The weekend before, I had shopped for a few items at the same grocery store, with my three year-old son in-tow.  I looked at him in the rear view mirror as we were en route, and commented to him that “I sure hope that they have cherries this time, buddy, don’t you”?  He looked at me perplexed for a moment, and then replied, his little green eyes beaming, bright with enthusiasm and excitement.

“Yes Daddy… I wuv cherwees…  I want some… they yummy…  I reary (really), REARY want some cherwees… I wuv them a lot, Daddy… cherwees… yeah…”

Then, as we were slowly pulling into the parking lot a few minutes later, I heard his little voice sheepishly ask from the back seat, just over the song playing on the car radio…

…“Daddy, what cherwees?”

An ever-growing number are shopping in the medical marketplace for something that seemingly isn’t quite yet in season as well – health.  The federal government, insurance companies, medical pundits, policy wonks, assorted other experts and even Drs. Oz, Phil, Sanjay and Oprah (not a doctor, but sometimes plays one on TV) are all asking that the general public be “healthier”, and that doctors, hospitals and health systems become more engaged in “managing health”.

Fair enough.  Sounds like the right thing to do.  So… I reply with the same unbridled enthusiasm as my young son – who can argue?  Let’s go!

There’s only one problem – what’s “health”?

If we are going to demand more of something, shouldn’t we have a clear understanding of what we are demanding?  My claim is that in this country, and at this time, most Americans do not know what “health” actually represents – either individually, or collectively.  In 1996, Diane Vaughn coined the terms “normalization of deviance” in her book “The Challenger Launch Decision – Risky Technology, Culture and Deviance at NASA”.  In her own words, taken from the text of an online interview from 2008, she suggested that:

“Social normalization of deviance means that people within the organization become so much accustomed to a deviant behavior that they don’t consider it as deviant…”

In this example, she was primarily describing the lack of concern regarding the design of rocket booster seals, called O-rings, on the shuttle, despite the fact that there were multiple warnings.  Nothing happened for several years despite these concerns and strong evidence of danger, so it was simply assumed that nothing ever would.  The obviously flawed processes of ignoring information that clearly pointed to a potential problem became habit.

The suggestion that we have normalized deviant behaviors in this country related to individual health should come as no revelation.  We have become accustomed to and normalized the habits that have led to our being designated, for example, as the most obese country in the developed world (actually, the most obese country in the world with a population of greater than 200,000 – Tonga, Samoa, the Solomon Islands and a couple of other similar-sized nations in that part of the world actually do outperform us here). In an endeavor that in 2012 The Economist termed “size inflation” – clothing manufacturers have purposefully enlarged items at each size designation specifically for the Western world such that medium is the new small, large is the new medium, etc.  We eat large quantities of processed and fast food, and only modest numbers of us exercise, or even walk any distance beyond what is absolutely necessary.  A three hundred and fifty pound thirty-five year old hypertensive and diabetic man that makes it back and forth from home to work during the week, and waddles to the La-Z-Boy in front of the television on the weekends where he polishes off a six pack or two may tell his doctor that he “feels fine” and is “healthy”.  The problem is that objectively he is not.  Individual liberty and individual rights are some of the important underpinnings of our democratic society, and are both important and welcomed.  However, the attitude that “I have a right to eat, drink and smoke what I want” leads down the path of diminishing returns collectively.  It is true – you can indeed do those things in our relatively free and open society, but when you do so, you infringe indirectly on the liberties of others by forcing them to subsidize your contemporary disease management, and your future complications.  Who on the Challenger engineering team was actually shocked when the O-ring disaster occurred, and why should the individual described above, or his family, be shocked when he has a myocardial infarction – perhaps“the big one” – at age fifty-five?

So what is a working definition of health?  If many Americans don’t know that this term really means, and therefore have lost sight of how to achieve it – how do we define it for them?  Wouldn’t having some working definition of the concept be reasonable before we promote it as an overarching societal goal?

The World Health Organization (WHO), in its 1948 constitution preamble, defined health as follows:

“Health is a state of complete mental, physical and social well-being, and not merely the absence of disease or infirmity.”

This definition was a great start, especially considering that it was written several decades ago – notably it included the concepts of social and mental well-being in addition to the physical, and it made it clear that simply being free of an identifiable disease did not constitute “health”.  The latter point has been proven to be quite prescient, as it is increasingly evident that it is generally unachievable.  What we are beginning to realize is none of us are actually completely “absent disease or infirmity”.  Advances in clinical and experimental human genomics suggest that in fact we all have biological predisposition as well as expression of disease states and conditions, in varying amounts depending on the individual, and to varying degrees at any one time in our lives.  Imagine that each of us has a built-in “mixing board” of conditions and illnesses from birth, and that as we age, the levers are pushed up or down for each of us, leading to more or less obvious expression of these individual conditions.  The point here is that no one has all the levers at the bottom, in the “off” position, and that most all human diseases, with the possible exception of the majority of infectious diseases, enjoy an ever-present range of expression in all of us, rather than existing in an “on and off” configuration.  In addition, it is likely that there are a host of “diseases” that we all live with that are yet to be characterized, but will be soon.  D. T. Max, in his fascinating book, “The Family That Couldn’t Sleep” discusses his own battle with an uncharacterized neuromuscular condition, and reminds that “absence of evidence isn’t evidence of absence” either in regard to what we might “have”, or what we might be able to do about it.

It is also important as we contemplate a better definition of health that we avoid inappropriate paternalism or generalization.  Many that a previous generation considered “disabled”, and that a generation prior to that termed “crippled” are obviously neither, but rather robust, functional, “healthy” individuals.  If you don’t believe that, just go find a wheelchair lacrosse match, walk out onto the field and make some disparaging comment about the health of those playing – I would suggest that you wear a helmet, or at least carry your own wicket if you plan to do so.

The WHO definition is wanting; however, as a guidepost for us to use in relation to discussions about discrete goals and behaviors.  In a recent article in the British Medical Journal, the folly of the notion of complete avoidance of disease was duly noted, and the importance of the concept of adaptability was stressed:

“By successfully adapting to an illness, people are able to work or to participate in social activities and feel healthy despite limitations. This is shown in evaluations of the Stanford chronic disease self management programme: extensively monitored patients with chronic illnesses, who learnt to manage their life better and to cope with their disease, reported improved self rated health, less distress, less fatigue, more energy, and fewer perceived disabilities and limitations in social activities after the training. Healthcare costs also fell”

I do not pretend to have a new definition of health for you here, but I do intend to ask you to struggle with the question of what that definition should include.  We desperately need to frame the concept in a more concrete way to assist us in our efforts to reverse the effects that the normalization of deviance have wrought on the citizens of this country, on the health care delivery system, and America’s competitive position globally.  I do have some suggestions; however, for some of the important components of that definition.  I would most definitely include mobility, freedom from suffering, mental well-being, social fulfillment and happiness along with the provision of tools to promote resilience and adaptability (as our “mixing boards” settings inevitably change over time).  The desire to be mobile seems to be more than just cultural – perhaps rather a biological imperative.  It’s seems almost as if the body senses immobility and begins to prepare for its own demise – muscles that are not used begin to atrophy, and bones begin to de-mineralize and soften.  We know, as a matter of fact, that regardless the general level of prior vitality, the elderly are much more likely to die once immobilized in-hospital.  We also know that the imposition of immobility correlates with the development of depression, and that regaining mobility can often be therapeutic. Certainly, the desire to be free from suffering is ideal, if not completely achievable, and the concepts of mental well being, social fulfillment and happiness, although perhaps difficult to define themselves, ring true.

When I was a child, I had to memorize the somewhat pithy poem “Happiness”, by Priscilla Leonard.  Priscilla Leonard was actually the pen name of Emily Bissell, a philanthropist and founder of Christmas Seals.  In this poem (which I considered marvelous as a fifth grader) she asks the reader to imagine happiness as a crystal sphere that is inevitably broken, and can never be fully reconstructed, or realized.  She suggests that we are to try to accumulate as many pieces of the broken object as we can as we move through life, always trying to envision what is possible…

“Treasure every fragment clear, Fit them as they may together, Imaging the shattered sphere…”

Perhaps this is how we should approach a definition of health?  Let us consider what the possible is for each individual, and let us try to help he or she achieve that possibility, understanding that perfection is obviously folly.  If we can somehow remind Americans what it really “feels like” to be “healthy”, rather than just being able to perhaps make it back and forth to work, and then plopping into a soft spot in front of the television set with a six-pack on the weekends… If we can have them imagine for a moment what it is like to be optimally mobile, to be as free as possible from specific conditions such as obesity, to have minimized physical and mental suffering as well as social disappointment, perhaps we can aspire to a new steady, “healthier” state, rather than just the continued normalization of deviance, with all that follows.

I was a first year surgical resident, or “intern” in a busy Philadelphia hospital, in the era prior to work hour restrictions.  When I started, I was given a “choice” of one-week vacation schedules, but only after the second- through seventh-year residents made theirs.  So, as one might imagine, I was on call every other night in the hospital (and not sleeping at all on those nights), for weeks one through fifty-two, and then had my “chosen” time off on week fifty-three of that year.  We rented a tiny little place at the Jersey shore, and every morning I would get up and drive into the little village nearby to buy a newspaper and get a cup of coffee before my wife and young daughter awakened.  On the third consecutive day of sleeping for more than eight hours in a real bed, I was driving to get my paper and noticed en route something different about the way that I felt, something not quite right.  I had been taking care of the sickest patients in Philadelphia for the past year, and by the time I got back to the little house from the newsstand, I was convinced that something terrible was wrong with me, perhaps some rare debilitating, or even fatal neurologic disease?  Later that day I spoke with our residency program administrator by phone to find out which clinical service I would be appointed to when I returned, and she asked me how our vacation was going.  I replied, “great, you know, but I feel funny… hyper… almost like I’m on amphetamines… energetic… too energetic, I think… I wonder if something isn’t wrong with me”.  She laughed on the other end of the phone, having likely had this conversation with countless interns in the past – all of whom had been forced to normalize “deviant” behaviors during that tough first year in order to meet the demands of the job, and said, “you’re not sick silly, that’s just the way that normal people feel.”

Now he is born, his parents base of stock… Of riper years to Wittenberg he went, whereas his Kinsmen chiefly brought him up, so soon he profits in divinity, the garden of scholarship being adorned by him, that shortly he was grac’d with doctor’s name.

At the outset of the play; however, he is not at all happy with his accomplishments, and feels that he has gained all of the personal benefit and gratification possible from knowledge.  In all arrogance, he also suggests that he has used this knowledge to achieve all that is humanly possible (and somewhat more, seemingly).  He relates that he no longer finds any enjoyment in the somewhat boring business of things such as curing the plague, and that the only thing that could perhaps make practicing medicine at this point worthwhile for him is resurrection of the dead – an achievement that he stops just short of claiming…

“The end of physic is our body’s health.  Why Faustus, hast not thou attained that end?  Is not thy common talk sound medical maxims?  Whereby whole cities have escap’d the plague, and thousand desperate maladies been eas’d?  Yet are thou still but Faustus and a man.  Couldst thou make men to live eternally, or being dead, raise them to life again, then this profession were to be esteem’d.  Physic, farewell. – Where is Justinian?  A petty case of paltry legacies.”

What Doctor Faustus admits to himself in the opening scene, after cataloging his displeasure, is that through the use of magic, and the knowledge that magical powers will bring to him, he could potentially enjoy the worldly rewards that he considers of value.  So… you know the rest of the story, and if you don’t it should sound fairly familiar to you.  Faustus conjures up Mephistopheles, a demon in the employ of Lucifer, and sells his soul in exchange for these things.

As I alluded to earlier, and similar to Doctor Faustus, the origins of the practice of “modern” medicine in this country were humble, consisting mainly of mystic and traditional practices ungrounded in the terra firma of either objective scrutiny or proof.  Over time; however, as the science progressed, it came to be a learned and somewhat effective undertaking.  In time as well, medicine moved from a populist, “home-based” endeavor, to a professional, “clinic-based” enterprise.  It moved away from the practices of agrarian self-sufficient individuals isolated from physicians, or adjacent to those that had nothing effective to offer, and eased into an industry that would become an incredibly powerful social and economic force.

