While cramming for my board exams, I found myself tucking away medical terms like crackers. A big part of doing well on these exams has to do with associations; read nitroblue tetrazolium and think chronic granulomatous disease. At one point I learned the details of what the former and latter actually mean. These days I retain a general sense, but a lot of the finer points that would help form a concrete image are lost in the process of remembering the words. Things have become more and more familiar to me, but I don't know them more deeply.
Despite learning so much, the time has been so compact that I can still remember what it was like in the beginning. I distinctly remember feeling as overwhelmed as I still do, but also completely bewildered (as opposed to 89% so, currently). I remember sitting in front of the computer with my classmate, going through learning exercises on our school website. I remember looking at pictures of the lungs, and looking at each other, and wondering, "What's parenchyma?"
Wikipedia told us that parenchyma is the "bulk of a substance." This wasn't quite clear to us. I was used to science depicting arrows to things and giving them names, names that you could then translate into something you could point to. Over the past few years, we've learned that learning science isn't so much about precision as much as it is generalities for the details we don't know yet or can't know. Over the same past few years, the term parenchyma has been thrown around so often in relation to so many organs that we feel we know it. We know it not by memorized definition but by sense and familiarity. We can't point it out but we can nod when we hear the word. I feel this way about a lot of things in science and medicine, but parenchyma specifically crossed my mind a couple of weeks ago, and yesterday a friend of mine brought it up as an example of something he still doesn't really understand.
It's not that I think our knowledge is hollow. Every so often when I study, I'm stopped by the sudden rediscovery of how smart people can be. Sometimes words are gloss-overs, but often they are substantial representations of observation and logic. But I do feel we know less of the bulk of substances than we like to admit. After all, it's supposed to be a catch-all term for the essence of something, and we throw it around like it's something we can hold, and we dismiss the fact that we don't have precise means to define it. But if it's kind of the essence of the thing, shouldn't we take more care with that? Shouldn't we want to express it more clearly, know it better? At the least, give credit to its depth by confessing that our hands are too slippery and clumsy for it?
Writing is important to me for being a way to give more substance to our vague sense of substance. Even though it doesn't give the step by step explanation that we seek and sometimes miss from science, it acknowledges the fact that it can't. The bulk of a substance might be heavy, but weight can make things more elusive, and it seems right that this is so. For all the parts of life we know and handle, we rarely absorb it as a whole. I don't think it's meant to be fully known (or maybe it's just not possible), but I do think we're meant to seek it out (or maybe we just want to).
Showing posts with label science and what follows. Show all posts
Showing posts with label science and what follows. Show all posts
Saturday, August 7, 2010
Saturday, July 17, 2010
empathy
Learned today about a phenomenon called sympathetic ophthalmia, which I initially thought would be more accurately called empathetic ophthalmia. Basically when one eye undergoes some kind of traumatic injury, weeks later the other eye will also become diseased, even without having been subjected to any injury. So this seems more like empathy, which involves experiencing on some level another entity's experience, instead of sympathy which is more like understanding from more distance. It also brings to the surface the self-detrimental component of empathy in its rawest form.
But there's more to it than that. The mechanism is thought to be that injury to the eye exposes the body to elements in the eye that it's not used to, so the body mounts an immune response against them. So this immune response attacks parts of the other eye, and it becomes inflamed and ill. I was struck by how the valiant inefficacy of this process. As so often happens, the ways our bodies try to protect themselves result in harm, and natural processes are ramped to the point to which they become unnatural.
It's also interesting how things exist in physical compartments in ourselves, such that one part of our body is completely foreign to another part. And kind of scared of each other, the way the body is freaked out by stuff in the eye that's always been there but that it's just never seen. A good chunk of diseases is about recognizing things that are simply in the wrong place; for example, nothing should cross the diaphragm that separates the chest from the abdomen. Sometimes when I'm learning about an organ I look down at myself and wonder at how close it is and yet how little I know about how it works and what it's doing at the moment.
With all the barriers, defenses, instincts, injuries, active and passive--empathy is not so easy, I think.
But there's more to it than that. The mechanism is thought to be that injury to the eye exposes the body to elements in the eye that it's not used to, so the body mounts an immune response against them. So this immune response attacks parts of the other eye, and it becomes inflamed and ill. I was struck by how the valiant inefficacy of this process. As so often happens, the ways our bodies try to protect themselves result in harm, and natural processes are ramped to the point to which they become unnatural.
It's also interesting how things exist in physical compartments in ourselves, such that one part of our body is completely foreign to another part. And kind of scared of each other, the way the body is freaked out by stuff in the eye that's always been there but that it's just never seen. A good chunk of diseases is about recognizing things that are simply in the wrong place; for example, nothing should cross the diaphragm that separates the chest from the abdomen. Sometimes when I'm learning about an organ I look down at myself and wonder at how close it is and yet how little I know about how it works and what it's doing at the moment.
With all the barriers, defenses, instincts, injuries, active and passive--empathy is not so easy, I think.
Saturday, May 23, 2009
complicated
Someone once said that I was as complicated as the blood supply to the stomach. At the time I thought that was kind of cool. Layers and connections and difficulties, all that. You can click the picture to see the actual names of the arteries (I know no one actually wants to know them). Currently attempting to cram 500 pages of such concepts in my head, few days before test time. Stomach, you are unnecessarily mixed up and wordy.
Monday, May 4, 2009
embryology
I have four or five half-done entries saved here. Despite doing nothing of importance over the past month (actually, probably because) I have a lot of stray thoughts I wanted to aggregate here. Instead of finishing them, I've been studying or rather, thinking about how I should study.
For example, I'm supposed to learn some embryology. In theory, embryology--to learn how we grow from one cell to what we are--is pretty awesome. But because we never learned it in school as a complete concept, because I'm bad at spatial visualization, because I learn slowly and need countless repetition, and because we're required to know a smattering of facts to which I thus have to allocate my limited mental space and energy, I can't describe to you this process or even really feel its core substance, the stuff that's supposed to come before the fray details.
Instead, I know which parts of the body arise from the neural crest: autonomic nervous system (ANS), dorsal root ganglion, melanocytes, chromaffin cells of adrenal medulla, enterochromaffin cells, pia and arachnoid, celiac ganglion, Schwann cells, odontoblasts, parafollicular C cells of thyroid, laryngeal cartilage, bones of the skull.
I came up with this crude (as in unadorned) story to remember: Aunts (ANS) are my roots (dorsal root/as in my ancestry), but why do I have more melanocytes (if you know me in real life you know I'm much darker than my family)? They (the color) come from chromaffin cells (which stain brown) and enterochromaffin cells. But if you peel off the layers (pia and arachnoid, layers overlying the brain), you find we're still a steely gang (celiac ganglion). We'll go on Swan boats (Schwann cells; my relatives in Vietnam took me on a Swan boat last summer), and have a blast (odontoblast), go parachuting (parafollicular cells; I like hot air balloons and parachutes seemed close enough), and scream (laryngeal cartilage) for fear of breaking our skulls (...skull bones).
I like science and I like stories. But if you multiply the above information by say, ten thousand, that might estimate what we're supposed to know. So if I come up with ten thousand semi-sensible stories for these lists, and then remember them, I might know what I need to know for the Boards. In conclusion I would just like to say...wtf.
Of course science is founded upon inherent stories that exist outside my unimaginative imagination, and we're supposed to know a lot of that too. Still, at this point in our education there are many things whose structures are too enmeshed in mere fact and jargon to see, at least for someone like me who needs a fair amount of time and struggle to understand. It's the embryological state I would really like to understand, and to see through to completion. Like my fragments of entries.
