a small fracture but it didn’t look serious and we’d get some x-rays to see exactly what was going on.

For an adult I wouldn’t even have needed an x-ray, although in a civilian hospital I probably would have gotten one just because it’s expected. Since she was a child, though, I wanted to make sure there was no crack in the growth plate. In the ends of every bone in a child’s body is a thin plate of cartilage sandwiched between the end (epiphysis) and shaft (diaphysis). The area where it attaches is called the metaphysis. As the child grows the cartilage grows and gets longer and longer, while at the same time it is being replaced by bone which does not grow. At some point, usually in the teen years, the bone replacement catches up with the cartilage growth and then that limb stops growing. When this happens in all bones of the body the person has reached his or her full height. However, if the plate is damaged while the child is still growing this can cause the growth to be lopsided or deformed or even to stop altogether. Hence the reason I ordered an x-ray.

As it turned out her growth plates were fine. The only damage was a torus fracture of the radius and ulna. Another characteristic of children’s bones is that they are softer and more flexible than an adult’s bones. Under stress they tend to bend and wrinkle rather than crack, somewhat analogous to the difference between a green twig and a dry stick. A torus fracture (also known as a buckle fracture) occurs when the outer layer of the bone, the cortex, wrinkles under pressure. It's pretty easy to see in this example from medscape. Follow the long bones up towards the wrist and you will see a buckle in each side of the bone. Hers looked very similar. She thought it was pretty cool that she could see it on the x-ray.

So we put her in a short arm splint to immobilize the wrist and signed her up for an orthopedic consult a week later. She was still chatting it up with the nurse as she fitted the splint, and I just had to go in to watch. If only all my patients had a sense of humor like that.

Scope of Practice

One night the EMS brought in a girl who was found unresponsive in her home. By the time she arrived at the ER she was answering questions, mostly appropriately, albeit with a significant delay. We were able to get a complete but contradictory history from her. She denied remembering anything, although she said she had had one drink and some marijuana with her friends that morning. We told her this looked like a drug overdose but she didn’t respond to that. She was a very pretty 21 year old, but she was far too thin for her body type and her forearms were crisscrossed by dozens of fine white scars. Physical exam was mostly unremarkable, except for a general lethargy and delayed/weakened motor responses in her extremities, and her pupils which were pinpointed, no focused and sluggishly reactive to light. She did not have the ability to follow a light with her eyes. All ocular movement was erratic and saltatory.


We did a urinalysis (UA) tox screen on her and it came back hot for barbiturates. Looking back in her file I found that this was her fourth time in the ER for prescription drug use. To top it all off, she was a pharmacy tech.

We had a long discussion with the ER doc about what we could do. We were all agreed that she shouldn’t be working in a pharmacy, but he said there was nothing we could do without violating patient doctor privilege. I argued that the laws contain a clause that states that if the patient is in imminent danger of causing harm to herself or others we not only have a right but a responsibility to report it to the appropriate authorities. In my view if a druggy is handing out drugs, her dipping into her own stock is the least of my worries. My worry is that she’ll be high at work and she’ll mislabel a bottle or put the wrong pills in it, or the wrong dose, or give it to the wrong patient and that could literally kill someone. Has it happened yet? No. I don’t think waiting for it to happen is a good plan. She needs to get fired for everyone else’s safety.

And what about her? Why the drugs and the alcohol and the cutting? Her mother showed up at the ER and wanted to take her home against her will. The charge nurse explained to her that we could not release her into anyone’s custody because she was not a minor. We could not keep her if she didn’t want to leave, we could not sign her over to her mother if she didn’t want to go. Her mother argued back, unable to see the plain facts of the situation through her grief and frustration. Didn’t we see that if she went back to her own house she would just get stuck with her friends again, and these friends were really bad. It was all their fault her daughter was doing drugs. If the patient could come home with her she (the mother) would keep the bad influences out of her life and she would turn around. Why couldn’t we just see that?