As this transition occurred, the initial focus of medical practice and care was effectiveness – disease outcomes.  Competitive advantage, in the eyes of both the general public and among hospitals and physicians themselves, was based on efficacy.  Now it is true that efficacy – defined as the “ability of an intervention to produce the desired beneficial effect in expert hands and under ideal circumstances” – was hard to measure in previous times, and still is.  One might compare it to the task of measuring a large snake as it rapidly slithers by, angered by your efforts to apply the measuring tape.  However, despite these durable difficulties, word, as they say, got around.  There was money to be made in the practice of medicine, most certainly, and for the most part, doctors “did well”, but revenue generation was not the goal, it was a byproduct.  The origins of this industrial and corporate transition antedated the Flexner Report of 1910, but there is no doubt that the after-effects of that report – a retooling of the medical education enterprise to ground it in fact rather than tradition and quackery, and the advancement of professional societies, boards and peer review, galvanized the process.  So the enterprise became both more expert, and more effective, but at some point during the past one-hundred years, Mephistopheles was conjured up by American medicine, as by Faustus.  There was a gradual realization that “magic”, in this instance a metaphor for “money”, could provide much more than the coarse benefits of a medical job well-done.  We gradually made the decision that we should compete not on the basis of medical outcomes, but on the basis of revenue, because this must be a surrogate measure of success, as it is in other industries, and besides, there is only so much you can do anyway, right?  it was impossible, after all, to “make men live eternally, or being dead, raise them to life again… Physic, farewell!” Faustus suggested that there were rewards well beyond knowledge and outcome:

“These metaphysics of magicians, and necromantic books are heavenly; lines, circles, scenes, letters and characters; Ay, these are those that Faustus most desires.  O, what a world of profit and delight, of power, of honour, and omnipotence, is promised…”

Before you start shaking your head and murmuring that “this guy is a zealot”, I will admit that this metaphor is a little overwrought.  The point that I am trying to vividly illustrate; however, is that we did make a gradual decision over the past century to compete in medicine for revenue rather than outcomes, and that has had significant and perverse consequences.  I am not, in fact, criticizing the concept of “profit motive” in health care, as many have done.  The provision of medical care is incredibly expensive, and if physicians, hospitals and systems cannot make a profit, there would be no way to reinvest sufficiently to keep the endeavor afloat.  I could most definitely condemn the wholesale application of an open market philosophy to health care, and do indirectly here.  The market and its competitive forces do indeed drive innovation, but to what end in health care?  There has perhaps been no more innovative area of human endeavor than American medicine over the past century, but a great deal of that innovation, and certainly how much of that innovation has been deployed, has been directed at the generation of revenue, and not directly at improving disease outcomes.

One obvious example is the cephalosporin antibiotic story.  There are around fifty of these drugs on the market.  Did the development of each of these drugs require innovative thought and process?  Yes.  Do we need fifty cephalosporin antibiotics to improve disease outcomes? No.  A defender of the history of the development of this class of drugs would be tempted to tell you that there are “five classes of cephalosporins, each with a different profile of effectiveness on various types of bacteria”, and that would be true.  What he or she would not perhaps admit is that for four of those classes there are ten to twenty drugs each, with near-identical effectiveness.  Why would that be?  The answer can’t be found rummaging around in the closet of boring medical outcomes, but in the open market – the market for these types of drugs is tremendous – millions and millions of dollars.  As it turns out, if you can grab two percent of a one hundred million dollar market – that translates to a good business investment, and generates revenue.  Oh, by the way, drugs come off patent protection in time, and the market forces the price down when that occurs with generic equivalents.  Might it pay to slightly change the molecule and put another one out in the same class as that time approaches, if you can market it and convince just enough providers to use it?

So, what are the downsides of this approach?  It is a “free and open market country”, correct?  What’s the harm if society benefits from the added productivity associated with the realization of good return on investment? As it turns out, there are downsides.  One downside is that research and development dollars are not spent on “truly” innovative antibiotics necessary to combat future resistance, and another that we learned painfully in retrospect is that pushing “me too” drugs out, and encouraging providers to use more and more of them leads to the development of drug resistance in the first place.  “Magical powers” are no doubt realized (money is made), in these endeavors; however.  Make no mistake – big pharma competes on the basis of who can generate the most magic.

How about another example?  How about the development of small volume open-heart surgery programs in community hospitals?  If created and resourced with any degree of sophistication, an open-heart program that performs between fifty and seventy-five cases per year can be profitable.  There are a lot of programs in small and medium-sized hospitals around the country that are working with these sorts of volumes.  Interesting; however, research suggests that the number of cases that an individual cardiac surgeon needs to perform in a year’s time to be proficient is minimally in the one-hundred to one-hundred fifty range.  Now it is true that many surgeons practicing in these sorts of arrangements perform cases at more than one hospital, but their teams do not.  How “good” are they if they do fifty per year, versus five hundred?  That, as it turns out, has been heavily investigated as well.  There is a direct correlation between volume, quality and cost in complex clinical care.  Sure, some very small programs “look” good in comparison to larger programs, but that can often be explained by “cherry-picking” the types of cases that are performed, or frankly not having enough data to make an educated assessment of overall quality.  The latter concept, one that statisticians call “type II error” is well known – the failure to reject a hypothesis (ie “our program is safe and effective”) due to a small sample size.  What are the downsides to this approach?  There are several.  Over time, the likelihood of a small program to cost more per case, and to have poorer outcomes, is high.  Second, this competition for revenue drives up the overall cost of care for the health system, and can actually paradoxically at times lower access.

The way to understand that latter point is via another cardiac surgery example – in 2008, the city of Chicago had five heart transplant programs. In an article authored by Judith Graham, in the Chicago Tribune, she stated that:

“Policy experts debate the value of competition in health care, and in this case competition appears to have backfired, leaving local heart transplant centers operating below capacity. Paradoxically, even with local hospitals’ vast investment, fewer severely ill patients here receive these potentially lifesaving surgeries than in other major urban areas.”

Each of those five transplant programs had the same overhead cost – millions, and theability to be cost-effective, and have optimal outcomes goes down as your volumes are diminished for a complex endeavor such as this, as suggested earlier in the open heart program example.  Why might access suffer when there are such programmatic riches available?  If you are you are low volume, one bad outcome can make your overall statistics go south quickly.  Transplantation, due to regulatory oversight, is one of the few areas where at least someone is scrutinizing results for continued certification.  So, you might be inclined to take fewer risks.  Why do organizations start transplant programs in crowded markets?  There is “ripple effect” money to be made from the endeavor, even if you aren’t high volume.  Each cardiac transplant recipient represents a much larger number of heart failure patients that come to your center for evaluation and care, not to mention the aura that such a program can generate, potentially attracting other patients to your facilities, and into your highly reimbursed hospital beds.

Try to go online and ferret out the five-year survival rate for colorectal cancer for an individual physician, or health system program.  How about the five year admission rate for congestive heart failure, or the number of times patients are admitted with exacerbations of chronic obstructive pulmonary disease, or the percentage of women that are disease free of breast cancer after ten years?  Perhaps you would like to know the percentage of diabetics that have avoided the ravages of retinopathy, or peripheral vascular disease?  There are a few data points out there, but it is very, very sparse.  Want to find out how many patients were seen, or how much revenue was generated?  That’s pretty easy.  Ask most health system CEO’s to describe their enterprise, and the first proud words uttered are quite often “we are a ‘X’ billion dollar health care system”.

Take a moment and consider the question – what is our “product” in health care?  I suggest that unlike many other businesses, even those that sell something tangible, but must generate increasing profits as a real “product” for shareholders, that revenue generation is not the end game for us.  The end game is what our patients care about – disease outcomes.  What they care about is “will I be alive in five years?”  “Will you be able to cure me?”  “Can you relieve my suffering?.  There are indeed nurses to be hired, aging technology (ideally technology that brings tangible disease outcome benefit – all of it does not unequivocally – think “surgical robot”) and other infrastructure to be replaced and upgraded, and providers of actual care to compensate.  It is not the “making” of money that is ill conceived here, or the seeking of profit per se, it is the focus on that aspect of the business above and beyond the actual product.  Pay us for our outcomes, and pay us more if they are better.  Innovation will come without competing for revenue in that scenario, and what will be sought is innovation that changes outcomes, not innovation that simply generates revenue.

In the Marlowe version of Faustus, the good doctor was not able to repent of his unsavory agreement with Mephistopeles and Lucifer and suffered dire consequences, as catalogued by some that were present at his demise:

SECOND SCHOLAR: O, help us, heaven! see, here are Faustus’ limbs, All torn asunder by the hand of death!

THIRD SCHOLAR: The devils whom Faustus serv’d have torn him thus; For, twixt the hours of twelve and one, methought, I heard him shriek and call aloud for help; At which self time the house seem’d all on fire With dreadful horror of these damned fiends.

SECOND SCHOLAR. Well, gentlemen, though Faustus’ end be such as every Christian heart laments to think on, yet, for he was a scholar once admir’d

In a later 1805 version by Wolfgang Geothe, the play entitled simply Faust, the ending of the story is much different.  In this version, our protagonist’s soul is spared as a result of the fact that although he has been compromised by his previous deal with the devil, in the end he still sought redemption via his actions:

THE ANGELS (Soaring in the highest atmosphere, carrying the immortal part of Faust.) He’s escaped, this noble member of the spirit world, from evil, whoever strives, in his endeavour, we can rescue from the devil. And if he has Love within, granted from above, the sacred crowd will meet him with welcome, and with love.

So, perhaps it is a little too late to “go back” on our own pact with Mephistopheles and his master Lucifer.  But maybe it isn’t too late to change our ultimate fate. Every schoolchild, even if he or she doesn’t know the actual literary underpinnings of the concept of “selling your soul” knows that this type of deal is never quite “clean” – the devil frequently gets the much better end of the bargain, and that all deals like this are time-limited.  In the case of Marlowe’s Doctor Faustus, Lucifer agrees to give him twenty-four years to enjoy his “magic”, and then he was committed to hell.  Many would argue that the time on American medicine’s Faustian deal is running out.

“The only solid piece of scientific truth about which I feel totally confident is that we are profoundly ignorant about nature… It is this sudden confrontation with the depth and scope of ignorance that represents the most significant contribution of twentieth-century science to the human intellect.” 

- Lewis Thomas

 Just in the last few weeks, results of the ENCODE (“Encyclopedia of DNA Elements”) project were published in several scientific journals around the world.  We had previously thought that up to 90% of our genetic material was “junk DNA” – performing no particular function.  It now appears that up to 80% is indeed functional, and may be working in a fascinating, but incredibly complex fashion, using both biochemical processes as well as three- and four-dimensional spatial relationships to regulate human genes (which make up only about 2% of the genome).  Interesting news?  Yes, but many scientists working in this area had already posited much of this.

So, what’s the big deal?  The ENCODE project findings are just a metaphor here.  The “big deal” is the increasingly unfathomable encyclopedia of biologic information about human life that has been, and continues to be, compiled.

Simply put, at some point during the past decade or two, we passed an important landmark in human history.  There was no fanfare or announcement, and most would not have recognized or have had any reason to be aware of its occurrence.  We came to a time at which the human mind was incapable of fully comprehending the human cell.

To quote the famous biomedical philosopher Yogi Berra – “it ain’t the heat, it’s the humility.”

In his Metaphysics, Aristotle commented, “In the case of all things which have several parts and in which the totality is not, as it were, a mere heap… the whole is something beside the parts”.  If we have been paying attention, it has become apparent that in consideration of the human form that the parts are themselves perhaps more complex than we ever imagined.

Back in high school (and a little later than Aristotle, despite what my children may think), my biology teacher stood in front of the class one day, and said with great thick-lensed and horn-rimmed authority that the “body is arranged from more to less complexity in this way – systems, organs, tissues and finally, cells.”  Thirty years ago, the assertion that the cell was the basic “building block” of biologic life would not necessarily have been questioned too vigorously, even by biologists.  In this paradigm, cells could be thought of much like bricks placed in a wall that supports an architecturally complex greater structure.  One could now argue that she was wrong; however, and that the complexity required to take masses of human cells and coalesce and coordinate them to construct a muscle, for example, is less than that required to create and maintain individual muscle cells themselves.

We may doggedly pursue scientific “truths” and perhaps seek a better general “understanding” of many things, but to fully comprehend them is different.  In view of this realization, the inability of the human mind to fully grasp the complexity of its biologic building blocks has always been there, just waiting for us to reach that point in time where we learned just enough to become aware, or to be “confronted with the depth and scope of ignorance”, as Dr. Thomas reminds us in the opening quote for this essay,  upon which we base our assumptions.  Of course, man has been in this situation before, and many times, in terms of coming to grips with the overwhelming complexity of nature and our shortcomings in comprehension of the entirety of it.   The universe comes to mind as an example, considering where we are now, and where we used to be.  Steven Hawkings once said that “my goal is simple.  It is a complete understanding of the universe, why it is as it is, and why it exists at all.”  Inspiring, but is this really feasible?

Edwin Hubble, the namesake of one of the modern world’s most important tools of discovery, the Hubble Telescope, comments in his 1936 book, The Realm of the Nebulae:

“…in cosmology, theory presents an infinite array of possible universes, and observation is eliminating them, class by class, until now the different types among which our particular universe must be included have become increasingly comprehensible.”

