Rituals of annotation

I am not exactly sure of what prompted me to do it, but I began keeping a tally of all the pronouncements I have done.  I never really knew this before, but pronouncements are done in a remarkably simple and impersonal way.  Most patients who die in the hospital do not go with a bang but with a whimper.  While some situations involve spectacular theatrics involving beeping monitors, charged paddles, and the cracking of cartilage from chest compressions, most patients die with a quiet, gasping sigh.  I am still not sure which is more unnerving, but the former is what we typically imagine or see on TV during a pronouncement: a sweaty and distraught doctor ripping off latex gloves in frustration and listlessly intoning, "Time of death..."

What usually happens, however, is that the person will expectedly but spontaneously expire.  Death is typically spotted from a fair distance and in most cases the family is cognizant of this.  Sometimes hospice arrangements are made and the patient goes home to die surrounded by family and friends.  Sometimes a volunteer in the hospital will keep a death vigil of sorts, sitting in a chair while reading a book or watching TV to pass the time as they wait to fulfill a promise "not to let anyone die alone."  Sometimes a nurse will make the rounds and discover that the patient is simply dead.  It happens at all hours and in most floors of the hospital.  Regardless, whenever the death is discovered a page is put out to whichever resident is on call to come by and make the official pronouncement, even though everyone already knows the truth.

This means that I usually know nothing about the patient or the family.  I have to make an effort to commit the name and overall disposition of the patient to heart long enough to speak with the family and request their permission to grant or deny an autopsy.  It typically takes thirty seconds to do the examination and less than thirty minutes to speak to everyone and document everything I need to before moving on to other things.

My little tally is nothing fancy, nothing more than a series of hatch marks in a small booklet of mundane medical information tucked into my white coat.  So far, there have been five marks in two weeks.  I can hardly remember the patients at all, much less their names or even what they died from.

But I remember the families.  I remember the different reactions of different people, some joking and laughing about the whole affair, some quietly sniffling in a brother or a sister's shoulder.  I remember their words, which are often filled with appreciation and deep respect for everything that has been done for this house of memories.  And I feel unworthy and deeply unsettled because I had no part in it... in fact, I never knew the patient, because the only reason I came into contact with him or her at all was because there was only an it left.

If the family was particularly effusive, I will write a little note of it in the chart: "No pulse, no audible heart beat; no corneal, pupillary, or gag reflexes.  Family expresses deep appreciation for all staff."  And every single time, I am tempted to then write, "Kyrie eleison," as has become my habit to say whenever I am otherwise speechless with sorrow.  But not all the patient's family members might appreciate that sort of addendum, so I say it to myself, place a little tick in my booklet, and move on.

To "pronounce" means to state, often with a degree of finality and certainty.  But to me, it has also meant to describe and therein impart an element of meaning.  Pronouncements have become a ritual of annotation, one that is suffused with meaning precisely because it is routine without being mundane.  Small wonder that the closest I have come to intimacy with God in this heavily secularized profession have been in moments like these, where that which is ephemeral proceeds into the eternal.

Making a note of it is the least that I can do.

     But someone may ask, “How are the dead raised? With what kind of body will they come?” How foolish! What you sow does not come to life unless it dies. When you sow, you do not plant the body that will be, but just a seed, perhaps of wheat or of something else. But God gives it a body as he has determined, and to each kind of seed he gives its own body...
     So will it be with the resurrection of the dead. The body that is sown is perishable, it is raised imperishable;  it is sown in dishonor, it is raised in glory; it is sown in weakness, it is raised in power; it is sown a natural body, it is raised a spiritual body.
     I declare to you, brothers, that flesh and blood cannot inherit the kingdom of God, nor does the perishable inherit the imperishable. Listen, I tell you a mystery: We will not all sleep, but we will all be changed— in a flash, in the twinkling of an eye, at the last trumpet. For the trumpet will sound, the dead will be raised imperishable, and we will be changed. For the perishable must clothe itself with the imperishable, and the mortal with immortality.
- 1 Corinthians 15 

Birthdays In Absentio

I'm somewhat used to Facebook catching me by surprise by now.  A friend (or two or three) has a new girlfriend.  And is now engaged.  With children.  Usually it happens to people that I'm tangentially friends with or to those with whom I've lost touch over the years.  Occasionally I will feel particularly disquieted by it.  I will feel guilty that I did not know, as if my ignorance were fundamentally due to a lack of genuine concern.  In some senses this is true; we tune in to the lives of those we feel strongly about, and for everyone else the starkness of such disconnects is often the first tangible indicator of the magnitude of that distance between.

I thought about this as I stared at the Birthdays section of my Facebook newsfeed.  It usually lists several people there, most of whom I haven't seen in months or even years.  But that day, there was only a single name.

Sonia K. Lee was a good friend, but we had grown apart by the time she got sick with leukemia and died.  I still feel guilty about it... not about her death, but about all the things I left unsaid about our friendship.  I don't suppose she would have wanted that but it's disquieting to shake off those sorts of feelings even now, these several years after her passing.  I suspect that part of me will always feel guilty in the same way that a part of me will always feel the responsibility of friendship.

