delirium

I met a wonderful 90 year old who came to the hospital for a serious infection in his lungs and blood, who would go in and out of clarity. There were moments where we could converse happily and he'd tell sweet, funny jokes; other times he'd blink slowly and stare blankly, and throughout his stay pain management was an issue. His intermittent moans of pain, physical and inner, gave slight insight into his distress and distressed his neighbors so that he was moved to his own room. Sometimes there was a physical source; other times it seemed expression for something deeper. A gland in his mouth was infected, making it painful for him to eat, dehydrating him. A nurse described his tongue as lizard skin, crusted over with yellow and white; his teeth and the back of his throat covered in the same film. I watched swabs be used to clean him, and I'd never seen so much foreign come from a person's mouth. Each day we'd check, and it looked better after that but I found myself compulsively swabbing him anyway. Brought heat packs and massaged the area, as recommended by the ear nose throat doctors, needing to do something concrete even though quite unsure of the use. In the hospital he began having pain in his rectum. He had diarrhea so much that the nurses put a tube in him ("fecal management system"), and we tried our best--creams, morphine, opiates delivered directly to the source of pain. Sometimes he cried. Not out of pain; out of sadness. He recovered from his infection, but with his continued delirium and inability to do physical therapy, the decision was made to move him to the hospice unit.

When we came to see him at hospice, he was clean. Every day now he says he has no pain. He draws our attention to his smooth skin, freshly shaven. One day he was in the hallway, and said he was waiting for a hair cut (a trim of handsome white peach fuzz). There are still moments of sadness, of his forming phrases--I don't want to leave you, I know all the answers but the game isn't there, I want to live, yes I know but more. And sometimes there are still hallucinations. But he is clean and without pain, and while we try to not let that be everything, we're grateful for that something.

Later we had a class on delirium. After going through a long list of causes of delirium (infection, decreased oxygen, too little salt, too much salt, kidney failure, dehydration, so on and on), our professor asked us how to prevent delirium. Antibiotics for infection? No. We drew a blank on how to prevent all the other causes, and he told us to give up because that wasn't how to think about it. Instead, he told us that studies had been done to show that when people are confronted with these illnesses, six things were shown to reduce the incidence of delirum: sleep, hydration, cognition, vision, hearing, and mobility. Ensuring lights out and reduced noise during hours of sleep, keeping people hydrated, playing daily memory games to maintain cognition, supplying visual and hearing aids, and having some sort of physical therapy--these things kept patients' senses functioning as their bodies fought sickness. Except for hydration, these things didn't target the direct causes of delirium; the people were still sick, but among those who were sick, their alertness and awareness, and thereby communication, interaction and general comfort, were healthier. So it makes much sense that a place like hospice, a place focused on comfort, kept his delirium a bit more at bay, and the idea of holistic care carries hope.

I've been reminded to take care of myself during the intense medicine rotation, and I think I have. It is true that there is less time and energy to go around during this rotation, but aside from a handful of tiring nights it hasn't been overwhelming. The time to spare does have to be allocated and delegated carefully, and after taking care of myself there's not much left over, but this also means that I've paid good attention to the things that provide care, and subsequently relished them. Everyone has their own six things to keep them sane, with some basics and some variation, and third year had me finding them quickly: sleep, cooking, running, friends, dancing, and places. Sleep goes without saying. Cooking at least once or twice a week reminds me that the days don't have to be rushed or prepackaged. The other week I sat down and ate without doing anything else, for the first time in I don't know how long. No company, no phone conversation, no tv, no internet, no reading book or textbook. Eating, and eating alone, allows for rest and like with any other isolation, for heightened senses; in this case, taste. I also associate a certain strange satisfaction with finishing leftovers, so even those days held a certain sense of still functioning. Aside from a two week hiatus during the height of a cough I still have, I've been running a slow six miles at least twice a week. So far this pace and time is suiting my schedule better than faster or longer, and the thing I now remember with running is that what happens on one run doesn't predict the next. Some days you just feel better and faster, and other days you feel like crap, and I've learned to not feel bad about the crappy days. On those days I remember that it's good just to be moving, and that it's enough to do it, regardless of how, and that the highs and lows balance. And this makes me feel better about whatever else I might be doing not so well at the moment, or at other moments.

As for friends, I continue to be glad every day for the people in my life, here and around, presently and from my past, and find that every interaction affirms the gratitude. I feel lucky to be in an environment where I feel comfortable with a good number of people; namely, a small place, as I think the number of people had a lot to do with some of my isolation in college. I feel lucky to find time for snippets and sprawls of conversation, for the emails and gchats and calls and meals and outings, to know people I really love, and love knowing, and love knowing of their presence. These tend to be with people with whom I'm particularly close, while dancing can extend to my class as a whole. It makes me happy to be dancing with my college roommates on another Halloween, with whom I've danced so many good nights, remembering we don't need much else than ourselves to be crazy and escape-happy. It also makes me happy to be dancing with a crowd of classmates, many I haven't seen in months, in a flashback of our first year when we danced almost every week. Several have distinct styles that are equally awesome and smile-so-hard-it-hurts inducing. And there's just something inherently fun and wonderful about a group of people going crazy for no real reason other than that it's inherently fun and wonderful. This weekend we celebrated two class birthdays, both with a lot of dancing, one more club-style the other a la karaoke, and I wasn't anticipating such fun before either, so all the more reason to relish. It was nice and hilarious to see A., usually not so mobile, moving with such adrenaline; M. singing everything from Beyonce to Barbie Girl; and clusters of us interacting with each other through something simple and thoughtless.

Places may be the most vague, and maybe that's why I need it. The day when it was decided to move him to hospice, we happened upon an ethereal cemetery on the way home from the hospital, and we went. It was palpably cathartic, and beautiful. N. had never been to a cemetery before, and I'd never been to one in quite that way. The air was autumn crisp, with much sun, and we came back another day for pictures, lying on patches of leaves, and re-exploration of its huge open fields, the rows upon rows of stone, slopey hills, and wheat like weeds brushing the pond. We've driven hours north for fall leaves to come across shallow streams we don't dare drive across, and few miles away for a coffeeshop with rain stained glass where we hide until it comes down too hard to wait any longer. Each time I feel the distance from here, from knowing there is more and that though he will be in one room from now on the space is wide.