 Hubble’s description of how the structure of the universe is gradually unveiled implies two things – one, that the elimination of earlier theories leads us closer to scientific “truth”, and two, that “comprehension” comes from narrowing the various possibilities under consideration.  Karl Popper, the philosopher of science who suggested that justification was inferior to skepticism and elimination of previous theory, would argue that the former is true, and I agree.  It was important, for example, to rule out the theory that the stars were torches carried by ancient charioteers.  However, I would argue as well that the latter consideration, of this process leading to comprehension for both the universe, and the human cell, is not.  The more we learn about the universe, the more we come to understand what we do not know, based on the fact that the “infinite array of possible universes” we were considering did not include, in fact, many possibilities that we could not have imagined, or simply did not imagine due to the need for more discovery.  The human cell is no different from the universe in this way.  Hubble’s greatest contribution came from proving that we did not exist as the universe’s only galaxy, and that the nebulae he visualized in the newest generation telescopes he was using were too distant to be in our own – they were, in fact, other galaxies.  He did not make that contribution by narrowing options, he added a new one and started us down a path to discovering the seemingly infinite complexity of the cosmos.  He nudged us over the edge to a vista of new discoveries, and an increasing human inability to comprehend them collectively.

Similar to Hubble’s use of the early more powerful telescopes, I would suggest that that J. Craig Venter, and the improvements his group at Celera Genomics introduced to genetic sequencing are what pushed us over the cliff in cellular biology.  Venter successfully sequenced a human genome several months before the federally funded Human Genome Project (HGP) accomplished that task, and since that time we have been trying to drink from a veritable high pressure fire hose of cellular discovery.  During the hundred-year period between 1900 and 2000, about one thousand genes correlated in some direct way to the development of a particular human disease were discovered.  Over the last ten years, since the HGP was completed, and new methods of genetic sequencing have been developed, we have easily tripled that number.  Functional genomic research, or the effort to understand gene and protein interactions that capitalize on new genomic information, has exploded recently, building on genomic sequencing findings, and a large number of genes and effector proteins that participate in everyday normal cellular activities have been discovered as a result, along with some entirely new pathways (processes in the cell that use proteins and other molecules in concert to achieve some cellular function).  Although these finding might have been anticipated by some, other recent developments in cellular biology have not been as predictable, and more are likely coming soon.

We have known for instance, since the work of Watson, Crick and Franklin in the 1950’s that deoxyribonucleic acid, or DNA, is the code of life, and the genetic material of both current and inherited traits and dispositions.  A closely related molecule, ribonucleic acid, or RNA, was thought to carry out a few specific jobs in the cell, and in the process existing solely for the purpose of helping DNA do its job. One set of RNAs worked by sending the message, or “instructions” from the DNA out from the nucleus of the cell, with another set ferrying amino acids, the building blocks of proteins, to areas where they could be combined into these more complex proteins.  What we did not anticipate was that there was an entire unknown RNA biology, and that these molecules have many other functions in human cells, including defense against viral infections, turning on and off the expression of genes, protecting against or causing cancer, enzymatic activities, or at times functioning as genetic material itself.  As a matter of fact, even though the existence of RNA has been known since early in the twentieth century, Science magazine dubbed the discovery of one class of small RNA molecules, small interfering RNA, or siRNA, which are capable of “turning off” human and viral genes, its “breakthrough of the year” only nine years ago, in 2002.  A Nobel Prize was awarded for the work leading up to the discovery of these molecules in 2006 to Craig Mello and Andrew Fire, at that time investigators working at the University of Massachusetts.  Interestingly, one of the members of the Nobel committee that year, Erna Moller, was quoted in the Associated Press following the announcement of the award, “Andrew Fire and Craig Mello’s research helped shed new light on a complicated process that had confused researchers for years. “It was like opening the blinds in the morning,” she said, “Suddenly you can see everything clearly.”

It may have allowed us to see more clearly this particular aspect of the cell’s biologic machinery, but perhaps not with the naked eye or mind.  It added to the depth and breadth of information about the human cell – a volume of information that render it so increasingly complex that the organ that contemplates it – the human brain – cannot possibly fully grasp it’s own cellular constituency.

I posed a question recently to a few well-known scientists working in areas that involve, by definition, a great deal of cell biology expertise, asking them simply “If I asked you to go to a large white board and diagram a ‘complete’ human cell, with all chromosomes, all genes, all membranes and constituents, all organelles, all pathways, enzymes and other effector proteins, all active RNA constructs, etc., could you do it?”   Dr. Irving L. Weismann is the Ludwig Professor of Clinical Investigation and Cancer Research and the Director of the Stanford Institute for Stem Cell Biology and Regenerative Medicine.  One could argue that Dr.Wiesmann knows something about cell biology, and perhaps as much as anyone – he was the first investigator to isolate any stem cell in any species when he discovered the hematopoietic or blood-forming stem cell in mice in the 1980’s, and he went on from there to identify the human hematopoietic stem cell, the human neuronal stem cell, and the human leukemia stem cell. His reply to my question?

“Not a chance on earth, and I hope no one has that much in their mind…”.

A review of some of the numbers, and the exponentially combinatorial nature of how things work in the cell is instructive.  As far as we know, there are between 22,000 and 30,000 human genes in each cell regulated by hundreds of thousands of other DNA sequences (see “ENCODE” above), and the genes are capable of making 3-4 times more proteins than simple sequences would predict – well more than 100,000 of them.  These proteins interact along with virtually countless other biochemicals and other substances in various pathways driving cellular processes and events, and are organized as well, with other constituents such as carbohydates, lipids, minerals, etc., into a myriad of structural components (“scaffolding”) and sub cellular organelles – literally, “little organs”.

One of these organelles provides an example of the complexity of the overall enterprise, the mitochondrion.  The mitochondrion is often referred to as the cell’s “energy plant”, as it is the producer of adenine tri-phosphate (ATP), which powers a lot of those pathways and processes referred to earlier.  However, it also participates in cell death and survival, cell signaling and growth, and a number of other activities.  It even has its own DNA, which although a fraction of the size of the DNA residing in the parent cell nucleus, uses a different “code”.  Add to this complexity the myriad processes and pathways and groups of proteins (at times several working together at one time) that turn genes on and off, and the fact that we are increasingly learning that some regions of the DNA that were felt to be silent (more than 90% of it – only about 1-2% has known gene sequences) are actually not, and have functional significance.  Layered on top of this is the dynamic nature of our cells, which change structure and function depending on the environment.  We are learning, for example, that cancer cells do not sit passively by and allow themselves to be attacked by chemotherapy – they react by turning on a number of “defensive” genes that are normally quiescent, and even “eat” their own organelles at times to “ride out” the stress.  Weismann is right, who could possibly get “that much into their mind”?

One might argue that technology, and a generational difference of opinion regarding what needs to be “known”, versus what needs to be “understood” or “completely comprehended” has changed the way that many of us view personal data management in general.  Immediately accessible electronic information may be rendering any existential angst regarding issues such as not fully comprehending the stuff we are made up of somewhat mute. Winifred Gallagher, in her book Rapt: Attention And The Focused Life, argues convincingly (and at times ominously) that we are becoming so engaged with electronic media that we are losing the ability to focus and concentrate, and learn some things at the depth at which might be optimal.  She references studies, and calls on a number of experts that demonstrate and agree that the true value of “multitasking” is a myth, and that humans were not neurologically engineered to read Facebook on a computer or iPad screen, text someone on a smartphone, listen to iTunes, watch a reality show on television (or perhaps any of the other devices enumerated), and do homework simultaneously, at least with any degree of anticipated retention of whatever we were supposed to be learning.  She even argues that “whenever you squander attention on something that doesn’t put your brain through its paces and stimulate change, your mind stagnates a little and life feels dull.”  Although I get it, I am not sure that the medical students I teach, or my teenage son would agree with that sentiment, nor that they feel that they need to necessarily focus or commit as much to long term memory.  Some might even suggest that the ability to be immediately connected to one another, and to whatever they need to know in the moment, is fun and convenient.  What took the last generation days to accomplish, a student can accomplish now in a fraction of the time,  and the time investment, which might encourage someone to commit facts to memory rather than to be forced to repeat the drudgery of the process of data acquisition, has been incredibly diminished.  If, for example, I had been asked as a medical student to summarize the last ten articles that were written on the topic of HIV infection, I would have had to take the following steps…  go to the library and look at a very thick citation index book (which was always a few months out of date) to find a listing of what had been recently published in that area.  I would then have had to find the bound or shelved journals in which those articles had been published, and copy them.  It would then be likely that my library did not carry all of the journals where articles had been published, and I would then have had to ask the librarian to order the articles and have them copied manually at another library, and mailed or faxed back to the one I was using.  This process would take a total of 2-3 hours up front, and then a wait of a week or two for the missing citations to be mailed.  All this can be accomplished today, using the website Pubmed, and the internet, in something less than 15 minutes.

E. O. Wilson, is an American biologist and theorist who has argued for a combining and coordination of the sciences, and the sciences with the arts.  He does, however, seem to understand that achievement of “Consilience”, as he terms this objective, will not lead to the ability of humans to comprehend science in its totality, and states in the book by the same name that, “we are drowning in information, while starving for wisdom. The world henceforth will be run by synthesizers, people able to put together the right information at the right time, think critically about it, and make important choices wisely.”  It isn’t clear to me that there is a difference in the fund of knowledge that the medical students I teach accumulate as they move through the curriculum – one that teaches them at its fundamental level, in fact, about nothing more important than the human cell – how it works, what is built from it, and what can happen when things go awry.

In objective fairness, and in an effort to avoid waxing nostalgic about the “days of the giants” when I, and every generation before me was learning to be a doctor, the amount one needs to know to be abreast of modern medicine, like knowledge of the universe, is obviously growing quickly.   I am, however, beginning to perceive a subtle shift in regard to what is committed by some students to long term memory, or can be recounted without accessing any sort of database.  Why commit something to memory if you can pull a phone out of your pocket, or turn to the ubiquitous computer keyboard and have the answer immediately?  What I am suggesting here is that we are perhaps becoming more comfortable with less depth of comprehension in some circumstances, in exchange for breadth and access – becoming therefore increasingly comfortable with and dependent on our immediate access to information, and increasingly admitting our inability to handle the information any other way.  The human mind, for the vast majority of us, has limited ability to store, process and make sense of things.  Perhaps these students will be much better synthesizers, as Wilson suggests, than their predecessors, and better doctors – just as long as they don’t lose electrical power, or run out of batteries.

So, if we are not to be existentially challenged by our incomprehension of self at the basic level, and we are comfortable with abrogating any individual imperative to do so, how do we manage this and other increasingly complex sets of scientific data?  In this light, the challenge presented by our biology is really just a metaphor for all knowledge,  scientific and otherwise, continually expanding in increasingly discrete areas.  If no one person, or even reasonably-sized groups of people can comprehend the whole, shouldn’t we still seek comprehension of the whole, and aren’t there likely important things that will be learned from that comprehension?  There has been a lot of attention paid to the concept of “big science” around the world, whereby large groups of researchers have been encouraged to work together across organizations and continents to solve difficult problems in science.  This has led to better understanding of many processes in many areas, perhaps most dramatically in physics, where the discovery and characterization of sub-atomic particles and their behavior has been facilitated by mass collaboration. However, even these groups have tended to focus on relatively discrete areas of science, digging deeper and deeper into singular questions rather than attempting to coalesce knowledge from disparate areas.

Obviously, we will increasingly turn to computing science, and so-called “artificial intelligence” (AI) to achieve the goal of supplanting, or at least augmenting somehow our biologically-limited storage and processing ability.  Daniel Hillis is the Chairman of Applied Minds, and has been a leading voice in the AI discussion for more than two decades. He suggests, in an essay entitled “A Forebrain for the World Mind”, a world in which we have a coordinated electronic data management network that is much more than an internet – “the Internet knows no more about the information it handles than the telephone system knows about the conversations that take place over its lines. Most of those zillions of transistors are either doing something very trivial or nothing at all”.  He compares this current technology to the unconscious mind, or the “hindbrain”.  What he sees on the horizon is a linkage of human minds and technology, more of a “forebrain” – “this is the development that will make a difference: a method for groups of people and machines to work together to make decisions in a way that takes advantage of scale… Given this, we will finally have access to intelligence greater than our own. The world mind will finally have a forebrain, and this will change everything”.

During the Inquisition, Galileo was tried by the church for his views on our small part of Hubble’s expanding universe, namely his heretical assertion that our nearby planetary neighbors and the sun did not rotate around the earth. He was found guilty, and was punished by papal authority for this with imprisonment.  He later commented bitterly that “in matters of science the authority of a thousand is not worth the humble reasoning of a single individual”.  He was absolutely correct; however, when one considers the complexities of the human cell, the humble reasoning of a single, distracted individual may well not be worth the coming together of thousands upon thousands of electronically linked minds as Hillis suggests.