For example, I'm supposed to learn some embryology. In theory, embryology--to learn how we grow from one cell to what we are--is pretty awesome. But because we never learned it in school as a complete concept, because I'm bad at spatial visualization, because I learn slowly and need countless repetition, and because we're required to know a smattering of facts to which I thus have to allocate my limited mental space and energy, I can't describe to you this process or even really feel its core substance, the stuff that's supposed to come before the fray details.
Instead, I know which parts of the body arise from the neural crest: autonomic nervous system (ANS), dorsal root ganglion, melanocytes, chromaffin cells of adrenal medulla, enterochromaffin cells, pia and arachnoid, celiac ganglion, Schwann cells, odontoblasts, parafollicular C cells of thyroid, laryngeal cartilage, bones of the skull.
I came up with this crude (as in unadorned) story to remember: Aunts (ANS) are my roots (dorsal root/as in my ancestry), but why do I have more melanocytes (if you know me in real life you know I'm much darker than my family)? They (the color) come from chromaffin cells (which stain brown) and enterochromaffin cells. But if you peel off the layers (pia and arachnoid, layers overlying the brain), you find we're still a steely gang (celiac ganglion). We'll go on Swan boats (Schwann cells; my relatives in Vietnam took me on a Swan boat last summer), and have a blast (odontoblast), go parachuting (parafollicular cells; I like hot air balloons and parachutes seemed close enough), and scream (laryngeal cartilage) for fear of breaking our skulls (...skull bones).
I like science and I like stories. But if you multiply the above information by say, ten thousand, that might estimate what we're supposed to know. So if I come up with ten thousand semi-sensible stories for these lists, and then remember them, I might know what I need to know for the Boards. In conclusion I would just like to say...wtf.
Of course science is founded upon inherent stories that exist outside my unimaginative imagination, and we're supposed to know a lot of that too. Still, at this point in our education there are many things whose structures are too enmeshed in mere fact and jargon to see, at least for someone like me who needs a fair amount of time and struggle to understand. It's the embryological state I would really like to understand, and to see through to completion. Like my fragments of entries.
Thursday, April 2, 2009
blindness
I have a throbbing headache, of a kind that would follow lots learned in a compact time but in my case is the result of considering the ONE thing I learned today that I'll actually remember. So we learned about a disease where the blood vessels in your head are inflamed, and when this affects the vessels to your eye, you can suffer sudden blindness. You have to treat this immediately with steroids, to save the other eye from blindness. Something I appreciated from lecture that can't be read from books was the comment on the context of the patient. The professor noted that because patients with this disease are often elderly with numerous co-morbidities, treating them with steroids is no light decision. Steroids affect just about every part of you, and it will worsen your diabetes, osteoporosis, and heart disease, all of which one elderly patient probably has. With perhaps not a very extended time left to live, the question arises of whether saving sight is worth exacerbating life-threatening conditions. Our professor posed this question and answered yes, because when blinded, the elderly often pass away within a few years. Such loss is difficult to adjust to, and depression is a co-morbidity as well, even as its path to loss of life is not as clearly defined as say, a stroke. While blindness leads to concrete things that affect health and may lead to death, like falls and fractures, it's really the general state of not seeing that is harmful.
The image of a body whose many parts have lost their respective vitalities, fighting for its sight, made me a little sad, but it also seemed right. I'm glad that when people choose to struggle, it's not for subsistence but for substance.
The image of a body whose many parts have lost their respective vitalities, fighting for its sight, made me a little sad, but it also seemed right. I'm glad that when people choose to struggle, it's not for subsistence but for substance.
Monday, February 23, 2009
iatrogenic
Learned today that before insulin was discovered, the treatment for diabetes was starvation. If you ate normally, you'd die from ketoacidosis (without insulin, your body makes too much acid, a process which pretty much messes up everything that's regulated by acid-base balance in your body and kills you). So people could choose, our teacher told us, a slow death of starvation over the quick one of diabetes. Then they found a way to isolate insulin and use it as treatment. Now, though there are still awful consequences of diabetes, it's possible to have it relatively under control. This all reminded me of how I recently learned the meaning of the word iatrogenic. This describes harmful, unintentional consequences of medical treatment. This doesn't quite exactly apply to the starving diabetics thing, but the extreme of a "treatment" directly causing death made the idea resurface.
It's something I've been thinking about for awhile. I've probably heard it before but the first time I remember it, and remember understanding it, was when I met a patient whose esophagus was perforated while receiving anesthesia for surgery for bladder cancer. This caused life-threatening inflammation of everything in his middle chest area. That was a mistake, which is what iatrogenic refers to. But somehow I take it to encompass all the fundamental harm medicine knowingly and necessarily inflicts, in order to treat illness. Last semester I met a patient with malignant bone cancer, a frank man in his thirties who managed to be friendly without smiling. He'd done a lot of research on his chemotherapy treatment, and told me that after he'd agreed to it, he read that there was a slight chance of developing leukemia from the chemo. He said he'd wished he'd been told that before. When I asked him whether it would've changed his decision, he said quite possibly, because why fight one bad thing to just acquire another.
I'd taken it for granted that one would choose to go through the treatment, especially for one so young. This is how I'm personally built, and in some ways how medicine is built. To try your damned hardest to do everything you can to fix people and situations and lives. But sometimes there's no insulin to be discovered, and trying too hard can mean starvation.
I wrote a long time ago about Jonathan Franzen's "The Corrections" and recently about "Breathing Lessons," both of which deal with the futility of our efforts to change things, and the irony of our solutions creating or worsening the problems they seek to resolve. I don't know myself how to get out of that cycle, sometimes. Despite complete understanding and direct acknowledgment of the reality of things, of the net gain or loss of happiness from my choices, of the same recurring hurt that results--I refuse to stop trying. I have found so many ways to see the value in things that are unpleasant, painful, non-ideal, but I have never reconciled myself to loss. And I mean, really. I think about it almost every day, and it is not just a matter of time or out of sight for me. People say that loss isn't your fault; it's natural, so you shouldn't try to resist so much. But I think it would be easier if it were our faults, because as reasonable and obvious as it is, the reality of loss as natural and incorrigible is incomprehensible to me sometimes. In the few connections I've had, I've fought so hard to preserve certain aspects, even when the process chipped away at me, that I ultimately have to let it all go if I want to keep myself together. I end up with a loss greater than the one I was trying to prevent.
I read Norwegian Wood during a time of all consuming ache, and one of the passages that meant most to me then comes to me again often and particularly now when I ache again: "Things will go where they're supposed to go if you just let them take their natural course. Despite your best efforts, people are going to be hurt when it's time for them to be hurt. Life is like that....You try too hard to make your life fit your way of doing things....But who can say what's best? That's why you need to grab whatever chance you have for happiness where you find it, and not worry too much about other people. My experience tells me that we get no more than two or three such chances in a lifetime, and if we let them go, we regret it for the rest of our lives."
I felt this to be so true and something that fit right into me at the time, but of course I didn't listen, not then or now. So here I am, a girl who for some inexplicable reason hates losing people more than anyone I know, turning away from a friendship that means so much to me. Giving up a connection in its entirety because not wanting to give up anything before, wanting to fix to make you and thereby myself happy, put me in a place to hurt you and be hurt. In the end it's true that this is right because we all deserve the same happiness, and it's true that we have a choice in our own happiness and I have to be the one to think of my own. Still, I'm sad.
