persistence

The other day a survivor of sexual assault as a child came to speak to our class. From childhood to puberty she'd been abused by her father. She was amazingly in tune with how she felt back then, how she feels now, and everything she had to go through in between. I admired very much her emphasis on surviving over being victimized. The thing she said that struck me most was how she described the physical effects of her trauma as persistent. Not continuous, necessarily, but ever latent. Neck pain, sore throat, jaw aches every so often. It drew attention to the way this is embedded in her identity as much as everything else. Afterwards I asked her whether this persistence applies to emotional pain, too. As someone whose feelings have too strong of a memory and who can't concentrate after anything remotely emotional happens, I was so impressed by her capacity to carry with her all of that, to be at home with continual feeling of this sort. Besides flashbacks and the like, how often does she consciously think about it? She said, often, but not about the actual events--more about what to do with it, how to proceed with what she has. That is conscious, and persistent.

I've been told that I'm too self-aware, and I know this to be true and how sometimes damaging it can be. So to see someone with such extreme self-awareness that wasn't crippling, in the face of so much that could be, that was a source of survival, was so strong and amazing to me. We're always being told that practicing medicine is a privilege, and really most things in my life are privileges. Being new means that it's still surprising, when you realize people share with you for a reason, with an expectation that you will remember and use it as to not waste their gift, and that you are working to live up to this trust. I know how idealistic that all is and how much of it is inevitably consumed in stress, worry, limitations, and so on; how sometimes you're not given the trust at all and how other times you are and you fail. But to be given the chance? I will always take it.

My chest pain is 99% gone. The sensation was so sharp while it was there that now every time I breathe or laugh without pain, I'm aware of its absence. I find myself breathing in more often and more deeply to feel it, and am reminded that that's persistent too.

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In Connecticut, a morning in January and a morning in March don’t look too different when you look outside for help with what you should wear that day. Usually it’s bright and there’s often unplowed white on the sidewalks and people shuffling in layers. Even if there aren’t, you know enough about this coast to know that your scarf is not accessory but requisite. I came here from California, where warmth is numbing. Here winter occupies half the year, and the seasons are stitched together. Sometime in April someone starts pulling the thread. White turns to gray to yellow, a familiar and welcome flow. As capricious as the outside can be, even if it’s cold when sunny or if twenty degrees separate two consecutive days, we sense its character. And so, the oft elusive weather becomes part of our concrete knowledge.

This is why, when testing a patient’s cognitive function, we ask them what season it is. It’s supposed to come naturally. Our patient is seventy-eight, and the deeply pressed lines of her face change what I consider natural. As she furrows her forehead in an effort to find the “right” answers that she so badly wants to give us, the rain falls steadily harder outside. Watching her sit and speak in front of the weather, the bus ride we took to the nursing home feels farther away in time. I’m suddenly aware of my socks wetly clinging to the inside of my shoes.

When asked, our patient tells us the correct month—April. It’s only when she says this that I realize how far into the year we are. Only a couple weeks ago stacks of muddy ice tinged with white still created tunnels on the street. Not so long did thirty degrees feel warm. At some point in that winter the snow glazed over and made a varnish still visible at night and worthy of ice skating. During the day a friend commented that he liked how bright it was, when the snow was fresh and the sun piercing. This year it all ebbed into spring slowly so there was no time for embrace or longing. But we still remember.

When then asked what season it is, the woman sharing with us her presence hesitates. She doesn’t consult the window behind her, even though I look past her to the outside. Instead she looks ahead and I wonder at what or for. I think the sound of her delicately mouthed April has faded. Then she says, “fall,” and I think our insides break a little.

Would she have known, if we had been sitting outside to let the falling water slip off our cheeks, rest in her creases? What if the season had been the stronger one of few weeks past, and she could hear the salted snow stuck in the grooves of our shoe soles as we walked across the room to her? Or if she’d walked long enough for the water to seep into her socks? It’s out of grasp to feel what touches her, much less link sense with thought.

And fall here is not far from spring, anyway; what does it mean to mix and match transitions? It’s solemn on the ride back to school. My classmate sitting next to me confesses some depression over what he’s seen. In not these exact words he says that life is for interaction with experience, and to not know your experience takes away purpose. It’s funny to me that this sounds and is often true, when I came to medical school with the purpose of meeting experience.