This scenario is likely, as well as a receding sense of just how much information we need to store away forcefully in our long term memory to be effective in many disciplines, as the knowledge in those disciplines continues to expand.  Sure, much will still come to reside there, in our limited biologic neural databases, based on repetitive use and regardless of the manner in which it is learned – previously by writing it on a blackboard a thousand times, and now perhaps by looking it up on Wikipedia a thousand times.  However, the ability to synthesize large amounts of information, as Wilson suggests, will perhaps come to be more valued in the future than encyclopedic memory for minute facts.

One of the continually empty promises of our modern advances in communication and access to information has been that we will have more discretionary time.  Ironically, we have never spent more time “working” than right now.  We spend less time doing the things that make us, collections of incomprehensible cells, uniquely human in our  incomprehensible universe.  If we are able to both learn more by allowing information to be stored and comprehended somewhere else, and access it for our use when needed rather than spending time chasing it down and continually trying to stuff it into our finite minds, could there be benefit over and above scientific consilience?  Might we have more time to be uniquely “humane”?  Might we find time to work at understanding one another, to value depth and breadth of relationships as much as we now value depth and breadth of factual recall?  Would we refocus on turning scientific knowledge, knowledge that will continue to accumulate, into human benefit and alleviation of pain, suffering, war, and fear?  Many would argue that we haven’t done those things commensurate with what we now know.  Would we gradually, like cultures that we now consider to be more “primitive”, come to value more highly time spent creating art and beauty?  I’m not sure.

What I am certain of is that I don’t lie in bed at night and fret over the fact that I can’t comprehend what I am made of.  Maybe I am smarter by just admitting this, as Lewis Thomas suggests in the opening quote for this essay.  Thomas, a physician, and a former President of Memorial Sloan-Kettering Cancer Center, was seemingly comfortable with this concept, and suggested that our obvious ignorance and our open-ended opportunity to discover was what made medical science enthralling.  He even posited that we think of the world as a giant single cell.  This was his interpretation and slight edit of the “Gaia Hypothesis”, whereby the earth is characterized as a living organism, rather than a place where life is simply casually smeared on inanimate rock, or carelessly plunked into dispassionate seas.  Lewis commented that, “I have been trying to think of the earth as a kind of organism, but it is a no go… it is most like a single cell.”   Perhaps what Lewis was trying to relate was the earth’s immediate incomprehensibility, complexity and interrelatedness, as well as our need to work at keeping it alive.

I’m not sure what the future of knowledge portends, or if it coming to terms with a world mind will be good, or bad for mankind.  I don’t know whether it will allow us to become more focused on humanity, or render humans irrelevant, leading to our replacement as a species by something non-cellular and far smarter than we are, or ever could be.  I am certain that a “change” has begun in the way that we relate to information; however, based on the behavior of the next generation, the first to be linked to one another and to all the world’s knowledge in an increasingly seamless fashion.  

By Will Smythe

(Narrative)

One of my junior surgical partners, Dr. Reese, called me from his clinic.

“Hey, would you mind coming down?” he hesitated, “I just haven’t ever seen anything like this before.”  He met me at the exam room door, wide eyed, with the patient’s chart in one hand, nervously slapping it into the other palm.

“This is wild,” he murmured, “a forty-year old man with bony masses in several areas of his body since childhood – hips, face… everywhere.  Now he has one in his chest that we might need to deal with – I’m just not sure it will be possible.”

We walked over to a computer to take a look at the CT scan.  He sat down and typed in the patient’s information on the keyboard – the images came up.

“Wow, you weren’t kidding”, I said, unconsciously leaning in closer to the screen.

There was a complex tumor mass originating from the ribs of the patient’s left chest wall, completely filling the left chest.  His heart, which would normally reside with the left lung, was pushed completely to the right side.

The consistency of the tumor was unusual – most cancers appear more or less solid on X-rays, but this one looked like a collection of giant popcorn kernels drawn by a child with a white crayon on the dark background of the radiograph.

“Where’s the left lung?” I asked.

“Good question,” Reese replied, “I don’t see it, do you?”

“No, nothing”, I said, puzzled, “were the previous masses malignant?”

“No, not malignant,” Dr. Reese replied, “benign.”

The most famous individual suffering from a syndrome of diffuse benign bony tumors was Joseph Merrick, the “Elephant Man”.  Merrick lived in London in the late 1800’s and became a well-known figure, largely due to his exploitation by others as a medical curiosity, his appearance altered dramatically by his disease.  Although debated for more than one hundred years, the causes most commonly mentioned by those examining his case are neurofibromatosis, the Proteus Syndrome, Mafucci Syndrome, and polyostotic fibrous dysplasia – all rare diseases with overlapping physical manifestations.

As all physicians are trained to do, I started the process of ruling things out, and ruling them in almost immediately.  With experience this process, termed “coming up with a differential diagnosis” is accomplished on two levels – one a very conscious and active process, and one much more complex and occult – embedded in the neural memory, and the subconscious mind.

The conscious process involves asking a set of systemically organized questions designed to narrow the possible disease processes being observed until only one really makes sense.  In this light, all physicians are students of Karl Popper – the famous philosopher of science who argued that skepticism, or the elimination of possibilities, is always superior to taking a stance and trying to prove it.

However, perhaps more important is the unfathomable information processing that is related to one’s experience – the thirty thousand previous X-rays reviewed, the twenty thousand cases that have been performed, the hundreds of thousands of discussions one has had with patients and other physicians… all woven into the grey matter of an experienced surgeon’s brain.  Here, decisions are made and syntheses in are performed in the subconscious that currently escape even the most sophisticated computer-based artificial intelligence – at least for now.

“Does he have any skin abnormalities, or diffuse soft-tissue nodules?” I asked.

“No,” Reese replied, “just obvious bony abnormalities – all over the place.”

This likely ruled out the neurofibromatoses, or Mafucci’s – both of which combine bony growths in various areas with abnormal multiple fleshy, nodular skin lesions.  Neurofibromatosis is also associated with “café-au’lait” spots, splotchy, light to dark brown discoloration of the skin – reminiscent of giant geographic “freckles”.

Proteus syndrome, a member of a larger group of abnormalities known as the “PTEN harmatoma tumor syndromes” (characterized by abnormalities in the PTEN – “phosphatase and tensin homolog gene”) and polyostotic fibrous dysplasia were both still options, but there had only been about two hundred documented cases of Proteus syndrome since it was described.

“Have you had a chance to review his past medical history?” I asked.

“Not yet,” he replied, “I called you as soon as I saw the films.”

We closed the X-ray program and opened up the patient’s electronic medical record.  His was a truly tale of woe and long-suffering – multiple operations related to these bony tumors from childhood, including removal of his right eye at one point, as well as other craniofacial, hip and lower extremity procedures.  Like small glaciers moving within and across the surfaces of his body, these bony lesions had remodeled or crowded out his normal anatomy – pushing his organs like his heart into areas where they shouldn’t be, or in the case of his lung, potentially obliterating them.

The chart review determined that previously, doctors had given him a diagnosis of fibrous dysplasia.  Fibrous dysplasia is a random, or non-inherited, genetic disease process, involving a mutation in a gene that codes for a portion of a protein called “Gs”.  When mutated, this gene leads to abnormal growth and function of the cells that create bone.

Dr. Reese suggested that he and I see the patient together.  “He’s young, and these are benign tumors,” I said as we walked toward the exam room door, “so why do you think he might benefit from surgery?”

“Because he’s suffocating,” he replied.

§§§§§§

We entered the room, to find Mr. Cortez, crowded into the small space along with eight women – his sisters, cousins and aunts.  He was wearing a nasal cannula – plastic tubing running from an oxygen tank to his nose.  A peculiar observation that distracted me for a moment was the fact that the average height of the women was at best somewhere around four foot eight, and Mr. Cortez was about six foot seven – it was as if the Lilliputians had decided to bring Gulliver in for some medical maintenance.

Mr. Cortez’s head was one and one-half times the normal size, and subtly misshapen, with “lumpy” areas.  He wore a baseball cap that seemed as if it were four sizes too small.  He had a prosthetic left eye, and stood with a stoop, his unusually large hands grasping the handlebar of a walker.  His speech was very deep and halting, the latter due to his shortness of breath.  He would gasp for several seconds after speaking, sucking in oxygen through the clear plastic tubing in his nostrils.

Polyostotic (literally, “many bones”) fibrous dysplasia with endocrine, or glandular, abnormalities is termed McCune-Albright Syndrome.  Although the isolated form of fibrous dysplasia (changes in one bone or area) numbers about 30,000 patients worldwide, McCune-Albright affects only 1000 or so.   Mr. Cortez met the criteria, with diffuse bony masses, which result from the unusual breakdown of normal bone in multiple areas of his body, and overzealous replacement with fibrous tissue, and acromegaly – a disorder related to the overproduction of growth hormone from the pituitary gland, leading to increased height, and enlargement of the hands and facial bones.

After introductions, I asked him, “Mr. Cortez, why did you come to see us?”

“I wanted to know if you could help me,” he replied, “I’ve been fighting this since I was a little boy… first the operations, and then… then folks making fun of me.”  He stopped, tears welling up in his eyes, and several of the tiny women began crying.

“I can’t get around, doc, and my breathing is really bad,” he gathered himself, wiped the tears from his eyes with back of one of his giant hands, and continued, “I want to do normal things, you know, the stuff everyone else gets to do… I want to coach little league baseball.”

“I understand,” I replied, “I’m afraid that this is going to get worse, and I don’t know how much longer you have if nothing is done.”

“What are my options, doc?” he asked.  I watched his fingers squeezing, then releasing the handlebar of the walker repeatedly.

I looked up at his face, “removing the mass in your chest is the only chance of getting better, but I need to test your lung function so that we can understand whether or not you can tolerate the operation.  It looks as if your left lung is basically gone.  It’s possible that you just don’t have enough lung function for us to do this operation.”

“Okay, doc,” he replied.

We went ahead with the tests, and few days later, reviewed the results.  Unfortunately, our concerns were substantiated – Mr. Cortez’s lung function was only about twelve percent of normal.  Dr. Reese and I met to discuss.

“I don’t think he’ll survive it,” Dr. Reese commented, “just removing the bony tumor will not be enough – he needs more lung tissue.”

“I know,” I replied, “but I think we might have a chance.”

“How’s that?”

“I’ve operated on a number of patients with bullous disease,” I replied, “and I think this might be similar.”

Dr. Reese looked at me quizzically.

What I knew was that “bullous disease” is a form of emphysema in which an area of a patient’s lungs degenerates and basically becomes a balloon that enlarges with air over time.  As it enlarges, it compresses the adjacent, normal lung.  Often times, when this ballooned-out area is removed surgically, the normal, compressed lung around it re-expands dramatically, even if it has been compressed for months or even years.

“This should be the same – there’s theoretically nothing wrong with his lung, just compressed over time by the bony mass,” I told Dr. Reese, trying to sound confident.

“Possibly for decades,” Reese added doubtfully, shaking his head “but that presupposes that he has some lung there, doesn’t it?  What if we remove the tumor and there isn’t any lung there, or what’s there can’t re-inflate?”

“He won’t survive,” I replied, “he’ll die on the table, or shortly after the operation…”

We called Mr. Cortez, and discussed the options.  He was adamant that he did not want to have surgery when we laid out the odds and the dilemma.

However, a week later, he called us back, and showed up for another appointment.

He was sitting in the exam room when we walked in, but stood up slowly, grasping the handlebar of his walker to steady himself.  He was so tall, and his movements were so slowed by his underlying breathing difficulty that he appeared to be “unfolding” more than standing up.

“I changed my mind,” he said forcefully, “I want to live, and I don’t want to live like this.”  He hesitated and looked at the faces of the tiny women accompanying him,  “I’ll take my chances, even if they aren’t so good.”

The Lilliputians accompanying him all simultaneously burst into tears.

§§§§§§

When I visited him in the holding area prior to surgery, Mr. Cortez grinned crookedly, his left eye pointing out the door and down the hall toward the operating room, and his right focused on me, as he shook my hand.

We placed Mr. Cortez on his side with his left chest up, and got started.  Four of his ribs had fused into a solid mass, which extended inward.  In the area of his spine, the mass had fused rib and vertebral body and tumor into one huge bone – we actually used a large hammer and chisel to separate it from his spinal cord area – these were not the type of tools we commonly used in thoracic surgyer while operating on the soft, fragile organs that those ribs were designed, in fact, to protect.

Once the mass was freed form the spine, and the ribs divided all around, it had to be separated from the center of his chest.  Here it was not invading anything, but avidly adherent – stuck to what was underneath, and underneath the mass was where the lung would be, if there was any present.  The tumor mass, the size of a watermelon, was too heavy; however, to lift and hold steady, away from the vital organs (heart, esophagus, great vessels, and possibly, lung).  We had to employ a hook and crank system attached to the operating room bed, normally reserved for large orthopedic procedures, to stabilize it, and lift it up and away from the patient’s body.

I felt under the tumor, where I could not yet see, with my fingers.  “It’s soft,” I said, unconvincingly, but not much of anything there.”