It's something I've been thinking about for awhile. I've probably heard it before but the first time I remember it, and remember understanding it, was when I met a patient whose esophagus was perforated while receiving anesthesia for surgery for bladder cancer. This caused life-threatening inflammation of everything in his middle chest area. That was a mistake, which is what iatrogenic refers to. But somehow I take it to encompass all the fundamental harm medicine knowingly and necessarily inflicts, in order to treat illness. Last semester I met a patient with malignant bone cancer, a frank man in his thirties who managed to be friendly without smiling. He'd done a lot of research on his chemotherapy treatment, and told me that after he'd agreed to it, he read that there was a slight chance of developing leukemia from the chemo. He said he'd wished he'd been told that before. When I asked him whether it would've changed his decision, he said quite possibly, because why fight one bad thing to just acquire another.
I'd taken it for granted that one would choose to go through the treatment, especially for one so young. This is how I'm personally built, and in some ways how medicine is built. To try your damned hardest to do everything you can to fix people and situations and lives. But sometimes there's no insulin to be discovered, and trying too hard can mean starvation.
I wrote a long time ago about Jonathan Franzen's "The Corrections" and recently about "Breathing Lessons," both of which deal with the futility of our efforts to change things, and the irony of our solutions creating or worsening the problems they seek to resolve. I don't know myself how to get out of that cycle, sometimes. Despite complete understanding and direct acknowledgment of the reality of things, of the net gain or loss of happiness from my choices, of the same recurring hurt that results--I refuse to stop trying. I have found so many ways to see the value in things that are unpleasant, painful, non-ideal, but I have never reconciled myself to loss. And I mean, really. I think about it almost every day, and it is not just a matter of time or out of sight for me. People say that loss isn't your fault; it's natural, so you shouldn't try to resist so much. But I think it would be easier if it were our faults, because as reasonable and obvious as it is, the reality of loss as natural and incorrigible is incomprehensible to me sometimes. In the few connections I've had, I've fought so hard to preserve certain aspects, even when the process chipped away at me, that I ultimately have to let it all go if I want to keep myself together. I end up with a loss greater than the one I was trying to prevent.
I read Norwegian Wood during a time of all consuming ache, and one of the passages that meant most to me then comes to me again often and particularly now when I ache again: "Things will go where they're supposed to go if you just let them take their natural course. Despite your best efforts, people are going to be hurt when it's time for them to be hurt. Life is like that....You try too hard to make your life fit your way of doing things....But who can say what's best? That's why you need to grab whatever chance you have for happiness where you find it, and not worry too much about other people. My experience tells me that we get no more than two or three such chances in a lifetime, and if we let them go, we regret it for the rest of our lives."
I felt this to be so true and something that fit right into me at the time, but of course I didn't listen, not then or now. So here I am, a girl who for some inexplicable reason hates losing people more than anyone I know, turning away from a friendship that means so much to me. Giving up a connection in its entirety because not wanting to give up anything before, wanting to fix to make you and thereby myself happy, put me in a place to hurt you and be hurt. In the end it's true that this is right because we all deserve the same happiness, and it's true that we have a choice in our own happiness and I have to be the one to think of my own. Still, I'm sad.
Wednesday, November 26, 2008
cancer, etc.
Hamlet is one of my favorite Shakespeare plays. Besides the richness of language, intense drama, and so many characters with sharp life, I can relate to Hamlet’s obsessive contemplation of his own consciousness. The accepted interpretation that Hamlet destroys himself with this introspection—he thinks so much that he can never act—is my own biggest fear. A major reason I want to be a doctor is to stop only thinking about stories and instead start shaping them. But I also feel that this assessment of Hamlet attributes his failure to one misleading cause—that is, he can’t apply his thoughts to real life. As hard and real of a problem that is for many, I don’t think Shakespeare had everyone die at the end merely to say, “just don’t think; just do it already.” It’s true that the tragedy lies in the disconnect between Hamlet’s interior and the outside world. But the source of that disconnect isn’t only his inability to externalize his desires, to physically do what he mentally feels. It’s also his inability to internalize his surroundings, to absorb what he sees and hears and relate it to himself. Because he never understands what the outside world has to do with him and his identity, he can never become a part of it and so can never make any sort of impact on it.
And so after our oncology module, a compressed period where I wished I could just-do-it and thereby not feel helpless, I’m still not doing, still trying to find time and space to internalize all we’ve been exposed to and were supposed to learn. Learning about cancer comprises a slim two weeks in our curriculum, devoted to teaching us the overarching mechanism of how cancerous cells arise, spread and hurt us, and how we fight back. We received a detailed lecture on breast cancer, as a model for other cancers, and a third of each of our three workshops is a case study of a specific cancer. But mostly we just learn about cancer as a whole. After doing leukemia research and interviewing cancer patients weekly during first year of medical school, cancer remains mysterious to me and I learned anew with this module. In class we learn about it scientifically, what distinguishes it from your normal cells, how it survives, and why it’s so bad. Once as we worked through cases someone asked a question I’d wondered often before: “What actually kills you?” A lot of things, any number of things.
In class we also learn about it emotionally, hearing patients speak about their experiences and physicians lecture on palliative care. We learn big topics in forty minute increments (resting dazed for ten minutes between lectures), eat lunch, and spend the afternoon being exposed to (depending on the day) age, illness, dying and death in hospitals and hospices and nursing homes. We dedicate any and all gaps in the day to studying. It’s made slightly easier and more pathetic by the fact that we’re in a group all doing the same things.
For people in their twenties, we hear a lot about death and all that goes along with that: the preceding disease, the lives that were had and how they changed. It makes me feel I’m on the edge of a world that’s eluded my grasp for so long, that I’m growing up and into real life. Then I learn in class that one way to reduce your risk of getting breast cancer is having a child before you’re twenty-four. I’m twenty-four, and I still am a child, and I wonder what exactly I’m supposed to do with the things I know.
The language of cancer is very distinct, not just a matter of science and technical terms but also a firm foundation of key concepts, containing a lot of m’s (metastasis, malignant, mortality) and rife with percentages and units of time. Like in other areas of science, we personify it. A professor called CML a naïve cancer because it involves just one gene, making it easier to target and eradicate. In pharmacology we learn that even though some drugs eliminate mechanisms that both cancer and normal cells use, they preferentially kill cancer cells because cancer cells get addicted to one mechanism. While a normal cell can rely on other means once one is taken away, a cancer cell has lost perspective and doesn’t know what to do with itself.
I think we personify disease to understand and fight it, but we also get addicted to our language. We talk about the effects of cancer and the success of treatment in terms of five-year survival. Which isn’t a very long time to survive. But no one addresses the instinctive thought that this living five years is almost the opposite of continuing to live, since we’re beyond instinct now. We know that if your cancer hasn’t overcome everything in five years, it either wasn’t that bad to begin with or treatment is good. We know our language so well that meaning surpasses words. I think I pay close attention to words and in a little over a week I forgot how to hear them and I learned this from being told so. During a lecture on palliative care, a kind oncologist whose gray hair and matching eyes projected a natural softness told us about his wife who’d had breast cancer and subsequently acute leukemia. After being diagnosed with leukemia, someone offered her comfort in the fact that 75% of people with acute leukemia have a five-year survival. When her husband came home to find her sobbing over this, he asked her what it was that bothered her, assuming that she’d interpreted the statement as a quarter of people not achieving five year survival. Instead, she told him, “I’m 41 years old. And I only have until 46.” She thought “five year survival” meant that she’d live five more years and then it would be over. Despite that being the words’ most intrinsic meaning, I hadn’t even thought of that possibility.