I couldn’t help but wonder, if that parental love hasn’t been sufficient thus far, what makes her think it’s going to become magically effective now? Regardless, legally there was nothing we could do. Like it or not, she was 21 years old. She was legally responsible for her own decisions and we could no more remand her into her mother’s custody than we could detox her. She was not in danger of her life. She was not overdosed, she was just stoned. That’s what those drugs are supposed to do. Even if she had been in danger the only treatment is to stick a tube in her stomach and pump out any pills that haven’t been absorbed, dilute with activated charcoal and support heart rate and respirations until the effects wear off.

What was up with her? The problem was far beyond emergency room scope of practice. Did her parents not love her? Had she been abused as a child? Had she not been able to find any good friends? Whatever the myriad single elements that made it up, they all came to one thing. The problem was that she had a deep, throbbing, aching, abysmal hole in the depths of her soul. That is beyond my scope of practice.

Cricket in the Dark

One time in Afghanistan, around Christmas I think it was, we stopped over in FOB Tillman. We were doing some blasting to cut out rock so the construction engineers could build a nice new road to the top of the mountain where the FOB had an observation point (OP). It was a nice easy job, only during daylight hours, and the cooks knew what they were doing at that FOB. They left the chowhall open at all hours, so no matter when you got the munchies you could walk in and grab some chips or those little single serving microwave pizzas or some raw fruit of some kind. Our sleeping arrangements weren't so bad either, apart from the mold-and-gasoline smell that permeated them. They were old brick buildings with I-beams supporting brick roofs, and they had clearly seen some use, but we didn't have to pull guard duty, there were plenty of cots, and some MRE boxes to use as card tables.


On this particular night, we were all packed up to be ready to leave the next morning and we turned the lights off at about nine. I was asleep fairly quickly. I slept about the same as I always sleep, which is to say I woke up every couple of hours to drink some water, and every time I woke up in the middle of the night I heard a cricket chirping away in some pitch black corner of the room. Sometimes I awoke to the sound of swearing or a flashlight being cursorily swung around the corners of the room. No one put it in any serious effort to find the offending insect. Instead they turned off their flashlights, muttered some vulgarity or profanity, and tried to muffle their ears with their pillows.

In the morning the LT was tired and cranky and almost the first thing he said after lights on was (I'll pay fifty bucks to anyone who can find that @#$%#@$%^ cricket and kill it!"

"Aw, come on, Sir," I said in the voice of sweet reason. "He's just trying to find a lady cricket. All he wants is a little love and affection."

"That's all well and good," the LT snapped. "But I think after six %$^#&! hours, I'd give up."

I didn't reply to that because he was in a bad mood, but secretely I was glad no one hunted down that cricket and killed him. He was a persistent little fellow and I was rooting for him. After all, faint heart never won fair lady.

"Arm Pain"

I had a 19 year old patient one night who came in with her boyfriend for “arm pain”. She had her left arm in a sling and she wouldn’t let go of it with her right hand. I went in to check her out after the nurse had her signed in. She was anxious and emotional, and her arm was obviously in pretty terrible pain. She had good sensory function in her fingers, good pulses and capillary refill, but she couldn’t grip my fingers with her left hand. I didn’t think it was due to a physiological defect, it was probably just too painful. It’s hard to explain, but there is a different look to someone who can’t move, as opposed to someone who simply won’t because of the pain.


I asked, “How did this happen?”

She answered, “I was lying in bed and I rolled over and hit my elbow on the wall.”

Her boyfriend cut in, “Yeah, didn’t you say you hit your funny bone? Show him where it hurts baby.”

She pointed to a spot on the ulnar side of her forearm, the bony part about three inches below her elbow. I took the sling off to take a better look. There was a swelling hematoma forming on the surface over her ulna, and the whole area was so tender and she was so hysterical there was no point in doing any more examination. It would only cause her pain and not tell me anything I wouldn’t learn when the x-ray came back.