“Does it feel like lung?” Reese asked.

“Not really.”

We used the electric knife, the electrocautery, to separate the mass from this tissue, and the huge, bulky tumor was gradually elevated up and out of the wound.

Finally, it was free.  Dr. Reese cradled it in his arms, and set it on a sterile scale on the nurse’s stand.  “Nine kilograms,” he proclaimed, looking over his mast at me in amazement, “almost twenty pounds.”

When he walked back to the table, he saw me staring into the empty space.

“Well?” he asked, sheepishly.

“It looks like lung tissue,” I said.  My heart was pounding, and my hands were trembling.

Gratefully, losing a patient in the operating room was something I had experienced very few times in my career.  That being said, the increasing possibility was triggering my own body’s innate fear response.

At the bottom of the wound was some pink fleshy material, no more than three millimeters thick.

I pointed to the pancake-like tissue.  “I think this is lung,” I replied, “but there isn’t much of it.”  I looked up at Dr. Reese.  He silently returned my anxious stare.

“Are we going to try?” he asked.

I looked up at the anesthesiologist.  The scrub nurse and a medical student were standing next to Dr. Reese and myself, respectively.  No one spoke for several moments.  The chest cavity and its little pink pancake moved along with the sound of the anesthesia machine, “psssstup,… psssstup”, inflating the lung hidden on the other side of the chest.

The breathing tube that anesthesiologist inserts at the beginning of a lung operation has two channels – one to each lung.  When operating, one side of the tube is clamped, and all of the airflow is directed to the lung that isn’t being treated – allowing the one you are working on to collapse and not move with respiration.

“Okay,” I said, “unclamp the tube.”  The anesthesiologist complied, and we watched, all of our hands resting on the patient, as if trying to levitate something at a vaudeville magic show.

Several breaths were delivered… but no inflation… nothing.

Suddenly, a couple of small areas popped up, like pink bubblegum bubbles – then, a few more.  The pancake thickened, and thickened again, and then, more bubbles, which grew and coalesced with others… Within three minutes, the entire lung had re-inflated, from a flat spongy nothingness to a real lung – thirty times its size before inflating it.

“Its working,” the anesthesiologist reported from the other side of the drape, “good oxygen exchange from that lung!”

“Impossible,” Dr. Reese murmured under his breath, “impossible.”

I smiled behind my mask, and shook my head.

Within a month, Mr. Cortez was off of oxygen, and walking without a walker.

Completely by chance one night at home a few months later, right before I turned the light out on my bed stand to go to sleep, I caught a glimpse of someone that looked familiar on a late night television news spot.  After a couple of seconds, I realized that it was Mr. Cortez – a local station had evidently put together a feature story on his fight and recovery.  I propped myself up on my elbow and squinted at the bright television image across the dark room.

I had been reading a book, and had turned the television volume down earlier so that it wouldn’t awaken my wife, who was already asleep beside me.  However, I didn’t need the narrative to let me know how things were going – I saw him smiling into the camera, walking without his walker and without any oxygen tubing in his nose,

He was surrounded by a large group of little boys in matching baseball caps.

‘

(Fiction) Reprinted in adapted form, with permission from Hektoen International: A Journal of the Humanities, Volume 4, Issue 1 – Spring 2012

http://www.hektoeninternational.org

By Will Smythe

In the hot Texas summer of my sixty-seventh year, my skin turned a little yella, and I lost some weight.

I didn’t know it right then, but come to find out, it was what would end me.

Doc Butler, who I had been seein’ for about thirty years now, told me to go to the “cancer center” in the city.  I didn’t want to go, but hell.  He says they don’t take care of nothin’ but cancer there, and that the folks up there know more than he does.  Hard to imagine anyone knowin’ more than him, but he’s the doctor.

I had been many things in my life, like most my age, but I guess that I could best be described as a farmer during the last few decades – really not much more than scratchin’ at dirt, and gettin’ it under my fingernails, but a farmer, nonetheless.  Some corn, some hay, and one big ol’ peach tree in the back yard.

I grew up in a small town in Texas, and when I say small, I mean small.  My granny used to say it “wasn’t no bigger than a cooked pea”. We had a grocery, a post office, a barber and beauty shop combo, a fillin’ station, and no stop lights.  When I was a young’n, my daddy was gone a lot – drove a truck.  Mama took care of the house, and my little brothers.

Benjy, the youngest, we lost to the whoopin’ cough when he was three.  I never thought mama was gonna get over that, she laid in bed for what seemed like a month of Sundays, and just cried and cried.  The doctor was thirty miles away during the day, and an hour at night, and his throat just shut off before we could get him to anyone that could help.  We shoulda’ takin’ him earlier, but I can remember mama worryin’ that they was gonna cut his neck. Daddy had to go to work afterwards regardless, as jobs was scarce and folks was cheap, and Aunt Elma had to drive in from the city to feed us.  She didn’t cook very good as I recall, we was awful glad when mama got up.

I was ten at the time, but death wasn’t a stranger to a farm boy, we lived it day in and day out with the animals – some dyin’ natural, and some endin’ up on the table.  We had some cows, and some chickens, and as soon as I was able, I tended to both.  I didn’t mind milkin’ the cows so much, sort of enjoyed it, but didn’t take at all to cleanin’ out those damn chicken coops.  I used to collect the eggs in the mornin’ before school, and would hold them up and look at them, wonderin’ how somethin’ so perfect and smooth and white could come out of the rear end of somethin’ that didn’t care if it crapped everywhere, and I mean everywhere, except just where it sat on that nest.

The cows, well, they was nice and gentle, and seemed cleaner somehow than the chickens – takin’ care of their business in the pasture.  They really didn’t smell bad at all, sort of a mix between milk and hay.  It got to where they would walk up as soon as they heard the back door screen slam shut in the mornin’, when it was still way too dark for them to see me come out the house.  They would just walk real peaceful right over to the little barn out back.  Belle, the oldest, would snort and I could hear her walkin’ up with the others before I could see them too.  She used to wear a bell, but it fell off and we didn’t have the money to get a new one from the catalog.  It didn’t matter, the others followed her around everwhere anyway.

I did a lot of thinkin’ when I milked in the mornin’, while the inside of the barn turned from pitch black to glowin’ grey and finally light blue as the sun come on up behind me through the big door that was swung open to let one of the cows in one at a time to the milkin’ stall.  I wasn’t thinkin’ about what my hands were doin’, or about the “pssst, pssst, pssst” sound of the milk hittin’ the bottom of the aluminum pail, but about other things – about growin’ up and leavin’ to live in the big city, and drivin’ a big fancy car.  Every now and then I would daydream about havin’ a family – what my wife would look like, how many kids I would have, and such.

I sat in the doctor’s office by myself.  Momma was at home with the grandkids, and I had a bad feelin’ anyway, a bad feelin’ about this visit.  I thought it might be better for her not to come.  I took out my wallet and slipped out the picture of my boy and girl, both in their forties now.  It was my favorite picture of the two of them, and thinkin’ about how I used to daydream when I milked those cows made me want to take it out and see it.  Actually, I had come to love not just lookin’ at, but the feel of it too, soft and fuzzy on the back side where the paper was rubbin’ slowly off, and sort of crinkled on the front.  I ran my fingers over the surface, over the tiny lines, and their little faces – faded to a light yellow by time.  Margaret was five then, and little Ronnie wasn’t quite two yet.

They sure were cute.  Folks used to stop us when we would go into the city, momma pushin’ the little fella in a buggy, and me carryin’ Margie in my arms, her little patent-leather shoes bumpin’ into my leg each time I took a step, indicatin’ that she was too tired to walk, and that she had just let go of tryin’ to control anything – anything other than me keepin’ on carryin’ her.

“They’re SO cute,” folks would say, and momma would beam, and I would laugh that little laugh that just seems to bubble up suddenly and come right out of you when somethin’ good happens with the kids.  I used to get that same laugh when Ronnie would run in a touchdown when he was playin’ high school ball, or when Margie would sing her solo in the church choir – it would just come out of you, a sort of joy that had to get out somehow.

They were both real tow-headed blondes, almost white-headed as a matter of fact, with bright blue eyes.  When they were little and you looked at them for long enough, sometimes it felt that some sort of light was comin’ out of em’ and into you.  Momma and I used to lay in bed at night, listenin’ to the crickets and the box fan, and talk about how much we loved them.

“I just wish they could stay little, like they are right now” I would say, and momma would answer, “me too Daddy, but it just doesn’t work that way, we have to enjoy them, and enjoy life while we can.”  Momma had always knew what to say it seemed like, remindin’ me of things like that, that enjoyin’ life was important.  I figured that was good, cause I often needed remindin’.  Workin’ always seemed like plenty of fun itself.

The doorknob jiggled, and a woman in a white coat busted into the room.  “Hello, uh…,” she looked down at the papers in her hand like she hadn’t laid eyes on em’ before right then, “…Mr…, uh…, Mr. Jones…, right?”

“Yes ma’am,” I replied, “that’s me.”  She only looked at me for a second until she confirmed that I wasn’t some sort of imposter, and then plopped right down in front of a computer.  She didn’t sit on that stool very lady-like, I didn’t think.  “Your date of birth is seven-fourteen-forty four?”

“Yes ma’am,” I answered, “that’s right, don’t seem as if I am that old, you…”

She interrupted me, “your address is twelve-hundred route sixteen?”

“Yes ma’am,” I answered again.  I  figured pretty quick that this was gonna be a one-way street, and that she was gonna do all the talkin’.  She clicked the computer keys real fast – I wasn’t sure I had seen anyone, except maybe our oldest grandkid, Bobbie, type like that.  How the hell could she do it that fast?

“I have an email here from Dr. Butler.  He says that his preliminary evaluation, which included laboratory assessment, a CT scan and a biopsy suggest that you have a pancreatic malignancy that has spread to your liver, is that correct?”

She was starin’ at the computer screen.  I waited a minute to see if she was gonna’ look over at me or somethin’, but she just kept starin’ at that piece of glass.  “If that means I got cancer in my pancreas that’s what Doc Butler said he was afraid of, yes.”  I knew what a pancreas was, and where it was.  We ate ‘em when I was growin’ up, tryin’ not to waste much when we put one of the milk cows down – mama called ‘em sweetbreads, and daddy thought they was delicious.

“Did the nurse get your vitals?” she asked, again peckin’ on the keys like a rooster about to spur, and lookin’ so hard at the computer screen and leanin’ in so far that her face looked like something out of one of them horror movies I used to watch on the black and white teevee – glowin’ white.

“Come again?” I asked.

She seemed a little put off, “your vitals…, you know, your blood pressure and heart rate, et cetera.”

“Yeah, she checked those right before I came in here, but she was in a big hurry, I didn’t see her write ‘em down or nothin’.”

“I TOLD her to log these in!” she said, and then she got up real fast and started to leave the room.

As she grabbed the doorknob, I got up my courage and asked her, “say ma’am, are you the doctor.”

“No, I’m the assist…”, the last part of the word cut off as the door shut behind her.

I sat there for a minute.  I thought I might just bust out laughin’, but this time not the type of laughin’ I was thinkin’ about earlier.  This is the type that also just bubbles up out and of you, but does it when you are so nervous and confused that no other response seems right, a sort of laughin’ and head shakin’ from side to side at the same time.  The kind of laugh the teacher made when you was a kid, and walked up her desk with your head hangin’ down and told her that the cow had eat your homework.  It was a laugh, but it didn’t mean nothin’ was funny.

It got real quiet in the room after she left, and took her airs with her.  Without all that machine gun typin’ goin’ on, I had time to stop and think and I realized – I was tired.  I got up early every day, around five or so, but had to get up at three this mornin’ to make the three hour drive into the city, and find a parkin’ spot before my eight o’clock appointment.  I looked at my watch – it was ten already and I hadn’t seen hide nor hair of the doctor that I was sent to see by Doc Butler, some sort of cancer surgeon.  I started wonderin’ whether or not I was gonna see him at all, maybe just these assistants and such?  Hell, I didn’t know.  I thought it was amazin’ that I had to pay the same just to have my car sit somewhere that I would have paid at the café for me and momma to have an entire lunch, with dessert.  Didn’t seem right to have to pay for it to have to just sit there on a piece of concrete between two yellow lines.

I hadn’t been sleepin’ real well besides, and my energy had been sort of low to be honest.  Margie was havin’ some trouble with her husband, and it was eatin’ on me pretty good, plus whatever it was that was wrong with me maybe eatin’ on me too.  The thought of someone bein’ mean to her, that little tow-headed five year old in that crinkled picture that I carried around in my wallet, was almost more than I could bear, and enough to keep me awake, stewin’.  I thought a few times that I would just drive over to their house in the middle of the night with my shotgun, and have a man to man with him, but was scared that I might just up and kill him.  Even though I knew Margie would get over it pretty quick, the grandkids wouldn’t, and momma would never forgive me for leavin’ her with the farm whilst they whisked me off to Huntsville.  It struck me that I might be leavin’ her with it anyway now, and I felt a little panicked.