These thoughts slip me because the days are crammed. One went like this. We begin the morning with a workshop on lung cancer (the cancer that takes most lives, with an overall survival rate of 15%) and brain metastases. If cancer has traveled from your lungs to your brain, they will irradiate your entire brain (our notes remind us that these patients will experience cognitive defects). It’s deemed prophylactic, and after treatment you can expect to live for one year. Following workshop, we listen to the lecture on breast cancer, which feels both scarier and less so by nature of being so prevalent in the population and mainstream culture. I know several people with breast cancer (seems like many in comparison to the number of people I know who have other illnesses, which are few) and somehow that commonness made me complacent. I am surprised to find that despite improved screening and detection, the percentage of survival isn’t as high as I expected. A quarter of women diagnosed with breast cancer die from it. We then hear from a breast cancer survivor, someone in our Yale community, who speaks to us for a near hour about her experience. From this I realize the more significant thing I’d forgotten was the visceral challenge of being ill with something that has any chance of killing you, no matter how positive the eventual outcome. In another workshop our teacher mentioned a procedure having a 5% risk of mortality, which is low, but well, “high if it’s your risk.” It’s true that on a daily basis we all face some slight percentage of dying, but cancer means having this overshadowed by something concrete and pseudo-quantifiable and personal and internal.
One thing I appreciate in medicine is individual context amidst the absolute values of care and quality of life, and there are few places wherein relativity is as palpable as cancer survival. While cure is always the ultimate goal, cancer can be so ominous that small advances are noteworthy. For colon cancer that's spread so that it's incurable by surgery, chemotherapy can prolong life significantly, “in some cases, up to two years.” A new treatment for kidney cancer is seen as an enormous breakthrough because it prolongs survival by 50%—increasing it from two months to four. Of course four versus two is a lot when it’s all you have, and who’s to say how much worth lies in any amount of time. Still, here relativity can feel like a copout.
Later that afternoon, as part of our pre-clinical curriculum we speak to a patient whose care is palliative, meaning being treated not for cure but for comfort. Ours is an 83 year old man with the mischievous sparkle of a teenager, coated with a brand of boyish charm that only comes with experience. He’d been diagnosed with lung cancer that he didn’t want to treat. He’d lived long enough, he felt, and if it’s time, it’s time. Then he came down with some sort of abdominal infection that doctors told him would kill him within a day, and still he didn’t want treatment. He hadn’t been seeking to die, but nor did he seek to live. He said goodbye to his family, and then the infection miraculously cleared on its own, leaving him alive, albeit with cancer still. When we see him, one of the first things he says is that the idea of dying in one or two days didn’t bother him. “Does that bother you?” he asks, pointing at me as I’m still maneuvering to find the right position in a narrow chair. I’m confused as to what he’s asking and I interpret it to mean, does his acceptance of his death bother me? Which is not a normal question to ask at all, but I don’t have the two seconds it takes to overthink the question even more than I already have and realize this isn’t what he means. So I respond with a quick no and during the ensuing chorus line of no’s from my classmates that might’ve just been nervous echoes of my response, I realize what he’d actually meant. And no, I do not want to die in the next couple of days. I’m completely happy with the life I’ve led so far but that doesn’t mean it’s done. If it were to happen, I’d be grateful for all that I’ve had in 24 years. But yes, I would be bothered.
In the evening, I have a meeting for the geriatrics interest group, and after talking to Don about the day he asks why I like old people. They’re different from me and I have no idea what it’s like to be them. I think maybe they’re honest not because they have nothing to lose but because they know what honesty gives. They carry everything with them that I am still looking ahead to, and they carry so much. They’re living with what I work for each day: experience, and they take that with them to each next day, because despite all they’ve lived they haven’t stopped living anew. At the meeting we talk about our screening of Rolling, a documentary where three people in wheelchairs tape their daily lives. None of them are “old.” Dr. Berland, the filmmaker, tells us the film is being promoted by the geriatrics group because it’s about facing change with dignity, and independence. I’m struck by how very different each person is, done not purposefully but truthfully. One tells us in an off-center closeup that he has so many blessings, and that nothing can take those from him. But “being blessed doesn’t mean it doesn’t hurt.” Like that Whitman line about how he’s a contradiction, and that makes sense because he’s large and he contains multitudes. That’s what each day feels like, a multitude.
And all I can do is sit with my books, which can feel empty and wrong even if necessary and engaging. After that day I go to the architecture library to study about breast and lung cancer in detail, making semi-meticulous notes from the textbook and lecture notes and workshop we’d had in the morning, putting together the details of screening, diagnosis, subtypes, staging and treatment. That we have this knowledge is beautiful, but cancer is so mysterious and we know really so little. When we first start learning about diseases we learn what begins them and here often we only know the end. All this crammed in one day, and no time at the end to think about what it means and how to use it. For lack of time and energy, I furiously scribble down events and details, with hopes of returning to fill gaps, but so much will be lost. Another day brings more, the feelings will gain different nuances, the way I started writing about my dad’s truck and he sold it before I finished the story. I’ll forget how it all started, what it was like to not know and to be introduced into these big things, encased in a hospital room and a one hour interview, to learn from these people as med students and as people. If I leave it for too long, I may look back and think I’m past the age to absorb it. As if reflection on the beginning only saves you from a blurry end where you can’t look back and remember, if you do it before you’re twenty-four.
And so after our oncology module, a compressed period where I wished I could just-do-it and thereby not feel helpless, I’m still not doing, still trying to find time and space to internalize all we’ve been exposed to and were supposed to learn. Learning about cancer comprises a slim two weeks in our curriculum, devoted to teaching us the overarching mechanism of how cancerous cells arise, spread and hurt us, and how we fight back. We received a detailed lecture on breast cancer, as a model for other cancers, and a third of each of our three workshops is a case study of a specific cancer. But mostly we just learn about cancer as a whole. After doing leukemia research and interviewing cancer patients weekly during first year of medical school, cancer remains mysterious to me and I learned anew with this module. In class we learn about it scientifically, what distinguishes it from your normal cells, how it survives, and why it’s so bad. Once as we worked through cases someone asked a question I’d wondered often before: “What actually kills you?” A lot of things, any number of things.
In class we also learn about it emotionally, hearing patients speak about their experiences and physicians lecture on palliative care. We learn big topics in forty minute increments (resting dazed for ten minutes between lectures), eat lunch, and spend the afternoon being exposed to (depending on the day) age, illness, dying and death in hospitals and hospices and nursing homes. We dedicate any and all gaps in the day to studying. It’s made slightly easier and more pathetic by the fact that we’re in a group all doing the same things.
For people in their twenties, we hear a lot about death and all that goes along with that: the preceding disease, the lives that were had and how they changed. It makes me feel I’m on the edge of a world that’s eluded my grasp for so long, that I’m growing up and into real life. Then I learn in class that one way to reduce your risk of getting breast cancer is having a child before you’re twenty-four. I’m twenty-four, and I still am a child, and I wonder what exactly I’m supposed to do with the things I know.
The language of cancer is very distinct, not just a matter of science and technical terms but also a firm foundation of key concepts, containing a lot of m’s (metastasis, malignant, mortality) and rife with percentages and units of time. Like in other areas of science, we personify it. A professor called CML a naïve cancer because it involves just one gene, making it easier to target and eradicate. In pharmacology we learn that even though some drugs eliminate mechanisms that both cancer and normal cells use, they preferentially kill cancer cells because cancer cells get addicted to one mechanism. While a normal cell can rely on other means once one is taken away, a cancer cell has lost perspective and doesn’t know what to do with itself.