The hard truth of life is that we move forward and only those who run a parallel path will continue to remain in our view.  I suppose it is equally natural that we, in the face of loss and displacement, continue to surround ourselves with activity and life.  We crowd our vision with elements that speak of community to us, that defy and deny the thought that we are progressing further and further into the unknown territory of the future, a land in which we may one day wake up to find ourselves frightfully alone.

I looked at the papers scattered around my table.  They were lab results, CT scans readings, and handwritten descriptions of a patient I had seen in the hospital and was writing up.  I thought about the divinely orchestrated irony that he had the exact same illness that killed Sonia three and a half years ago, and had also been in good health before being struck down so suddenly.  Such things used to fill me with fury, but repeated exposure has tamed the sentiment into a mild frustration.  I wonder, with a mild sense of surprise, at my loss of innocence and sense of justice.

Perhaps I am being morbid in consistently dwelling on these topics, returning to them again and again.  Perhaps some part of me does so out of fear; in this moment, I struggle to fend off the thought that as a brother, lover, father, I might one day also wake to find myself frightfully alone, a Facebook profile with a feed filled with ghosts.  But I think more fundamentally, I simply don't want to forget.  I want these things to amplify the momentum of life instead of being brushed aside by it.  I want the gravity of eternity to tug at my heart with all the irresistibility of the divine.

Psalm 103

Of David.

Praise the LORD, O my soul;
   all my inmost being, praise his holy name.
Praise the LORD, O my soul,
   and forget not all his benefits—
who forgives all your sins
   and heals all your diseases,
who redeems your life from the pit
   and crowns you with love and compassion,
who satisfies your desires with good things
   so that your youth is renewed like the eagle’s.

Dedicated to Sonia K. Lee, born January 27.  You are not forgotten, and we are not alone.  Reposted from http://wasaiwarrior.xanga.com/740099664/birthdays-in-absentio/

Leave It There

"I thought I could beat the ICU, you know?"  My resident looked into the distance abstractly as he spoke, talking more to himself than to me.  "Sometimes you think you won't let it get you down, but you can't.  It always wins."

I wondered what he meant by winning.  Did he mean getting to leave on time?  Did he mean keeping a positive attitude?  How can you "win" in the ICU?  I thought about all of the patients we were caring for.  A comprehensive list of their names was scrawled all over a big whiteboard, where imminent changes were haphazardly heralded by beeping pagers and a flurry of activity.  The rapid shuffling of names and the random clamor made it seem like a perverse scoreboard; successes were annotated with new room numbers and locations for transfer elsewhere, while failures were simply wiped away with minimal fanfare, leaving an off-white space that waited patiently for a marker to squeak out a new set of letters.

The resident's pager went off.  There were phone calls, some hastily scribbling, and we were off to pick up the next patient.

The night wore on and I kept my eye on the clock.  Of my sixteen hour shift, there were two hours left.  Then one hour.  Five minutes.  Finally my resident dismissed me.  "Go get some rest," he said kindly as he scanned the computer screen and mechanically punched in orders.  "All that's left is paperwork.  Nothing more for you."  As per medical student etiquette, I thanked him, wished him a good night, and strode out of the ICU.  I walked down a quiet hallway paneled on both sides by glass.  The view on the left side faced out into the cold, dark, northeastern night.  The right side faced the surgical ICU waiting room, still lit with muted, tubular fluorescent bulbs.  I glanced into it momentarily and was surprised to see someone still waiting inside.

She was sitting alone.  Her eyes were puffy and red, but they were dry, and they looked as if they had been that way for a long time.  A thin hospital blanket was draped carelessly around her shoulders, which were hunched forward slightly as if carrying a palpable heaviness.  Her motionless presence made the room seem more static than if it had been empty, as if Time himself had decided to stop in and say hello, that there was nothing particularly important for him to do and he could afford to wait around for awhile and sink into the vinyl furniture, listening to the ventilation hum while he got things ready for eternity to end next Thursday or perhaps the week after that.

My feet continued to move.  I got in my car and felt immensely grateful that I could simply drive away.  I could leave this place and the bodies in their beds and the score on the whiteboard and the timeless terror of the waiting room.  I could sleep without nightmares and wake up without fearing that moment when I suddenly remember that everything is different now that she's gone, ohmygod she's really gone.

*****

So tempting to take up a crown

of guilt around my head

and proudly wear another's weight

of paralytic dread.

So hard to sacrifice the love

of self-divinity

And rather speak a better word

of true humility:

"Fear not the lack of task to do,

presumed irrelevance,

Or for the merit to survive

The deathly duty dance.

Recall instead the words they sang

to pause and leave it there

in callused hands long pierced by all

the burdens that we bear:

There is a balm in Gilead

To make the wounded whole;

There is a balm in Gilead

To heal the sin-sick soul.

Some times I feel discouraged,

And think my work’s in vain,

But then the Holy Spirit

Revives my soul again.