That passed.  I leaned my head back on the wall, and fell right to sleep.

The door bust open again, startlin’ me awake.  I sat up on the edge of the chair, and rubbed my bad eye.  I say it was bad because it had been the recipient of a big grasshopper movin’ at thirty miles an hour about three years ago.  Actually, I didn’t know exactly how fast it was flyin’, but I was drivin’ the tractor on the farm to market road about thirty miles an hour, as fast as it would go, and he flew right into my eye.  I never saw the doctor about it, but he must of scratched somethin’, cause ever since when I wake up it’s slow to open compared to the other side, and rubbin’ it seems to speed it up.

Out of my other eye I saw what must have been the doctor stride in, ahead of three others.  He was tall, and looked real young.  He had on a coat so white that it almost hurt my one good eye that was lookin’ at it, and it looked starched stiff enough to ward off buckshot from six paces.  It was immediately obvious that he, or somebody in his retinue had gotten a little overexcited when they were puttin’ on the cologne that morning, it was a nice smell, but a little too much for my taste.

His shoes were real shiny – I wondered if he knew how to do that, or if someone did it for him.  I was starin’ down at his shoes, with both eyes now, when I noticed he was standin’ over me lookin’ down.  I stood up and reached out, lookin’ for his hand to shake but he was rubbing them together with something that was green and smelled like liniment.  I put my hand back in my pocket and sat back down.

“Hi, Mr…,” I be damned if he didn’t have to look at them papers to know who I was too, but this time he had to reach over and grab it out of one of the other’s hands, “Mr…, Jones?”.

“That’s right,” I replied.  The other two folks, also in white coats, but shorter ones, moved back to the back wall of the little room we was in.  They was starin’ at me like I was a new calf comin’ out breach that they didn’t know what to do with.  The doctor sat down on the same stool as the lady before him, and I’ll be damned if he didn’t start clickin’ away at the keys too, just like the “assist…” had done.  Thinkin’ about callin’ her the “assist…” was funny to me, I knew full well it was “assistant”, but hell, she hadn’t felt the need to get the entire word out before she waltzed out of here, had she?

“So,” the doctor said cheerfully, like he was the clerk at Macy’s or somethin’, “how are you feeling.”  He was lookin’ at the computer, just like the “assist…”, and not at me.  I figured he knew how the other two folks were, as he come in with ‘em, and that he was askin’ me, but I wasn’t sure.

“Alright,” I said.

“Good, good…,” he replied, readin’ the computer, and squintin’ a little.  He shifted on his stool and I could hear that starched coat folding on itself.  “So…,” and he tailed off, clicking away like a madman at them keys, and squintin’ even harder at the screen.  I cleared my throat sort of loud to get his attention – I wanted to know what the hell came after “so”.  “I’m sorry,” he said, “we have a new computer system, very expensive, and a little confusing, you know?”  I didn’t know, but he was the doctor.

I looked over at the two in the back of the room. One of them had taken out her phone and was “thumbin” it like my grandson Bobbie seemed to be doin’ about three quarters of the time, and laughing under her breath, and the other one looked like he was sleepin’ standin’ up.  I didn’t think a man could do that until I went to Viet Nam.  You can sleep standin’ up alright, and you can do it holdin’ a gun, and in four and a half feet of water if your life depends on it – I knew firsthand.

“Doctor Butler your referring?” he asked me, still squinting at the screen.

“You mean my doctor?” I asked.

“Yes, yes,” he said, and whipped out about twenty more keystrokes, the last one with his right hand, lifting it up and snapping it down like a conductor stoppin’ the orchestra with his baton at the end of a piece of fancy music.  He looked over at me for the first time in several minutes, smiling like he had done something important, and clever.

“You have pancreatic adenocarcinoma,” he said, and looked over at the two in the back of the room like he was about to ask ‘em somethin’.  The fella on the left was still sleepin’, and the girl looked up from her phone.  He then went on, “Ms. Valdez,” can you tell me anything about the presentation of pancreatic adenocarcinoma, say, one located in the head of the pancreas, near the common bile duct?”  I had no idea what any of those words meant.  I understood pancreatic must have to do with my pancreas, and that that word ending in “oma” might have meant cancer, if he wasn’t talkin’ about someone’s German granny, but the rest sounded mostly like mama’s goulash.

“Yes,” she replied, “elderly, thin, painless jaundice, perhaps Courvoisier’s sign.”

I was old and a little skinny, but I didn’t speak no French… and what the hell are them John dice she’s talkin’ about?

“Abraham?” the doctor said to the other one.

“Yes?” he replied, startled awake all the sudden, “what?”

I was thinkin’ that these two were students of some sort, and I decided right there that the fella that was sleepin’ had some work to do to make a doctor.  He didn’t look worried enough to me that he had no idea what his boss was askin’.  I hoped that he was just tired from workin’ too hard, and that it wasn’t that he was just short of grain in his silo.  I took careful notice, though, that his hair was slicked back real careful and pretty, and thought twice about him actually bein’ tired from workin’.

The doctor looked back at me, “do you understand what this all means, Mr. Jones?”  His voice sounded a little bit like the fella that read the news on the radio – real sure of hisself, but like he was readin’ somethin’ that he didn’t have no real connection to.

“Well,” I said, “it ain’t good, right?”

He looked back at the computer, and started typing again.  I noticed that both of the students was thumbin’ on their phones now, not payin’ any attention what-so-ever – it seemed like they should.  “That’s right,” he said, “nothing that we can do for you surgically, with metastatic disease.  You could consider chemotherapy, with some investigational agents…, I’m looking up some biologic agent clinical trials now…, yes, there is a monoclonal antibody trial up in Boston, you should consider that.  I have to admit that the biologic underpinnings are sound.”  He was smiling like he had figured something out again.  I had no damn idea what he was talkin’ about, except the part about havin’ no surgery.

“So let me get this straight, doctor,” I said, trying not to sound too worked up, “there ain’t no surgery option, but there might be some medicine I can take to make this go away?”  Both of the students stopped thumbin’ at the same time, like they was on cue, and looked at me, a little anxious.  “Well…,” he said, “there are other options, like the trial in Boston.”  “Boston Massachusetts?” I asked, “what’s the chance that this “anti-body” medicine there will work?”

“Hard to say, clinical trial,” he answered.

I had no idea what a clinical trial was, but it sounded like an experiment of some sort, and this doctor wasn’t sounding too optimistic.  Also seemed to me like it shoulda’ been “anti-cancer”, instead of “anti-body”, but I let that go.

“Listen, doctor,” I said, “I’m not a stupid man.  I know a lot about animal husbandry, and  fair bit about farmin’ – how to plant, fertilize, grow and harvest crops, and how to take a tractor engine apart, fix it and put it together.  That all being said, I don’t know nothin’ about doctorin’.  Now, what’s the chance I can beat this thing?”

He kept looking at the computer screen, but took his hands off of the keyboard, and put them in those stiff white pockets of his lab coat.  “Hard to say,” he replied.  I waited for the next shoe to drop, but it didn’t even come off the foot.

I decided to press my bet.  “Okay, is it better than five in ten?”

“No,” he replied.

“Okay then, how’s about two in ten?”

“Probably not,” he replied again, glancing over his shoulder, lookin’ for some sign of agreement from his students, both of which was still thumbin’ around on their phones, and still not payin’ us no mind.  I sat there and looked at him for a long moment, not knowin’ what I was supposed to ask now, of if we were done.

He finally looked over at me.  “Do you have any other questions?” he asked, not really lookin’ any which way – not happy or sad, just like he was done.

“No sir,” I replied, “I think I get the picture, I get it just fine.  What you’re tellin’ me here is that I drank downstream from the herd.”  I could tell that I had turned the table on him by the confused expression on his face, he had no idea whatsoever what I meant for a change.

He got up, and put some more of that green stuff on his hands out of an electric spigot of some sort, and rubbed them together again.  “Thanks for coming in, Mr…”

“Jones,” I said, “Jones.”  He and the students left the room, the smell of that damn cologne still hangin’ in the air like fog on the riverbank in the mornin’.  I kept sittin’ there for a minute or two, and figured since no one had said nothin’ otherwise, that I could leave.  I started walkin’ down the hall to the exit door, when a nurse came and grabbed me by the arm.

“Mr. Jones,” she laughed, “you can’t leave yet, you have a co-pay that you have to take care of.”

It struck me strange when I left the desk and headed toward the parkin’ garage that it would be called co-any-goddamn-thing.  Where the hell was the ‘co-’ they was referrin’ to?  Seemed like I was the only one payin’.

The back screen slammed shut as I closed the wooden door behind me back at the house.  “Hi Papa,” Momma called from the kitchen.  I could both smell and hear salt pork gettin’ browned in the skillet.

“Little ones gone?” I asked, a little disappointed.

“Yes, Margie came and got ‘em early,” she yelled over the sizzle.

“How’s she doin’ with that no account?” I asked.

“One day at a time, Papa, one day at a time.”

I changed into my work boots in the bedroom, and went over to the kitchen and kissed Momma on the cheek.  She smiled, but was focused on dinner.  She was a serious cook – not fancy, but serious.  I once heard my daddy tell my mama that she was “only good at cookin’ staples”, and she run out of the room cryin’.  I made it a point to only say good things about what Momma fed me, it beat the hell outta K-rations.

I looked over my shoulder as I left her there and walked out the back door again.  She was a beautiful woman, I always liked it when her cheeks turned red, like now when she was cookin’ over a hot stove, or other times when she laughed a little too hard about somethin’ we both thought was funny.  When she was younger, her cheeks would look like that when we got frisky – she was tow-headed too, you see, and light complected.  We had been together now for fifty years.  It pained me powerful when I thought about havin’ to tell her the bad news, but knew I had a little time.  Not tonight.

I walked through the back yard, ducked under the clothesline, which I had just re-twined earlier in the week, and stopped at the big peach tree over in the corner.   No tellin’ how old it was, I had never seen one bigger.  I had even drove around in the truck lookin’ for one as big, but as best I could tell, it was in fact the biggest in the county, maybe the state.  It marked off the imaginary dividin’ line between the back yard, and where the cornfields started.   There were only about handful of peaches left on, and one that looked ready for pickin’, just where I could reach it.  Standin’ this close to a peach tree at this time of year is like bein’ baked right into a pie – it was the combination of the heat, and the smell.  There are some on the ground that are in various stages of sweet rottin’, and those on the tree that are gettin’ ripe, fragrant and juicy.

I reached up on my tip-toes and plucked off the one that I had spotted, and kept walking south, out of the yard and into the fields.  I stood a few rows in, and looked over the stalks of corn, and at the setting sun to my left.

The sky in Texas at times in the summer takes on an unbelievable pinkish orange color, reflectin’ off of the bottoms of clouds, standin’ out against the late afternoon cornflower light blue sky.  Tonight the clouds looked like great big angel’s wings, turned upside down.  I could smell the warm musky black earth that made this part of the world such good farmin’ country beneath my feet, and the clean green grass smell of the corn plants.  The evenin’ heat felt real good on the back of my neck after all that time in the air conditionin’ at the hospital.

Goddamn it, I love this place, I thought to myself.  I took a bite of the peach.  It was perfect – sweet and tart and crunchy.  I wiped the juice off of my chin with the back of my sleeve, and cried.  I just stood there and cried until I couldn’t see the clouds any longer, and the moon rose just above the horizon in the darkened sky, a brilliant thin white sliver of an “eights” moon, as my granddaddy used to call it.

That night, momma and I laid in bed, and she turned over on her back kinda quick – like when she was getting’ ready to talk about somethin’.  “Papa, what did the doctor tell you anyway?” she asked, with just a touch of worry in her voice.  I cleared my throat, and tried to sound like I wasn’t bothered by any of it, “he has to run some more tests, won’t know for a while, but he didn’t seem worried,” I replied, “you know, them doctors look good, but they don’t know much.”

She laughed, “yeah but its good to have ‘em when you need ‘em.”

“I guess,” I replied, “you know, it was funny today.  I think I got through the whole damn visit at that fancy cancer center without anyone touchin’ me except the nurse that took my blood pressure.”

“Really?” she asked.

“Yeah,” and there was two students in the room with the doctor that acted like I wasn’t even there.  Neither one said nothin’ to me – not hi, bye, or kiss my ass for that matter, and all three of ‘em walked around like they had oil wells in the back yard.”

“Too bad,” momma replied, yawning, “you oughta get some sleep now papa.”

“Yeah,” I replied, “I know.

Say momma, do you remember when we used to lie in bed and wish our two little ones would never grow up, you know, stay little?”  “Sure,” she replied, “I always thought that you meant it, too.”

“I did,” I replied, “I did, but I guess that life just goes on, don’t it.”