I think we personify disease to understand and fight it, but we also get addicted to our language. We talk about the effects of cancer and the success of treatment in terms of five-year survival. Which isn’t a very long time to survive. But no one addresses the instinctive thought that this living five years is almost the opposite of continuing to live, since we’re beyond instinct now. We know that if your cancer hasn’t overcome everything in five years, it either wasn’t that bad to begin with or treatment is good. We know our language so well that meaning surpasses words. I think I pay close attention to words and in a little over a week I forgot how to hear them and I learned this from being told so. During a lecture on palliative care, a kind oncologist whose gray hair and matching eyes projected a natural softness told us about his wife who’d had breast cancer and subsequently acute leukemia. After being diagnosed with leukemia, someone offered her comfort in the fact that 75% of people with acute leukemia have a five-year survival. When her husband came home to find her sobbing over this, he asked her what it was that bothered her, assuming that she’d interpreted the statement as a quarter of people not achieving five year survival. Instead, she told him, “I’m 41 years old. And I only have until 46.” She thought “five year survival” meant that she’d live five more years and then it would be over. Despite that being the words’ most intrinsic meaning, I hadn’t even thought of that possibility.
These thoughts slip me because the days are crammed. One went like this. We begin the morning with a workshop on lung cancer (the cancer that takes most lives, with an overall survival rate of 15%) and brain metastases. If cancer has traveled from your lungs to your brain, they will irradiate your entire brain (our notes remind us that these patients will experience cognitive defects). It’s deemed prophylactic, and after treatment you can expect to live for one year. Following workshop, we listen to the lecture on breast cancer, which feels both scarier and less so by nature of being so prevalent in the population and mainstream culture. I know several people with breast cancer (seems like many in comparison to the number of people I know who have other illnesses, which are few) and somehow that commonness made me complacent. I am surprised to find that despite improved screening and detection, the percentage of survival isn’t as high as I expected. A quarter of women diagnosed with breast cancer die from it. We then hear from a breast cancer survivor, someone in our Yale community, who speaks to us for a near hour about her experience. From this I realize the more significant thing I’d forgotten was the visceral challenge of being ill with something that has any chance of killing you, no matter how positive the eventual outcome. In another workshop our teacher mentioned a procedure having a 5% risk of mortality, which is low, but well, “high if it’s your risk.” It’s true that on a daily basis we all face some slight percentage of dying, but cancer means having this overshadowed by something concrete and pseudo-quantifiable and personal and internal.
One thing I appreciate in medicine is individual context amidst the absolute values of care and quality of life, and there are few places wherein relativity is as palpable as cancer survival. While cure is always the ultimate goal, cancer can be so ominous that small advances are noteworthy. For colon cancer that's spread so that it's incurable by surgery, chemotherapy can prolong life significantly, “in some cases, up to two years.” A new treatment for kidney cancer is seen as an enormous breakthrough because it prolongs survival by 50%—increasing it from two months to four. Of course four versus two is a lot when it’s all you have, and who’s to say how much worth lies in any amount of time. Still, here relativity can feel like a copout.
Later that afternoon, as part of our pre-clinical curriculum we speak to a patient whose care is palliative, meaning being treated not for cure but for comfort. Ours is an 83 year old man with the mischievous sparkle of a teenager, coated with a brand of boyish charm that only comes with experience. He’d been diagnosed with lung cancer that he didn’t want to treat. He’d lived long enough, he felt, and if it’s time, it’s time. Then he came down with some sort of abdominal infection that doctors told him would kill him within a day, and still he didn’t want treatment. He hadn’t been seeking to die, but nor did he seek to live. He said goodbye to his family, and then the infection miraculously cleared on its own, leaving him alive, albeit with cancer still. When we see him, one of the first things he says is that the idea of dying in one or two days didn’t bother him. “Does that bother you?” he asks, pointing at me as I’m still maneuvering to find the right position in a narrow chair. I’m confused as to what he’s asking and I interpret it to mean, does his acceptance of his death bother me? Which is not a normal question to ask at all, but I don’t have the two seconds it takes to overthink the question even more than I already have and realize this isn’t what he means. So I respond with a quick no and during the ensuing chorus line of no’s from my classmates that might’ve just been nervous echoes of my response, I realize what he’d actually meant. And no, I do not want to die in the next couple of days. I’m completely happy with the life I’ve led so far but that doesn’t mean it’s done. If it were to happen, I’d be grateful for all that I’ve had in 24 years. But yes, I would be bothered.
In the evening, I have a meeting for the geriatrics interest group, and after talking to Don about the day he asks why I like old people. They’re different from me and I have no idea what it’s like to be them. I think maybe they’re honest not because they have nothing to lose but because they know what honesty gives. They carry everything with them that I am still looking ahead to, and they carry so much. They’re living with what I work for each day: experience, and they take that with them to each next day, because despite all they’ve lived they haven’t stopped living anew. At the meeting we talk about our screening of Rolling, a documentary where three people in wheelchairs tape their daily lives. None of them are “old.” Dr. Berland, the filmmaker, tells us the film is being promoted by the geriatrics group because it’s about facing change with dignity, and independence. I’m struck by how very different each person is, done not purposefully but truthfully. One tells us in an off-center closeup that he has so many blessings, and that nothing can take those from him. But “being blessed doesn’t mean it doesn’t hurt.” Like that Whitman line about how he’s a contradiction, and that makes sense because he’s large and he contains multitudes. That’s what each day feels like, a multitude.
And all I can do is sit with my books, which can feel empty and wrong even if necessary and engaging. After that day I go to the architecture library to study about breast and lung cancer in detail, making semi-meticulous notes from the textbook and lecture notes and workshop we’d had in the morning, putting together the details of screening, diagnosis, subtypes, staging and treatment. That we have this knowledge is beautiful, but cancer is so mysterious and we know really so little. When we first start learning about diseases we learn what begins them and here often we only know the end. All this crammed in one day, and no time at the end to think about what it means and how to use it. For lack of time and energy, I furiously scribble down events and details, with hopes of returning to fill gaps, but so much will be lost. Another day brings more, the feelings will gain different nuances, the way I started writing about my dad’s truck and he sold it before I finished the story. I’ll forget how it all started, what it was like to not know and to be introduced into these big things, encased in a hospital room and a one hour interview, to learn from these people as med students and as people. If I leave it for too long, I may look back and think I’m past the age to absorb it. As if reflection on the beginning only saves you from a blurry end where you can’t look back and remember, if you do it before you’re twenty-four.
Tuesday, May 20, 2008
the second time around
Back in the fall, in biochemistry, we learned about Lesch-Nyhan disease. People with Lesch-Nyhan are deficient in an enzyme called HGPRT involved in purine salvage, which leads to uric acid buildup. I remember these details because the other thing about people with Lesch-Nyhan is that they for some reason also mutilate themselves. They bite their own lips and fingers. Completely helpless to stop themselves, people with this disease often bandage their hands to prevent inflicting hurt upon themselves. Our professor referred us to a New Yorker article about a man with Lesch-Nyhan, and how the lack of control in self-mutilation pervades his entire approach to life. Instead of telling someone he loves them, he swears at them. Seeing a sharp pencil induces an uncontrollable urge to take it and do harm. He uses his right hand to grab and restrain his left hand from grabbing a knife and hurting himself or someone else. His intentions and his actions are completely at odds, and they divide his body.