If you can’t preach like Peter,

If you can’t pray like Paul,

Just tell the love of Jesus,

And say He died for all." Reposted from http://wasaiwarrior.xanga.com/739512670/leave-it-there/

Preparing to Die

She was like so many other patients I had seen: thin, pale, elderly, and short of breath.  The oxygen mask and its large ballooning bag seemed unnatural and almost comically oversized on her face, obscuring everything but her eyes and the dusky, blood-matted hair plastered to her forehead.  She squeezed the bag, hungrily trying to force more air into her cancer-infested lungs.  The situation was bad.  I knew it, my team knew it, and it was becoming increasingly clear that she knew it as well.

Some of the other medical staff said that she showed signs of confusion, but her words were clear in speech and meaning.

"Oh God... This is it... I don't want to..."

She was afraid of so many things, and we weren't doing much to help that.  There was the strangeness of the environment, the necessary but painful things we were doing, and above all, the dreaded possibility that she could die, heightened by the worry and concern frozen on my face.  One of the attendings was repeatedly jabbing a large needle (I mean inches long) into her neck and she would occasionally moan and move feebly in pain.  I was holding her hand and doing my best to reassure her, but I didn't know what to say or to think.  In that moment, all the isolation and chaos and alienation that has become modern medicine hit me hard, and I looked around the room littered with medical waste and harsh noises and complete strangers.  I thought, "No one should have to die this way," and realized that it was not the first time I have thought this.

These words seem so melodramatic and cliched now that I write them, but perhaps I have the manner of things backwards.  Perhaps melodrama is so overdone because it tries to imitate these sorts of events and emotions with some reflection of their gravity and substance.  But there is no truth to the imitation, because in reality no words can express the absolute lack of poetry or grace that characterizes death.  There is no premonitory music that plays in the background, no dramatic panning of camera angles or dynamic lighting to throw the monumental event into starker contrast.  The physics and mechanics of death are unglamorous.  We often die in appalling ways: lying in a pool of our own urine and bodily waste, surrounded by alien and otherwise threatening entities, unknown and possibly unloved.  Death can easily happen in the next room without leaving anyone the wiser; in fact, that is often why people do die... because no one else knew it was likely to happen.  In so many ways, death is one of the most unmagical and ordinary things that happen.  As medical students are often taught, "Nothing else in existence is more certain or inevitable."

And yet there is such a strong, innate resistance to this notion, one that has been ritualized in every known human culture.  We make death meaningful, as if the act of remembrance and reverence elevates the importance of who and what has passed.  Such respect is somehow written into our emotional DNA, though some philosophers (and one of my professors) have argued that this is because human beings are arrogant, elevating their self-worth something of greater value than what our naturalistic compositions warrant.

But this is not what I thought of, staring at the large needle boring itself into and out of her neck.  I did not philosophize or ruminate.  Instead, I looked down at my own hand, which was holding hers, and realized that I was the one clenching my fists the most.  I was not any more prepared for her death than she was, and for some bewildering reason, this gave me great comfort at the same time that it struck me with sorrow.

I am not sure why I am still writing, except that I desperately want to believe in the Divine.  I want to believe in persistent purpose, in the significance of death, in a life beyond what we can see and know in the here and now.  All the evidence and momentum of this great engine of the soul inside me screams for something more and meaningful and lovely and beautiful and it will not be denied, it cannot be refused, it must not be quieted.

You are witness to it.  Speak its truth to me, again and again.  I want for us to be eternal, for us to be prepared and consequently, divine.

Listen, I tell you a mystery: We will not all sleep, but we will all be changed— in a flash, in the twinkling of an eye, at the last trumpet. For the trumpet will sound, the dead will be raised imperishable, and we will be changed.  For the perishable must clothe itself with the imperishable, and the mortal with immortality.  When the perishable has been clothed with the imperishable, and the mortal with immortality, then the saying that is written will come true: “Death has been swallowed up in victory.”

  “Where, O death, is your victory? 
   Where, O death, is your sting?”

1 Corinthians 15:51-55

Dedicated to my patient.  Reprinted from http://wasaiwarrior.xanga.com/738626008/preparing-to-die.

Stall

I could name a million reasons describing why progress on this book has been stalled, but the main one is this: I tried too hard.  I tried to figure out a plot.  I tried to expound on points I thought were important but weren't as inspiring.  I tried to write a book and not a memoir.

Zinsser puts it best:

...beware of "about." Beware of deciding in advance how your memoir or your family history will be organized and what it will say. Don't visualize the finished product at the end of your journey; it will look different when you get there. Be ready to be surprised by the crazy, wonderful events that will come dancing out of your past when you stir the pot of memory. Embrace those long-lost visitors. If they shove aside some events you originally thought you wanted to write about, it's because they have more vitality. Go with what interests and amuses you. Trust the process, and the product will take care of itself. - Writing About Your Life

 Things have changed.  You'll see.

I had forgotten what sorrow, that fog of the soul, feels like. It doesn't feel good.

Repository

As a participant of this year's NaNoWriMo competition, I need a dumping ground for the literary detritus that will eventually constitute a whole book but isn't as public as my Xanga site. Hence, new life to this blog.