“It sure does honey,” she said, “it’s the natural cycle of things, like the crops out back – we live, we grow, we bloom, and we die.  I guess we hope that we get some love in, and leave something behind us that someone can remember us by.  I don’t know, really.”  She turned all the way over and snuggled up tight next to me.

“Momma,” I asked, “when its my time, will you bury me under that big old peach tree out back, and angle me so that I can see the sun set in the afternoon every day?

“Yes papa,” she replied, and fell asleep in my arms.

By Will Smythe

(Narrative)

I was in the middle of a normal clinic day when the nurse placing patients in the exam rooms told me that someone had arrived with a diagnostic video.

“A video?” I asked, “a video of what?”

“I don’t know,” she replied, “but I set the CD next to the computer in the work room for you.”

As a general thoracic surgeon, I was used to viewing chest X-rays, CT scans and other similar radiographic tests, but not videos, as I was primarily a lung surgeon.  Adult cardiac surgeons – those that operate on the human heart – review these video studies much more often when planning for what they do each day.

I walked over to the computer, sat down and put the CD into the drive.  I watched as the program booted up, and the patient’s name appeared at the top of the study information on the screen.

“Hmm,” I said to myself, “a real-time cardiac MRI study – why would I be looking at this?”

I began to click through the images, first in still frames, and then with the heart contracting.  This is where the “real-time” name comes from – seeing the heart anatomy, and function in a “moving Xray”, over time.

What I saw was frightening.

There was a large mass growing in the patient’s heart, in the back, or posterior wall of the left atrial chamber – this was simply the worst place in the heart to have a problem like this.

My own heart sank. Primary tumors, which originate in tissues rather than spreading there from some other place in the body, are uncommon in the heart. They occur in less than 0.05 percent of autopsies, or less than 5 in 10,000. Seventy-five percent of them are benign, but this one did not look harmless. Benign tumors typically grow out from the surface of the cardiac wall like a mushroom on a stalk; malignant tumors look more like a bulge of varying thickness in the wall. Most cardiac surgeons will encounter only a few benign primary tumors in a career, and many will never deal with a malignant one.

Imagine the heart as a large hollow bell pepper, divided into four chambers – two small ones on the top, and two larger ones on the bottom, with a small and a large chamber to the left, and one of each to the right.  Now, rotate it forty-five degrees counter-clockwise, so that the two left chambers are mostly behind the two right ones.  Next, lean the pepper back about forty-five degrees, so that the right upper and lower chambers are at about the same height, and the bottom of the heart where the two large chambers end is pointing out, termed contradictorily the “apex”.  This is how the heart lies in the chest of most people.

The right atrium collects blood from the entire body once it has been depleted of oxygen, and pumps it into the larger right ventricle, which in turn pumps it into the lungs to get more oxygen.  Once the blood leaves the lungs, it is collected into the left atrium, which in turn pumps it into the left ventricle, which pushes oxygenated blood throughout the body.

The right atrium and both ventricles are somewhat accessible to the surgeon’s knife.  However, the left atrium, on the back of the heart next to the spine, is in a difficult area to reach.  The lateral walls can be seen easily, but the anterior wall is in the center of the rotated and tilted heart, and the back wall is next to the spine, behind everything.

I watched the heart contract on the images.  Blood in motion is much brighter than the structures surrounding it, which are depicted in varying shades of grey.  The moving fluid is actually beautiful to watch, like white syrup saturated with white glitter, flowing in some areas smoothly, and in others with small whorls and eddy currents.  These images were indeed beautiful, but what they indicated was anything but.

One of my partners, also seeing patients in clinic, wandered over and looked over my shoulder.

“You doing cardiac surgery now?” he asked.

“Not exactly,” I replied, but hey… take a closer look at this.”

The left atrium anterior wall, opposite the tumor, ballooned out awkwardly as it contracted.  The blood didn’t flow smoothly into the area, and some was forced back out into the lung vessels.  The mass was taking up a lot of space in the chamber, and impeding the normal flow pattern.

“I don’t know what that thing is,” my partner said, shoving his hands into his lab-coat pockets definitively, and leaning back away from the computer screen, “but if it gets about five percent larger, you’re going to find out on autopsy – that chamber is close to being completely obstructed, and if that happens….”

“Agreed,” I said.

I decided to call one of my adult cardiac surgery colleagues in the medical center, Dr. Mike Reardon, and ask him to take a look with me.  I rebooted the study when he arrived.

“Man,” Mike said, “that’s a tumor alright, and in a bad place.” He was transfixed.  I looked over at him as he flipped through the images, the grey/white/black rectangular representation of the computer screen reflecting back at me from his glasses.

“If we were to think about removing it,” I asked, “how would we approach it?  Do you think its possible?”

The reclining office chair Mike was sitting in squeaked as he leaned back, and put his hands behind his head – his brow furrowed, and his expression searching.  He was looking for additional data to begin to formulate his plan.

“How old is the patient?”

“Thirty-seven,” I answered.

“Any history of coronary disease?  Is his heart normal?  Does he have any other medical problems… lung disease?  diabetes?…”

“I haven’t spoken with him yet, but the transfer notes from the outside doctor don’t mention anything.”

“Good,” Mike answered.  He leaned forward now, and shook his head, as if agreeing with himself about what he was thinking, “there might be one way to remove this, but it is drastic.”

“What’s that?” I asked.

“We can take his heart out of his body, remove the tumor, reconstruct his heart, and put it back in.”

I hesitated, and muttered under my breath, “okay…, wow.”

He was describing an extremely rare procedure: a cardiac auto-transplant. We would operate on the heart outside the chest cavity and use cardiopulmonary bypass to support his body while we worked. The first successful auto-transplant to remove a cardiac tumor was performed in the 1990s. Since then, the procedure has been undertaken fewer than 50 times worldwide.

We went into the exam room together, and discussed the options with Mr. Johnson, an executive for a well-known company headquartered in another state, and his wife.

He told us that he had become increasingly short of breath with exertion, and now would experience the symptoms when just simply walking.

We told him the mass was probably a cardiac sarcoma, a malignant tumor originating in either the heart muscle or the blood vessels located there. We also told him that he faced significant risk of sudden death if the chamber became completely blocked, and that chemotherapy was usually ineffective for larger tumors of this type. Surgery was the only reasonable option, and we needed to move fast.

“However,” I related, “it will be complex, and there will be a fair amount of risk.”

“How much risk?” the patient asked, sitting wringing his hands together tightly.

This was a familiar site to me, as a cancer surgeon.  I had learned over time that you can tell a lot about what a patient is thinking not only from the expression on his or her face, but also from the hands – were they relaxed?  Were they waving above his head?  Was she grabbing her thighs so tightly that the blood flow was no longer able to reach the fingers – blanched white?  Were they shaking, or sweaty?  The hands, unlike the eyes, may not be the window to the soul, but they may well serve at times as a reasonable road-sign to the subconscious.

His wife was sitting next to him, her own left hand resting on top of both of his.  Her other hand, palm down on her lap, was visibly trembling, as well as her lower lip.

She spoke up, her eyes moist and wide with alarm, “we have children, doctor – young children.”

Doctor Reardon reached over and placed his hand on top of theirs.

“Let’s talk about it,” he said, softly, but confidently, “I think we can do this.”

He went on to describe the auto-transplant procedure.   We would use cardiopulmonary bypass to support his body while we worked on the heart, outside his body.  His wife looked horrified.

Bypass was literally that – collecting the blood in tubes inserted into the large veins which return spent blood to the heart, then sending it to a pump where it is also supplied with oxygen.  The system then bypasses the heart and lungs, and delivers blood to the body via tubing inserted into the large vessel leaving the heart – the aorta.

“Have you ever done this before?” the patient asked.

“Yes,” Mike replied, confidently, but with no hubris, “I have done this two other times – and thats as many as anyone else, anywhere in the world, actually.”

“And the risk?” he asked.

“There are three things to worry about,” I replied, “one is whether or not we can remove the entire tumor, the second is whether or not we can put the heart back together again so that it will function normally, and the last thing is the overall risk of having to stop your heart completely, fix it, put it back in and make sure that it is able to start beating on its own again.  We normally quote between a one and five percent risk of dying for heart surgery, but your risk will be higher.”

“How much?” he asked,  his expression unchanged.

Mike responded, “best case scenario, or if all goes well in other words, perhaps a ten percent risk.  Worst case?  Hard to tell, maybe four to five times higher than that.  In one of the cases I have done, it went very well.  The other one did not.”

“Let’s do this,” the patient said, without hesitation.

His wife put her head on his shoulder, sobbing quietly, and daubing her eyes with a tissue.

ώ ώ ώ ώ ώ ώ ώ ώ

Two days later we were in the operating room, where I would assist Mike. As the anesthetizing medications were administered, Mr. Johnson’s blood pressure dropped dangerously. The anesthesia team quickly gave him epinephrine, a drug that increases the pumping action of the heart, and constricts the blood vessels, to bring it back up. “Not much blood getting into that left side,” the anesthesiologist said as he looked at the monitor. “That’s why his pressure dropped. Good thing you didn’t wait too much longer.”

We divided Mr. Jones’ sternum with the electric saw designed for this purpose.  We are often asked by patients if we are going to “crack their chests”, but there is actually no “cracking” or breaking involved, just the smooth, low buzzing of the saw as it moves through the outer and inner rigid “tables” of bone – the hard part of the sternum, and the soft, trabecular marrow space that lies between.  The marrow is loaded with fat, and in older patients, takes on the consistency of reddish-yellow butter.  Interestingly, some heart surgeons start at the bottom of the breastbone and move upward, and others come from the top down.  In this use of the terminology, I was a top-down man.

We placed a retractor to distract the two sides of the bony shield apart from one another, and open up the chest, exposing the soft organs beneath that evolution had engineered the now breached bony surface to normally protect.  The sternal retractor is a metal device with two grasping arms, and a toothy ratcheted crank that is turned to move the arms apart once it is inserted into the narrow space left by the saw.  I had always thought that it looked somewhat like a polished modern version of some sort of ancient torture device.

The outer sac in which the heart is bathed in fluid and protected, the pericardium, was opened carefully using an electric knife, and we inserted the tubing into the large vessels entering and leaving the heart so to establish bypass.

“Go on bypass!” Mike stated, loud enough for the technicians, called perfusionists, managing the pump behind us to hear, as well as the other team members.  The heart began to empty of blood.

I had always imagined, as it emptied. and the movements became more exaggerated due to the associated loss of volume in the hollow chambers, that the heart looked as if it were struggling anxiously, perhaps desperately sensing that it’s vital function – to deliver blood, was threatened.

A very cold solution heavily laden with potassium was injected into the coronary vessels, which normally supply blood laden with oxygen and important nutrients such as glucose – the heart muscle’s fuel.  In a few moments, the beating stopped.  Cold saline slush was placed in the surrounding sac, to cool it further and maintain a state of suspended animation, and Mike and I went to work dividing the vessels entering the heart.  Once they were divided, Mike lifted the organ up and out of the body.

I looked down into the patient’s open chest as Mike placed the his cold, now flaccid heart gently on the table a few feet away.  The room had become eerily quiet save the sound of softly clanking instruments as they were moved around on the tables nearby by the nurses, and the rhythmic rotation of the rotor bypass pump.  Where his heart should have been was literally an open space, a void, with tubes leaving it from the margins.  It garishly reminded me of a spider without a head, or a body – only legs.  The central part that should have been there simply wasn’t.  It was an unnerving, unnatural sight.  The only other time you got this particular view was during a traditional heart transplant procedure, immediately before you placed a donor heart into the recipient’s chest, after the removal of the diseased one.  The difference in this situation; however, was critical.  During donor organ transplants, we never take out the diseased heart until we had the new one in the room.  In this case, there was no normal donor and a chance that we wouldn’t be able to fix one we took out, and put it back in.

I wrested my eyes away and looked over at the bypass pump a few feet away, like a mother’s body powering the movement of blood via a clear plastic umbilical cord – coming from, and leading back into the patient’s body.  I looked, mesmerized for several seconds, at the smooth, steel rotary wheels turning quietly and dispassionately, compressing the tubing and moving, moving, moving the red fluid of life.

I wonder which of us will tell the perfusionist to just turn the machine off if this doesn’t work out?

I focused again on the task at hand.  Mike worked quickly at the back table with my assistance.  The heart was cradled in a cold saline-soaked cloth, to try to continue to keep it metabolically silent and sleeping as long as possible – to protect the heart muscle which was obviously not being supplied with blood.

“The tumor is bigger than it looked on the images,” Mike said, as he made a final pass with a pair of sharp scissors across a tiny peninsula of muscle attached to the mass, “but that looks like all of it.”

The fleshy heart wall and tumor were placed in a small blue plastic bucket to transfer to a waiting pathologist.  We had to check the margins of the specimen to make sure that we had removed the entire tumor.  Out of the body, the small, pink fleshy piece of tissue looked so harmless, but we knew better.