The author of the article framed the disease as the extreme end of a phenomenon of which we are all victim, what Edgar Allen Poe termed "the imp of the perverse." The idea that we all do things that we know are bad for ourselves, like eating too much junk food to the point it's not pleasurable anymore or contemplating swerving your car into oncoming traffic for no particular reason. I remember first learning about this strange, rare disease and thinking that I must have some emotional form of Lesch-Nyhan, where I perpetuate things that I know, in mind and in heart, are not good for me and will hurt me.
Doing it once made me none the wiser the second time around. In a recent lecture about the biological basis of pain, we learned that when you feel a certain kind of pain for the second time, you feel it more acutely because you know its character. I'm not sure about the implications about your recovery and resilience, because I would guess there is also a desensitization process, the idea that pain makes you stronger and more able the next time. But what was clear is that once you get to know pain through first encounter, you are more aware when it hits you again. You don't have to feel around in the dark to learn its edges and figure out how to hold it. You know its contours without exploration.
The professor who lectured on pain did make a mistake, though, when he alluded to Lesch-Nyhan and said that people with the disease don't feel pain when they self-mutilate. I distinctly remember that they do feel pain, but the awareness of it can't stop them from hurting themselves. For them there is no desensitization or increased strength, only a constant fight against recurring pain. But I admired the man in the article, because there was a deliberate fight, a will against what he did to himself even if he knew it would continue.
For all the mistakes that I make twice and three times, growth does lurk in the corners. Despite similar themes, and a similar trajectory of trying not to hurt anyone and in the process hurting everyone including myself--there are different circumstances, reasons, people, feelings, and most importantly, more things learned. It does make me wonder again if I'll ever feel the same as I did the first time around. That used to worry me, but now I know that each thing offers something else, and it's valuable. And if I experience that feeling again, it will still have newness and surprises and a sense of other. It makes me think that for the man with Lesch-Nyhan, each finger bitten is not quite the same, and that even though you know the shape of its pain, you still reach out to find something different.
When I told Guson I was going home before summer because I missed my parents, he said I was maturing. My immediate reaction was to reject that idea, because isn't growing up about not missing home, not needing your parents? But it turns out he was right. There's only been one other time when I made sudden plans to go home. That time was a result of wanting to be away from where I was, a push from there to home. This time, I don't feel a push away from anything--I absolutely love where I am, in all senses--instead, it's a pull from home. That time I felt a little weak and this time I feel stronger. This time around, it's different.
The author of the article framed the disease as the extreme end of a phenomenon of which we are all victim, what Edgar Allen Poe termed "the imp of the perverse." The idea that we all do things that we know are bad for ourselves, like eating too much junk food to the point it's not pleasurable anymore or contemplating swerving your car into oncoming traffic for no particular reason. I remember first learning about this strange, rare disease and thinking that I must have some emotional form of Lesch-Nyhan, where I perpetuate things that I know, in mind and in heart, are not good for me and will hurt me.
Doing it once made me none the wiser the second time around. In a recent lecture about the biological basis of pain, we learned that when you feel a certain kind of pain for the second time, you feel it more acutely because you know its character. I'm not sure about the implications about your recovery and resilience, because I would guess there is also a desensitization process, the idea that pain makes you stronger and more able the next time. But what was clear is that once you get to know pain through first encounter, you are more aware when it hits you again. You don't have to feel around in the dark to learn its edges and figure out how to hold it. You know its contours without exploration.
The professor who lectured on pain did make a mistake, though, when he alluded to Lesch-Nyhan and said that people with the disease don't feel pain when they self-mutilate. I distinctly remember that they do feel pain, but the awareness of it can't stop them from hurting themselves. For them there is no desensitization or increased strength, only a constant fight against recurring pain. But I admired the man in the article, because there was a deliberate fight, a will against what he did to himself even if he knew it would continue.
For all the mistakes that I make twice and three times, growth does lurk in the corners. Despite similar themes, and a similar trajectory of trying not to hurt anyone and in the process hurting everyone including myself--there are different circumstances, reasons, people, feelings, and most importantly, more things learned. It does make me wonder again if I'll ever feel the same as I did the first time around. That used to worry me, but now I know that each thing offers something else, and it's valuable. And if I experience that feeling again, it will still have newness and surprises and a sense of other. It makes me think that for the man with Lesch-Nyhan, each finger bitten is not quite the same, and that even though you know the shape of its pain, you still reach out to find something different.
When I told Guson I was going home before summer because I missed my parents, he said I was maturing. My immediate reaction was to reject that idea, because isn't growing up about not missing home, not needing your parents? But it turns out he was right. There's only been one other time when I made sudden plans to go home. That time was a result of wanting to be away from where I was, a push from there to home. This time, I don't feel a push away from anything--I absolutely love where I am, in all senses--instead, it's a pull from home. That time I felt a little weak and this time I feel stronger. This time around, it's different.
Monday, February 4, 2008
lub-dub
Last Thursday, on the last day of this year's first month, thirty and some of us sat in a lecture hall with stethophones on our laps and in our ears, listening to heart sounds that a stout doctor committed to principles of the physical exam played for us on a mysterious machine that used infrared waves to contact some rectangular box attached to our devices. His words are clear and serious. You've all been listening to normal hearts. It's important to know what abnormalities sound like. Know murmurs. Here's what mitral regurgitation sounds like. Once you hear it, you'll never forget it. First I'll start out with the normal heartbeat, and then I'll add the murmur.
We listen and wait. Here it comes. Lub-dub. Lub-dub. So soothing and constant and rhythmic and after such a long day, more than a bit sleep-inducing. I see him turn a knob and then whooosh. There's the murmur. Lub-d--whooosh--ub. Lub-d-whooosh-ub. I thought, suddenly--wow. That's it. My life is this lub-dub and I'm that whooosh that's just passing it by.
*
Thursday began with a 9 AM lecture on renal physiology. In college I hated studying the kidney because there are so many parts and each one functions intricately differently. But it's true that repetition helps, because after a very cursory look in college, the first overview lecture here, and the histology lab, I wasn't as intimidated by having to hear someone talk about how the kidney reabsorbs salt and water for an hour. It turned out to be an hour lecture on the proximal tubule (1/6 of the kidney's tubules). Just the proximal tubule. It was surprisingly good. The proximal tubule is a hard worker and very smart.
From 10 AM-1 PM we had our last anatomy lab. It was the most brutal we've had, and yet anticlimatic. I haven't been too bothered by the physicality of anatomy; it's been more beautiful than disturbing. Removing the chest wall, dislocating the shoulder, uncovering the hand muscle by muscle--it's all been for something, even at times we spend more time with dissection than actual visualization. It never seemed disrespectful, and we are reminded so often of what our donor should mean to us, to respect their gift.
This time, the sounds and movements and my own inability to distinguish anything in the nasal and oral pharynxes made the procedure seem unnecessary and made me feel sorry for doing it. It involved sawing the head--skull and all--in half. Through the nasal septum, if you managed to be exact. The sound was in one word, awful. We used a manual saw, and it was worse than the loud grinding of the mechanical one we've had in the past. Because the exertion was so obvious and physical, the back-and-forth and the amount of time was palpable.
Perhaps I should have prepared more, but the fact that I didn't know anything about the nose and mouth and gained very little from the lab made me feel infinitely more guilty for doing this to our donor. I don't attach too much significance to the body after death; I'd like to be cremated and I have some sense of some sort of soul. So it's not like I prioritize bodily preservation, but the sacred the body holds when alive can't help but remain.