But our windows tell us little, and what we feel of the outside is inexplicable. For the woman giving us her words, the layers of expression have been shed, and the experience left so bare that it’s gone from our view. Without even the frayed threads of winter past to twist around her fingers, it’s still spring.

broken

My laptop fell against the wooden table in the dining hall and the wireless card cracked, so that the covering doesn't seal the metal beneath. I Scotch-taped it, and lodged a book underneath it to keep it semi-stable. My internet flickers in and out. I have to reconnect, both to wireless and to Yale's private network each time. Don lent me a wireless card until I get a new one, but I've yet to use it or to order a new one. I'm waiting for this one to completely die out. My cell phone got caught in the rain, and wouldn't turn on. When it finally did turn on, I couldn't dial or receive calls. When I can hear someone, there's a lot of static. It sometimes turns back off, and is stubborn about returning to me. I check on it every few hours, nurse it and hold out hope that I will not need to replace it.

I have a neurotic thing about using up all my toiletries, a habit that didn't develop or become evident until I came to college and had to move each year. I like to finish my soap, toothpaste, shampoo, laundry detergent down to their last sliver, pea-sized blob, drop and so on, before I go on to another place, and in the rare case that I time it incorrectly, I bring these things with me. I can't throw them away. I have old folders whose sides I've taped up repeatedly to use again. I'm also obsessive about recycling paper, and it has little to do with the environment, more about making use of things. I keep most things, and often not out of sentimental value but out of pure value. I still have my first pair of flip-flops, from high school. And it's not about being frugal. They probably cost four dollars and I definitely got my money's worth after the first year of constant wear. I still have them because I can still wear them and because I still like them. Their jean-blue is interrupted by lines of white as their fabric's worn, and I've scruffed the layers down near the sole. I keep most anything that still fits no matter how old, I re-use and re-use.

Yesterday I wanted to write about how amazing anatomy has been. Working on her foregut pre-lab in my room, Allison mentioned how "hardy" the body is. How so many things go wrong but we find ways to survive, imperfectly. You don't REALLY need a gallbladder because bile can go from your liver to the duodenum fine. Every place in your body has at least two sources of blood, just in case one goes astray. It might make the vessels in your abdomen protrude like the head of Medusa, but you'll be alive. And of course we learn about syndrome after syndrome. Marfan, Wilson's, Horner's. Have seen patients with kidney transplants, spleens five times the normal size, cancers of the kidney and blood and so much. And each person functions in their own way, a little broken in places in the body and sometimes, most painfully, in heart.

The frail woman with Wilson's sat so still, clenched her hands so tight, stared out at us without blinking and little fear. When the light of the projector flooded her face, she squinted slowly and covered her eyes matter-of-factly. For all that calm, it felt at times like she was hiding, and how much of it was her illness and how much of it was her, I couldn't tell. I came out of that lecture thinking that my body's built better but she's stronger. With her, the way the pieces fit differently was visible, and you feel that with every patient who tells you that this or that is wrong, and it made something else wrong, and they're trying to put themselves back together but things might be missing or awry but they just want to be kept together somehow. It's okay, things have to be moved around. Scotch-taped.

And so it's hard for me to let go. I understand the difference between a quality existence and a mere existence for existence sake, but I believe so strongly in giving something its fullest life, to finding what lies in between the broken pieces. And the thing is, I do believe in an inherent, inexplicable value in just existing, continuing.

Today we had class about patient autonomy, the right of a patient to refuse treatment, to be treated as he wishes. We watched part of a documentary about Dax Cowart, a man who was severely burned in a freak explosion. Words could never conjure the image of his pain in that aftermath; it looked and felt excruciating. He wanted badly to die. He felt his life would so decrease in quality, that it wouldn't be worth going through the pain of rehabilitation to get there. He was a versatile athlete, and those days would be long over. His shrunken figure, with skin so foreign you could barely register it except for when a limb moved beneath it, begged to relieve its burden. I don't think anyone watching his whole self asking to be gone wanted to say no.

We talked for awhile about Dax. Then we saw a clip of him years later. After rehabilitation and two suicide attempts, Dax became a married lawyer. He'd lost his sight, but could live independently and actively. He fights for patients' rights to autonomy. He says that he doesn't blame his mother for keeping him alive, but that he should've been the one to make the decision. He emphasizes quality. For example, he says, if he lost his hearing, he would see that as a lesser life and he wouldn't want that. I didn't buy that, though. If he'd lost his hearing first and still had his sight, he'd probably value his sight in the same way. But because he'd already lost it, he learned to live without it. And yes, who am I to judge whether he is living as fully as if he weren't like that? I do respect people's choices, and I know that how I see life is different from how each person sees life. And of course there are boundaries and limits to how much pain a person can bear, and it depends on what lies ahead, and quality does matter because life is the non-necessities, the more-than-breathing. How I feel about this isn't a straightforward statement about how I'd want to treat a patient or even Dax himself; I still have much to learn.

But what I think about most is this. He's still living; each day he chooses to live. Do the pieces fit differently? Yes. Do they hurt, jamming into each other and sliding past and reorganizing? Yes. But do they continue? Yes.