My Antonia

Recently My Antonia by Willa Cather made it to the top of my reading pile. As I get older and my years growing up in Iowa get further and fewer I get more romantic about life there and My Antonia is nothing if not romantic. I was pleased to see that Cather and I shared some of the same notions about the effect of the wide open landscape and harsh weather on the people there. A shared notion seems more likely to be one of those with a grain of truth in it. Forgive me for providing a few excerpts here since I cannot possibly improve upon her writing.

The landscape:
As we walked homeward across the fields, the sun dropped and lay like a great golden globe in the low west. While it hung there, the moon rose in the east, as big as a cart-wheel, pale silver and streaked with rose colour, thin as a bubble or a ghost-moon. For five, perhaps ten minutes, the two luminaries confronted each other across the level land, resting on opposite edges of the world.
In that singular light every little tree and shock of wheat, every sunflower stalk and clump of snow-on-the-mountain, drew itself up high and pointed; the very clods and furrows in the fields seemed to stand up sharply. I felt the old pull of the earth, the solemn magic that comes out of those fields at nightfall.

The ingenue at the theater:
This introduced the most brilliant, wordly, the most enchantingly gay scene I had ever looked upon. I had never seen champagne bottles opened on the stage before--indeed, I had never seen them opened anywhere... The men were dressed more or less after the period in which the play was written; the women were not. I saw no inconsistency. Their talk seemed to open to one the brilliant world in which they lived; every sentence made one older and wiser, every pleasantry enlarged one's horizon. One could experience excess and satiety without the inconvenience of learning what to do with one's hands in a drawing-room.

Small town pass-times:
Mrs. Cutter painted china so assiduously that even her washbowls and pitchers, and her husband's shaving mug, were covered with violets and lilies. Once, when Cutter was exhibiting some of his wife's china to a caller, he dropped a piece. Mrs. Cutter put her handkerchief to her lips as if she were going to faint and said grandly: "Mr. Cutter, you have broken all the Commandments--spare the finger-bowls!"

Religion:
Mr. Shimerda rose, crossed himself, and quietly knelt down before the tree, his head sunk forward. His long body formed a letter "S." I saw grandmother look apprehensively at grandfather. He was rather narrow in religious matters, and sometimes spoke out and hurt people's feelings. There had been nothing strange about the tree before, but now, with some one kneeling before it--images, candles... Grandfather merely put his finger tips to his brow and bowed his venerable head, thus Protestantizing the atmosphere... As we turned back into the sitting-room, grandfather looked at me searchingly. "The prayers of all good people are good," he said quietly.

Creativity

One of my favorite things about Blogger is getting to click on the button labeled "create." I don't think most people would consider medicine to be a very creative profession. Certainly I don't very often have a tangible product to show for my efforts unless you count the piles of paperwork. As I bet you can guess I am about to tell you all about how creative the practice of medicine really is. First there is the atmosphere of trust and empathy that must be created. I don't mean an atmosphere created by the color of the walls or the furniture. I mean that little bubble of focus that needs to form around the physician and patient. A really good physician can create this type of therapeutic emotional space standing on a street corner with a patient. Next is the creation of knowlege or understanding. This is a team project. The patient and the physician cooperate to produce an understanding of the patient's experience for the physician and of the physician's interpretation for the patient. This knowlege creates the final product of the encounter: the portable bit of wellness in the form of power over the problem which the patient can take with her when she leaves the encounter. I do this a minimum of 30 times a day.

A Saturday Off

My first year in practice I applied the headache adage to a patient (see posting on Sept. 10). The patient was a fine strapping young family man and upstanding member of his community. I would later apply another medical adage to him. The worst diseases only happen to the best people. For the last three years he has largely been under the care of his oncologist and neurosurgeon for the god-awful tumor that turned out to be the cause of his headaches. I saw him on the occasions of his gall bladder attack, a bad case of poison ivy and a few other mishaps. It doesn't seem fair but having cancer does not protect you for other illnesses. Lately he has been in the hospital rather a lot. His headaches got worse. He got a blood clot in his leg. His heart rate went up. None of this is particularly unusual for a person receiving active cancer treatment and each problem was being addressed with reasonable success.