I will remember where I saw my donor's ligamentum arteriosum because it made sense based on what I knew about it--I remember Rizzolo forcing us to reason out why it would be there and how satisfying it was to confirm it both anatomically and intellectually. I will remember the long tendons of his arm and hand and moving them to move his fingers, my favorite lab. I will remember the subdural hematoma that engulfed his brain and how that both fascinated and hurt me. But how much anatomy will I remember? Likely little. Are those memories enough to justify everything else? I'm not sure. I'm not sure if it would be enough for me to give myself up, even as a person who thinks little of what will happen to my body after this is all over.
And so, it ended. Not quite with a whimper, but definitely no bang. Allison and I were talking afterwards about whether we'd have strong visual memories of our donors. I said I didn't think so, because we never looked at the body in its entirety. We always covered parts we weren't working on, including the face, which would be easiest to remember. It's hard to really retain vivid images of things in isolation.
Yet--though I don't feel I've solidified an image of his body or even his face, I do know I've acquired, in slow and fast gulps, an entirely new perspective of body. They say anatomy is a rite of passage, and it is. It is, not for all the arteries and nerves and muscles, but for the new and complex and strange and wordless.
After lunch (and no, it's not really strange at all to eat after anatomy lab), I made a quick run to the post-office to drop off my ballot for Super Tuesday; the fresh air was nice. Then I had a meeting from 2-2:30 PM with a professor at the Public Health school. It was one of two required meetings for my application to go to Vietnam this summer. I'm hoping to do a social health project to evaluate the effects of the healthcare system on low-income patients, in terms of their living conditions, employment and education. The professor was helpful in telling me what I needed to do to make the study design tighter--which is the most difficult part of the whole thing. If it pans out, I'd be based in Hanoi, but also live with a family in a rural commune while doing fieldwork. Talking about the finer details made some anxiety about getting it all done re-surge, but I'm hoping very hard it works out.
From 3-5 PM we had Pre-Clinical Clerkship. Since the new semester started, it's been all physical exam. I honestly hadn't given much thought to doing the physical exam prior to this; despite it being a core experience, it wasn't something I associated with medical school like I did with anatomy. I guess I couldn't really see myself doing it. It's been fairly incredible. I feel as inept as ever, but small improvements like actually knowing the names of my instruments and how to hold them makes me feel disproportionately good. The fulfillment of DOING stuff gets so lost in academics, and it's been refreshing to feel things very concretely.
The hardest thing thus far has been using the opthalmoscope to look into people's eyes. You have to get uncomfortably close to a person's face to do so, and keep one eye closed. I discovered what a struggle it is to keep my left eye open when my right's closed. Then seeing the person's blood vessels is surprisingly difficult--finding the optic disc near-impossible. After many, many tries on different weeks I finally saw one, and again the excitement was too large for such a tiny thing.
Dean Angoff introduced our introduction to the physical exam by saying how important it is to feel the discomfort, anxiety, vulnerability of the patient. That by being patients for our partners to practice on, we have some sense of what it's like to have to bare yourself for inspection. I love Dean Angoff, and I love that after so many years in medicine she is still so in tune with people. I have definitely felt anxiety being the patient, and she makes me remember to be thankful to have that feeling to draw upon in the future. I'm not going to lie. Taking my shirt off for the lung and heart exams was uncomfortable. Actually, even having a light shone in my nostrils was discomfiting. And that's with an awesome partner who couldn't be more considerate. I imagine it's worse for a patient, who doesn't even know why we're doing things, whereas we understand why someone's poking us in this place and that.
The physical exam has also added yet another thing to draw our class into a cult, of people who torture each other with bright lights in our eyes and amateur percussing and hesitantly sticking otoscopes in our ears without damaging something in there. I try to step back and look at that from the outside, and it amuses me and find that as awkward as it can be to do this on people you know, it's another aspect of the med student bond. However, I welcome any of you to be my patients for practice.
This week's physical exam practice was supplemented with the heart sounds session I mentioned before. It is amazing to hear something buried in you beating in your ears. It is extremely hard for me to distinguish sounds, which beat is louder at certain places, the timing of a beat and an underlying/overlying murmur. It's such an art.
The day finally officially ended, and I spent my hour before dinner ordering books--Let's Go for PUERTO RICO, and yet more Murakami to read while in PUERTO RICO. After a five-hour planning party wherein ten or so people were in and out of my room on three computers searching for travel deals and spilling tea and yogurt on my sheets, we booked TWO rooms for FOURTEEN people in San Juan. Six nights, six-and-a-half days with packed, co-ed rooms. I am so excited, and so glad that all my good friends here will be together in another country with no med school frenzy.
After a nice dinner (our dorm food is always bad, but company is always good), I thought about doing work, but ended up g-chatting with Allison for a couple hours about boys, school, motivation, friends. Even though we're so busy, I think we all give a lot of thought to our experience here--why and how. It's necessary to stop to consider what we're doing, because it's so easy to get swept up in the rhythm of things.
I did manage to review the kidney lecture from the morning, but that was about it before we headed to PubMed. PubMed is a free party with open-bar on the first floor of our dorm. Its convenience cannot be beat. We got pretty tipsy. Some of our classmates who have formed a band performed several songs. Events like this make me want to grow super arms to hug my entire class at once. They are so goofy and amusing and supportive of one another. I like how, since the first day we went out, we can all dance with each other in complete innocence and fun. He and I had a tiff and a moment, which consumed most of the night but ended with me glad for how people surprise you.
*
I don't write much about daily happenings, because for me they don't give a good impression of how things are. But giving a sense of what medical school is like is difficult. Thoughts and responses clamor for space and it's hard to fully revisit any one of them. Thursday, January 31 was a long day with a smattering of almost every thing that comprises my life here, and one I'd like to remember in detail. I'd like to calm that murmur and listen to the beat of things.
Sunday, December 9, 2007
anastomoses
I used to think that fiction would bring about my downfall, but am finding that scientific fact is contributing too. Each offers a glimpse of beauty whose existence I appreciate and consequently strive to possess, but can't quite create for myself.
Everyone here turns to me when they want to know in what context the word "satiate" can be used or which Shakespeare play "Get thee to a nunnery" is from or what some eight-letter word means. I've almost never been able to give an accurate or complete answer. I would like to explain to everyone that for me, studying literature means only appreciation, not expertise. We speak the same language; I don't know any secrets. I can't verbalize myself any better than you--I'm probably worse at it because I value all the feelings and know none of the constructs.
On the other end of the spectrum, Aud says that I'm already using a different language now that I'm in medical school (something everyone warns you about). Three months of massive amounts of material and learning later, I find myself with a new vocabulary but little fluency. I know a lot of multisyllabic words but don't expect me to tell you a story.
"Kafka on the Shore" alternates chapters between two narrators whose stories appear disparate and converge as the novel goes on. A familiar device, but Murakami is aware of its contrived nature. He makes us conscious that he's conscious of it. We grow to understand that the point is not that this kind of connection actually exists. In fact, the out-of-reality happenings remind us that this doesn't happen and won't happen. The point is we can substantiate our underlying desire for connection in fiction. Murakami never confirms the connection, never actually says that this could happen, but nudges us and says, but doesn't it make sense to happen this way? Isn't it beautiful this way, doesn't it hurt in that lovely aching way and make you breathe slightly irregularly?
In anatomy we hear "anastomosis" over and over. Two arteries start from the same source (the aorta), branch off and become different things (the posterior and anterior intercostal arteries), then these different things come back and converge. So it does happen in a concrete thing, and it makes sense, and it's beautiful in how it works. Every part of the body is related to another, and it is a system of connections that keeps you breathing so you can tell when someone like Murakami comes along and makes you breathe offbeat.
