Soteriology

Snap, crackle, pop. With each compression I felt the man's chest wall crunch under my weight. I straddle the side of his bed, my knees resting against his yellowish, cold arm, my feet dangling four feet above the fluorescent-lit floor.  This is the most violent and barbaric act I have ever performed against another human being. The irony of prolonging a life. 

I balk at the phrase "saving a life," because no such concept exists. We prolong, not save. To think otherwise demands a hubris and carelessness that I refuse to entertain. The man whose rib cage I destroyed was "saved." Twice. His heart failed his body completely, and twice restarted, albeit with the aid of copious amounts of epinephrine and electricity. Success is measured in heartbeats.

In the aftermath, once the obliging mob vacated the scene, he remained alone. I stood at his doorway a while and watched him. Propped up in bed he almost looked human. Air entered his lungs again, now through a beeping machine. Color returned to his face, highlighting his pencil-thin mustache. Blood surged through his half-starved tissues once again, like a flooding river washing the debris and detritus downstream. But this river flows in a circle. There is no delta, no escape. 

I watched this man, knowing he was in the final moments of his life. We had paralyzed him, broken him, and prolonged him. We had traded his body and his dignity for an extra hour of chaos. This brand of salvation, I think, may be the most powerful drug we feed the dying.

Wet Vet

I saw a veteran the other day. He shuffled into the room. Parkinsons. He had a rash on his rear-- dry hypertrophied skin with a small amount of ulceration and dried blood. When I asked him to drop his trousers to examine him he wet himself.  All over the floor. Then, we biopsied his ass rash.

This man likely served in Korea or WWII. He served his country. Now he has trouble walking, has trouble controlling his bladder, and has a chunk missing from his backside. Dignity is a fickle thing.

I think when I was younger I had a fixed view of what a "veteran" was. Young people often have fixed views, you know. My view was, shamefully, one of superiority, perhaps even one of scorn, for those who chose the military life. But these men and women deserve honor and respect, not merely because they donned the uniform, but because these are men and women.

Solemn declaration

I have now declared the deaths of two people.  I don't think it's something I could easily get used to.  One of them was in her late 20s, and I watched her grieving father fill out an autopsy form. He said to me, "I never thought I'd be doing this," and I had no words for him.  I watched her grieving mother sit by her bedside for hours after she passed, weeping and talking with her.

Parenthood scares the hell out of me after moments like this.

X-rays from Beira

Often mistaken for an effusion (note the costophrenic angle is clear)

 TB: numerous cavitations with an obstructive disease picture

TB: just a mess in so many ways.

Fascist Train Ride?

I approached the dusty station before the sunrise. The gates were locked, but a mass of people had already gathered-- men and women sitting separately in the dirt with an assortment of makeshift bags and luggage; baskets of fruit, vegetables, peanuts, a few chickens gripped at the ankles (if chickens have ankles).
The sun came up slowly, shedding a grim and reluctant light over the scene before me. The Train came into view between the station bars. This was no silver bullet. The cars visible did not shine or sparkle in the morning light. They were rusted, busted metal tombs with sliding doors and one small window a piece. Storage cars. Cattle cars.
The guards called us to attention. In an instant two lines formed at the gate-- one for men, the other for women. Visions of the Holocaust swept through my mind. Was I to be deloused as well? Was my destination Nampula or Auschwitz? I no longer knew.
Hasn't man advanced sufficiently such that he no longer subjects his fellow man to such harrowing mass transit? Don't they see the parallels? And what's more, I had PAID to be treated like cattle, like a prisoner of war, like so many victims of genocide and Nazism. Oh Capitalism! Fiend of Fiends! Thief in the Night! Have you no scruples? No respect for history, for human dignity?

Of course I was mistaken.
My head and unsettled stomach had leapt far ahead of my eyes and reason. The passenger cars sat plainly behind the storage cars, previously obscured from view by the whitewashed walls of the station. While still far from comfortable, they had benches and windows. And my faith in humanity soared...

Bunny Hop

I just taught myself to bunny hop at the age of 26.
Maybe someday I'll learn to whistle.
Hope springs eternal.

The Burden of Knowledge

From a long time ago:

Some college friends of mine just had a baby with some complications- specifically, the kid has a congenital diaphragmatic hernia with subsequent pulmonary hypoplasia- ie his stomach and bowels are in his chest, so his lungs never developed properly.  I found out about this tragedy via the f-book when I noticed that they had posted their child's chest x-ray. Half of the poor kid's thorax was white-out, and my heart sank. I am by no means a pediatrician, but I've had enough training to spot the huge abnormality on the x-ray, to identify the abnormality as a diaphragmatic hernia, and to know how poor the outcomes typically are for diaphragmatic hernias. I've had enough training to know that Zeke, the kid, would need extensive surgery, and with it the substantial risks of infection and hemorrhage in addition to continued respiratory problems.  A glance at one photo and I knew what the outlook was for Zeke. In a word: bleak.

This is the trouble with amassing medical knowledge. Ignorance is bliss, as the adage goes. Prior to medical school, when I heard about someone's dad developing cancer I could sincerely hope and believe that "he'll be the exception to the rule. He'll come out of this ok."  But when you know the diseases and their mortality, when you really know the numbers and the odds it becomes tough to cling to miracles.  Realism sets in. And let me tell you, realism is a harsh bastard.

A perfect example is my friend Suj. When I was a bright-eyed and bushy-tailed second year med student my former housemate was thrown from a motorcycle taxi in Uganda. He wasn't wearing a helmet at the time, so his injuries were severe. When news of Suj's accident reached me and my other housemates, all of whom were ahead of me in school and well into their clinical years already, it was reported to us that Suj's GCS was 5.  FIVE!

The Glasgow Coma Scale (GCS) is a crude tool used to grossly assess brain function. The letters GCS meant nothing to me at the time of Suj's boda boda crash.  I didn't know GCS  from GPS, let alone what a 5 indicated. My housemates, on the other hand, knew full well what a GCS of five looks like.

To paint a picture, five looks a shade of grey away from death. Actually, it's 2 shades away. Literally. A dead person has a GCS of 3. Your regular bloke walking the street (assuming he's not inebriated) gets a GCS of 15, the max score. A GCS of less than 8 typically means a person needs a breathing tube because they're probably unconscious with significant neurologic deficits. My housemates had been in the Neuro ICU. They had taken care of people with scores of 5. They had the image and knew the likely outcome.  I, on the other hand, was ignorant of all of this.


I had left this post as an unfinished draft for well over a year. I returned to it today to finish it. Zeke has since died, and I have never known how to sum up this post in some poignant or hopeful way. Sure, knowledge is a curse. Reality is harsh. People die. Hope is hard. But if hope were easy, it wouldn't be such a special and powerful concept.