Friday evening I rounded at the hospital and saw him last before going home. He was surrounded by family as usual and thanked me for my visit as I was going out. On my way home I spoke with the physician on call for the weekend and gave him my usual telegraphic but droll sign-out on my hospitalized patients. My comments went something like "bad disease, perfectly stable, consults aren't letting on as to their plans, pain control, blood thinners, ride hog on the specialists." Later I was sitting stuporously in front of the television probably watching a pledge drive when my cell phone emitted the special ear-splitting screech I've assigned to certain other doctors. I climbed down from the ceiling and wrestled the phone to the floor thinking "this had better be important." My colleague was audibly upset. Breathlessly but concisely he relayed to me. "Your patient just arrested and died." He repeated this in various ways in response to my disbelief. "I thought you'd want to know" he said before hanging up.

Next I called the hospital and had the "What the Hell Happened" conversation with the tearful nurse. I learned The Oncologist had happened to be there when the patient arrested and that he was still talking with the family. I phoned My Beloved and asked him to return with the car right away and spent the next half hour sitting on the back stoop watching darkness fall in the back yard. He had been dead about an hour by the time I got to the hospital. The Oncologist was sitting at the nurses station staring at the counter top. I'd never actually met him before but at that hour the odds of a middle aged orthodox physician sitting in this particular nurses station being anyone but him were slim. I introduced myself. He had been present for the entire "cataclysm" as he called it. After a clipped and clinical review of the events we established that we were in agreement on the most likely cause of death. As we went down the hall he said to no one in particular "He was the last patient I needed to see before I could go home." According to him the family was still in the "screaming and crying phase" and indeed they formed a crushed and weepy group around his corpse. His mother burst into tears and fell into my arms when she saw me and eventually had to be passed off to the priest. The others spoke with strangled voices and gasping breath. The room slowly filled with people who one by one embraced the man's wife who sat next to the feet of the profoundly still body of her husband and then joined the living tableau of mourners standing around the room.

I don't really remember the transition to the next scene but quickly I found myself in a small conference room listening to The Oncologist discuss the issue of an autopsy with the new widow. She listened intently asked a couple of questions and then dismissed The Oncologist tipping her head towards me and saying "I'd like to speak to Doctor now." "What do you think I should do?" she asked me after he left.

Last for me was the ceremonial paperwork. The autopsy authorization signed and witnessed. The death pronounced and certified for the department of records. The discharge summary dictated although the patient was being discharged to the morgue. Some "nerve pills" called in for the grieving mother. I left the hospital with the knowledge that when I awoke in the morning I would not enjoy the secret pleasure of a Saturday without having to round but would think instead of this devastated family.

Fortune Cookie

It is much easier to be critical than to be correct.
Lucky Numbers: 8, 12, 15, 21, 24, 34.
Learn Chinese: Squid = You-yu.

The Hour Was Early

"The hour was early; the morning still, warm and beautiful. Shimmering leaves, reflecting sunlight from a cloudless sky, made a pleasant contrast with shadows in my garden as I gazed absently through wide-flung doors...
"Suddenly, a strong flash of light startled me--and then another. So well does one recall little things that I remember vividly how a stone lantern in the garden became brilliantly lit and I debated whether this light was caused by a magnesium flare or sparks from a passing trolley.
"Garden shadows disappeared. The view where a moment before all had been so bright and sunny was now dark and hazy. Through swirling dust I could barely discern a wooden column that had supported one corner of my house. It was leaning crazily and the roof sagged dangerously.
"Moving instinctively, I tried to escape, but rubble and fallen timbers barred the way. By picking my way cautiously I managed to reach... the garden... To my surprise I discovered that I was completely naked. How odd!
"What had happened?"

The above is not a description of anyone's experience on September 11, 2001. Rather they are the words of a Japanese doctor in Hiroshima on August 6th 1945.
I don't think these events change the world so much as they change humanity and we live in the rush of their consequences.

A Regular Joe

A headache is rarely anything bad and bad things rarely cause headaches. That is what the neurologists tell us. I take this approach to lots of very anxious people who are convinced that their every headache is a tumor. Recently our newly elected mayor died of a very aggressive central nervous system lymphoma. The death of the mayor is a sad thing for us here. He was perceived as a regular Joe sort of guy which suited us. He was also a genuine true believer when it comes to Pittsburgh. He will be missed. The Mayor's illness started while I myself was in the hospital. He was admitted down the hall in one of the other "nice" rooms. Since then I've gotten so much better that I now tend to give people a puzzled look when they ask how I'm doing with a voice full of concern. As I got better he got worse until his death Labor Day weekend. I expect I'll see a lot more headaches for a while.