So I went out to wait for that and talk it over with the ER Doc. See, here’s the thing. It is next to impossible to break a bone knocking your elbow against a wall. Not only that, but when you roll over and smack your elbow against a wall you hit the head of the humerus, and maybe if you are very, very skinny, the very tip of your ulna. Long before you hit hard enough to break a bone, a healthy young woman is going to put her elbow through the plaster or wallboard. Bone is a lot harder. Yeah, it can hurt to jolt the ulnar nerve, what we call the “funny bone”, but it goes away in minutes, it doesn’t break bone, and it certainly doesn’t cause a transverse fracture of the ulna three inches lower. Sure enough, that’s what the x-ray showed. One of the bones of her forearm was cracked right through, but still in place without angulation. This is what we call a defensive injury, meaning it is associated with someone putting a forearm up to ward off a blow to the head.

The ER Doc went in and showed her the x-ray, and asked her boyfriend to step out for a few minutes. He refused. The doctor asked her again how this happened. She said she fell out of bed onto the floor. He explained that didn’t make sense, and asked if someone had maybe hit her in the forearm with a stick or a pipe or something. She denied it. He explained that if she was being hit, or if she remembered anything different eventually she could come back in and we had resources for her. There is an organization here that provides free shelter to women and children in dangerous domestic situations. She said she was fine. She just wanted pain meds and a cast.

So the doctor sent the nurse in to splint the arm and fix the sling so it would work right. I went in to watch and size up the boyfriend. He wouldn’t make eye-contact with me until just as they were leaving, but right at the end I caught his eye and looked him dead on.

There is no proof, of course, and we can’t press charges without her consent. But I believe he is guilty. So I stared him down. Irrationally I wanted him to take a swing at me. He was taller than I am by about four or five inches, and heavier by at least twenty pounds, but I guarantee in a fight I would kill him, because the extent of his courage is beating up on a woman.

But if she won’t stand up for herself, there is nothing I can do for her.

Bleeding Stories

I had a 58 year old patient one night who came in because he couldn’t stop bleeding.


The first sight I had of him was when I glanced into the room where the nurse was checking him in. I wasn’t planning on talking to him, but he was sitting on the gurney with his feet towards me, and a bloody washcloth between his feet. My eye zoomed straight in to a definite blood splatter right across his crotch! Now, here’s the thing about blood. It doesn’t go up, usually. It goes down. Unless, of course, it is squirting out of something, like say, an open artery. Veins don’t squirt, only arteries do. But even if it was an arterial bleed, how would it squirt upwards from his ankle to his crotch? It took me a few minutes to get the story straight, but eventually it came out that he had been lying on his back with his leg up in the air when the bleeding started. He had been taking off his socks to go to bed and he had felt something rough underneath the sock. He scratched it and it came off and started bleeding, and he couldn’t get it to stop, so he went and stood in the bath tub and called his daughter. She came to see and she couldn’t get it to stop either, so she covered it with a wash cloth, took off her belt, wrapped it three times around his ankle, and buckled it. Then she drove him into the ER where I saw him. It’s somewhat ironic that my intervention was to teach a man in his fifties how to stop a bleeding cut with direct pressure and to scold him for picking at his scabs. Seriously though, the number of people who don’t know how to do something as simple as stop bleeding is astonishing. Even civilian EMS personnel are generally useless at stopping bleeding.

This incident led the nurse to share a story from when she was working in a trauma center in a major city (I won’t say which city, but it was in the New York, San Francisco, Houston level of majorness) and an upper class looking lady came running in at three in the morning with blood all over her face. “Look,” she said, “I don’t want you to tell anyone I’m here, and I don’t want anyone to know what happened.”

“Okay,” said the nurse. “Why is that?”

“Do you know who I am,” the lady asked.

“No,” the nurse said, “I’m a travel nurse, I’m not from around here. Who are you?”

“I’m the mayor.”

“You have a nose bleed. What’s so terrible about that?”

“I was picking my nose. People cannot know about this!”

I don’t know whether or not that ever got out, but apparently the mayor, before she left for the hospital had called her son when she couldn’t get the bleeding to stop. Then she had decided she didn’t want him to know what happened, hung up and left for the ER herself. He was worried, so he came over and knocked on her door, and getting no response, peered in through the windows. And of course, all he saw was an empty house with blood all over the floor. So he called his buddies and they kicked down the door and raided his mom’s house while she was at the ER. I wonder how she explained that one when she came home to a house surrounded by lights and sirens.