But that's a body and that's a book, and this is me.
Everyone here turns to me when they want to know in what context the word "satiate" can be used or which Shakespeare play "Get thee to a nunnery" is from or what some eight-letter word means. I've almost never been able to give an accurate or complete answer. I would like to explain to everyone that for me, studying literature means only appreciation, not expertise. We speak the same language; I don't know any secrets. I can't verbalize myself any better than you--I'm probably worse at it because I value all the feelings and know none of the constructs.
On the other end of the spectrum, Aud says that I'm already using a different language now that I'm in medical school (something everyone warns you about). Three months of massive amounts of material and learning later, I find myself with a new vocabulary but little fluency. I know a lot of multisyllabic words but don't expect me to tell you a story.
"Kafka on the Shore" alternates chapters between two narrators whose stories appear disparate and converge as the novel goes on. A familiar device, but Murakami is aware of its contrived nature. He makes us conscious that he's conscious of it. We grow to understand that the point is not that this kind of connection actually exists. In fact, the out-of-reality happenings remind us that this doesn't happen and won't happen. The point is we can substantiate our underlying desire for connection in fiction. Murakami never confirms the connection, never actually says that this could happen, but nudges us and says, but doesn't it make sense to happen this way? Isn't it beautiful this way, doesn't it hurt in that lovely aching way and make you breathe slightly irregularly?
In anatomy we hear "anastomosis" over and over. Two arteries start from the same source (the aorta), branch off and become different things (the posterior and anterior intercostal arteries), then these different things come back and converge. So it does happen in a concrete thing, and it makes sense, and it's beautiful in how it works. Every part of the body is related to another, and it is a system of connections that keeps you breathing so you can tell when someone like Murakami comes along and makes you breathe offbeat.
But that's a body and that's a book, and this is me.
Wednesday, October 24, 2007
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.
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.
Wednesday, September 26, 2007
the heart
Me: I think I have a heart defect.
Friend: Why?
Me: I have to think about it. I just know it's an odd heart.
*
We've been learning about the heart. We've read about it from the point that two cells make one embryo, to how it functions in a baby, to how it morphs into an adult. We've seen our professor twist foam tubes to help us visualize (couldn't tell one end from another). We've watched animations on our computer on how the heart folds, closes, develops. We've detached the lungs from the heart in our donors, and held the heart in our hands--not fully, still clinging onto the body. We haven't seen the individual chambers yet, but we can peer at the vessels cut open on either side.
The heart, like everything when you really think about it, is complicated and simple. It is important and complex. It's a system, and of course another system could have worked, but it's this one that we have. It's an amazing one, but a million things can go wrong. In the end it's a fragile thing; it gets confused and malformed and tired out. It is so beautiful.
The fetal heart can't depend on lungs for oxygen. So it comes up with all these mechanisms to deal with it. It might make you wonder why the fetus doesn't just have functional lungs. But you don't instinctually think that. Instinctually you think that of course, it has to grow. Its starts one way and it learns and ends up in another way. It doesn't happen right away. I think it's funny, though, that the mechanisms the heart has to cope with not being fully developed yet, are just as complex as the development the heart is waiting for.
Sometimes the adult heart suffers because one of these fetal heart qualities persists, never goes away. In the fetal heart blood can travel between the right and left atria. In the adult heart, this portal closes. It should close.
In one of our case studies, a patient had a thrombus (clot) in his vein that traveled to his brain and caused a stroke. In a normal person, this clot would have traveled through his heart to his lungs and might not have caused much of a problem. But this patient still had the portal between his atria. So the clot has two paths: a normal one through one atrium to the lung and an abnormal one, through one atrium to the next atrium and to the body, to the brain. The clot in this patient took the latter path. An online animation showed the clot on its course, and I found myself mourning it aloud. Oh no. Oh, that's sad.
This is called a "paradoxical" clot, because it starts out in one system (pulmonary, that of the lungs), but it ends in another (systemic, that of the body). That's the price of staying undeveloped, of staying open, of leaving another path, one that's not right and not healthy. Your system hurts itself, makes a mistake, misjudges.
But you can't say it's unnatural, this so-called defect--it's natural, it's how you were made. And so what if you didn't make the decision to have it that way, to keep a remnant of your innocent, brand-new self? And so what if you still have the choice of two paths, when inevitably you are going to have to go down both and one will hurt?
I love the heart. It's so strong and vulnerable. It can adjust to some alterations, but it's particular. It needs certain things, and it needs them to give them away, all the while sustaining itself. I love the heart. But I don't think I will study it in isolation. Someone else should prevent strokes and the like, but me, I don't think I can look after odd hearts. I wouldn't want to fix them.
Friend: Why?
Me: I have to think about it. I just know it's an odd heart.
*
We've been learning about the heart. We've read about it from the point that two cells make one embryo, to how it functions in a baby, to how it morphs into an adult. We've seen our professor twist foam tubes to help us visualize (couldn't tell one end from another). We've watched animations on our computer on how the heart folds, closes, develops. We've detached the lungs from the heart in our donors, and held the heart in our hands--not fully, still clinging onto the body. We haven't seen the individual chambers yet, but we can peer at the vessels cut open on either side.
The heart, like everything when you really think about it, is complicated and simple. It is important and complex. It's a system, and of course another system could have worked, but it's this one that we have. It's an amazing one, but a million things can go wrong. In the end it's a fragile thing; it gets confused and malformed and tired out. It is so beautiful.
The fetal heart can't depend on lungs for oxygen. So it comes up with all these mechanisms to deal with it. It might make you wonder why the fetus doesn't just have functional lungs. But you don't instinctually think that. Instinctually you think that of course, it has to grow. Its starts one way and it learns and ends up in another way. It doesn't happen right away. I think it's funny, though, that the mechanisms the heart has to cope with not being fully developed yet, are just as complex as the development the heart is waiting for.
Sometimes the adult heart suffers because one of these fetal heart qualities persists, never goes away. In the fetal heart blood can travel between the right and left atria. In the adult heart, this portal closes. It should close.
In one of our case studies, a patient had a thrombus (clot) in his vein that traveled to his brain and caused a stroke. In a normal person, this clot would have traveled through his heart to his lungs and might not have caused much of a problem. But this patient still had the portal between his atria. So the clot has two paths: a normal one through one atrium to the lung and an abnormal one, through one atrium to the next atrium and to the body, to the brain. The clot in this patient took the latter path. An online animation showed the clot on its course, and I found myself mourning it aloud. Oh no. Oh, that's sad.
This is called a "paradoxical" clot, because it starts out in one system (pulmonary, that of the lungs), but it ends in another (systemic, that of the body). That's the price of staying undeveloped, of staying open, of leaving another path, one that's not right and not healthy. Your system hurts itself, makes a mistake, misjudges.
But you can't say it's unnatural, this so-called defect--it's natural, it's how you were made. And so what if you didn't make the decision to have it that way, to keep a remnant of your innocent, brand-new self? And so what if you still have the choice of two paths, when inevitably you are going to have to go down both and one will hurt?
I love the heart. It's so strong and vulnerable. It can adjust to some alterations, but it's particular. It needs certain things, and it needs them to give them away, all the while sustaining itself. I love the heart. But I don't think I will study it in isolation. Someone else should prevent strokes and the like, but me, I don't think I can look after odd hearts. I wouldn't want to fix them.
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