We waited, between furtive glances at the normally invisible standard institution-issue clock, with its unadorned black frame, white face, and black hands.  The pathologist called into the room a few moments later, “there is some microscopic tumor at the margin.”

Mike sat there for a long moment, staring down at the opening in the back of the heart he had created.  His head was bowed, and he was completely motionless – it almost looked as if he were praying.  He remained this way for what seemed like several minutes.

It has been suggested by research studies that some surgeons have an unusual ability to focus on challenging tasks, and to completely eliminate outside “noise” in the process – at times for hours at a time.  Some have called this the state of “flow” – whereby the conscious mind lets the subconscious take the wheel, and others have noticed this ability, paradoxically, in individuals suffering with attention deficit disorder.  In the latter group, it seems that at some level of complexity they are able to shed the inability to focus, and actually become unusually focused on a task – as if they had been saving it up in a central nervous system bank account to withdraw only occasionally, and under the right circumstances.

He cleared his throat to speak, but did not look up. “If I take any more,” he said, “I may not be able to reconstruct it.”

“We can give chemotherapy,” I replied, “it has a better chance of working with microscopic disease only… better for him to have at least a chance, than not leave the OR, what do you think?”

“I agree,” he said, and went immediately to work.

“We don’t have much time,” Mike said, “we need to get this organ back in there.”

He sewed a piece of bovine pericardium—the heart sac from a cow which has been sterilized and preserved for this purpose—into the large opening left where the tumor had previously been. We then carried the heart back over to the patient and placed it in the void.

“Looks better already,” I said.

We then began sewing the large vessels back together, and allowed the heart to gradually re-warm.  We knew from donor transplantation that a healthy heart will often start to beat once it is warmed, even without a blood supply re-established.  We waited, without speaking of it, for the familiar and comforting signs of reanimation.

But this time… nothing happened.

We continued to work, completing the suture lines, and began to allow blood to flow back into the coronary vessels of the heart as we finished up.

“No action here,” the anesthesiologist said, watching the electrocardiogram.

Mike inserted a small needle into the muscle to measure the temperature.

“Should be working, the temp is good,” he said, “and, it’s a normal heart.”

Several more seconds passed.

Then, we noticed a little quiver down near the apex of the heart…, then another, and then the heart sprang back to life, beating vigorously.  We removed the tubes, and closed the patient’s sternum in the usual fashion, using thick wires on the bony structures, and suture on the muscle and skin.

Mr. Jones recovered well, and was discharged from the hospital several days later.

By Will Smythe

When I was a surgical resident, I once won a teaching award from the students at the school where I was training.  It was called the “Pearls” award, and those that were chosen were asked to deliver a ten-minute lecture on something that they deemed important to those, the students, learning the art and science of medicine –we were supposed to share, as we say in medicine, a “clinical pearl”.

An actual medical research paper was written just a few years ago on the topic of the clinical pearl, and it was defined by the authors as follows:

“Clinical pearls are best defined as small bits of free standing, clinically relevant information based on experience or observation. They are part of the vast domain of experience-based medicine, and can be helpful in dealing with clinical problems for which controlled data do not exist”.

That’s a fairly long-winded explanation for what I would describe, a bit more simply, as “advice”.

In any event, I was excited about the award, but didn’t really know what to discuss.  Actually, I was fairly apprehensive – there was only one resident trainee that received the award each year at the school, and several established faculty members – all of whom had much more of an opportunity in the “vast domain of experience-based medicine”.  To make it worse, the other awardees were not junior faculty.  A quick review of the those listed on an announcement sent out a few weeks before showed that the others were all “Professors” – most considered national, if not international experts in their respected fields.

I, on the other hand, was only halfway through my first Surgery textbook, and I was still pulling out the anatomy atlas fairly frequently before surgical cases, where as the most junior member of the surgical team I demonstrated daily the many reasons for my own acclaim – cutting sutures, placing bandages, making sure that the postoperative orders were written legibly, and keeping track of patient’s room numbers.

I fretted for several weeks over the topic that I would discuss.  It had to be something that the students would enjoy, and that the faculty illuminati would be impressed by as well.  I imagined in more optimistic moments (fleeting, rare moments) that the professors would all smile, and frequently shake their heads with approval as I spoke, and that several students would come up and mob me at the podium, with looks of adulation and perhaps envy – all obviously clamoring… no, hungering for more “pearls”.  I settled on a concept that I thought would accomplish both – a lecture entitled “The Importance of Observation of Surgical Patients”.  I actually gave a lecture during which I suggested, with what I thought was a great deal of earnest erudition that it was important to look at patients before operating on them.

Shockingly, it didn’t go as well as I had hoped.

It was convention for the resident awardee to speak last, so I followed the other speakers’ lectures on topics that sounded to me a lot like: “How You Can Discover The Cure For Cancer, Like I Did”, and “The Importance Of Humility While Receiving The Nobel Prize” with my profound discourse on “Hey, Make Sure You Look at Your Patients”.

The professors, all looking to me like assorted versions of Buddy Holly with a bad attitude, sporting 1950’s haircuts and heavy black-framed glasses, just sat motionless and scowled for the entire ten minutes, and the medical students scurried out of the back doors of the auditorium when I was finished like mice in the kitchen when the lights come on.

Despite this and a few other notable miscalculations, I eventually completed residency, and got to the point in my career where someone else cut my suture, placed bandages on my patients, made sure that post-operative orders, were accurately keyed into the computer, and told me where to find my patients on rounds.  Interestingly, despite my unfortunate lecture experience, I never really let go completely of the notion that a lot can be learned from observing patients – by seeing them before they see you, or our name-badge and white coat, and then by just “paying attention” to details as you interview and examine them.

In the years following that lecture, as a more senior resident responsible for surgical consultations in an inner-city emergency room, I learned that a peek around the curtain could yield a great deal of useful information.  I learned that it could at times jumpstart the process of making a diagnosis and plan for action well before the patient’s body was passed through the CT scanner, or a thousand blood samples were collected and analyzed.  There was, as it turned out, a lot to be learned from a “surreptitious stare”.

Was the patient malingering?  Did he begin moaning only when I entered the room, happily humming a tune beforehand?  Did she get out of her chair, and lean over easily from the waist to grab something out of her purse and then lie back down on the gurney before I drew back the curtain, at which time she claimed that her “back was hurting too bad to move or bend over”, and that she was “too weak to stand up”?

Was the patient lying ply-board stiff and still on the stretcher with knees slightly flexed, or literally writhing in pain like a snake on a hot skillet, unable to find a comfortable position?  The former might suggest inflammation of the tissues lining the abdominal cavity – maybe peritonitis due to a ruptured appendix or colon diverticulum, and the latter – colic, the acute obstruction of a hollow organ caused by an irresponsible loop of bowel kinking on itself, or an indifferent stone wedging itself somewhere in the gall bladder.

Did the patient appear… depressed?  Alone?  Unkempt? Angry?  What was the patient wearing?  An expensive suit?  A fur coat?  Dirty, tattered rags?  Scrubs?  A football uniform?  Knowledge of any of these could direct the tone and line of initial questioning, and focus the exam.  It could actually begin to narrow a differential diagnosis before the patient was even aware of my existence.  Having an idea about the constellation of problems ahead of time could also allow me to be more efficient, and at times, at least an opportunity to be more empathetic about whatever the patient might be experiencing.

As I found myself involved in more and more specialized care, and taking fewer trips to the emergency room to evaluate acute conditions, I had less opportunity to practice this form of medical voyeurism.  However, I still caught a glimpse of patients from time to time in the clinic where I evaluated them for elective cancer surgery before they had a chance to see me – and such was the case with Anne.

The clinic had a large rectangular common area, where the doctors would review Xrays and records, delimited on both sides by long, linear hallways of examination rooms.  I was sitting at my workstation in one of the corners of that space between patients, and happened to turn and look through an open door – across the hall and into an exam room.  I watched as a new patient was led there, and deposited by the clinic nurse.  She sat down in a chair next to the small working desk, facing the examination table on the other side of the room, her right side toward me.

I began to form an opinion about several things, as I watched.  She was older… perhaps well over seventy.  She sat down carefully in the chair after the nurse departed, but with no evidence of musculoskeletal compromise, and folded her hands in her lap with no evidence of a tremor.  She was trim, but not too thin, and certainly not emaciated, which could be consistent with a number of chronic conditions, and at times, a cancer that had advanced too quickly to intercede surgically.  She was neatly dressed – wearing a pressed, perhaps starched, white open-collar blouse, khaki pants, and dark flats. Her dress suggested that if not well-to-do, that she was at least “comfortable” financially.  Her shoes and handbag were new, and stylish, but not flashy.  She slumped her shoulders slightly forward, and lowered her head, eyes open.  Her hair was short and simply styled – grey, with streaks of white here and there.

I continued to watch her – she still oblivious to me for now, from more than forty feet away.  Actually, she seemed oblivious to just about everything – I noticed that the nurse passed by the open door three times, two of them leading other patients or family members in one direction or the other, but she never once looked up in curiosity, or perhaps just in response to the nearby motion, as we humans are apt to do. She just sat still, staring at the floor.

She looked, or perhaps seemed very, very alone.  I wondered if she were widowed.  I had taken care of very few widowed men in my career as a cancer surgeon, but too many widowed women to actually count – it was just the way the odds settled out, at least for her generation.  It was also possible, certainly, that her husband wasn’t able to come with her for some reason, but I found that to be less common above the age of seventy.  The men either came, even if they required assistance, or they were no longer around.

Her posture, disinterest to her environment, and her inanimate state suggested either pain, fatigue, or worse – the habitus of depression.  If she were lowering her head and leaning forward due to pain, it struck me that she would have closed her eyes, and not kept them open.  It is admittedly quite difficult to discern fatigue from depression – they are close friends, and are often seen huddling together in the corners of cancer clinics.  However, the fact that she was sitting in a lung cancer surgeon’s clinic certainly enhanced the possibility that she had heard some bad news from the doctor that sent her here, as most had – I opted for depression.

The time came for me to see her, so I walked over and knocked on the doorframe.

“Hello,” I said, cheerfully, “can I come in?”

She turned her head quickly, sat up straight, and set her purse on the floor next to her chair.

“Of course,” she replied, the grimace on her face temporarily becoming a smile.  A forced smile, I pondered.

“Mrs. Johnson, Anne Johnson?” I asked.

“Yes… yes that’s me,” she replied, looking down for a moment before she answered and again grimacing, as if she were searching her mind to make sure that she was indeed this person, or perhaps suddenly bothered by some thought or feeling that I had brought to her mind.

“Is everything okay?” I asked.

“Yes, yes,” she replied quickly, looking up and smiling again, “it just struck me how infrequently I had been called Anne over the years.  I always know that it’s something official when I am – you know, called Anne – a trip to the doctor, or a lawyer, that sort of thing.”

At this point, I would normally have just opted for “Ms. Johnson”, but since she had given me an entre, I took it.

“What do you prefer to be called,” I asked, “if not Anne?”

Her face, relaxed slightly for the first time since I walked in.  She leaned back in her chair a bit, but kept her proper posture.  “My parents… well, my father… who adored me, called me Annie.” She stopped, and shook her head up and down as if answering in the affirmative to a question she had posed to herself,  “you know, I adored him too.”

She then looked up at me, with a slightly surprised expression, her eyebrows lifted ever so slightly.  “Funny,” she said, “I’m seventy-seven, and a little scared.  It just struck me that I wish my father were here now with me to deal with this.  Of course, he’s been gone for fifty years, so it’s silly to even think about it, isn’t it?  I haven’t had this feeling for a long, long time.”

“No,” I replied, “I lost my father when I was a teenager.  I have the urge to talk to him every now and then as well, for a number of different reasons, and especially when something’s upsetting, or troubling me – I understand.”

“Teenager?” she countered, “Poor dear… your mother?  How about brothers and sisters?”

“No ma’am,” I replied, “my mother died around the same time, and I was the only child.”

She looked at my face tenderly for a moment, like a mother would, it occurred to me.

“I had two sisters and a brother,” she offered, sadly, as if anticipating the next question, “but they’re all gone now as well…. all gone”  She slumped forward again, and gazed at the floor.

“Your husband?” I asked, trying to slip the question in behind the previous one, like a car running through a parking gate after the one in front of it, without stopping or waiting its turn.

“Gone,” she said, flatly, “gone too.”

“Did you have any children?” I asked.

She sat back again, looked down her lap, and squinted her eyes nearly shut, as if trying to keep a thought or a memory from forming completely.  She clenched her hands together tightly, her fingers and wrists trembling with the effort.

“Yes… of course… I do.  I mean, my late husband and I did.  A boy.  A son. Yes, my… our, I guess, son, Robbie.”

“Does he live nearby?” I asked.

“No, they live in Chicago,” she said – her hands kneading one another now as if she were working cold dough that was stiff and requiring a great deal of force to deform.  Her fingers blanched with the effort.  She turned and looked past me, out the window.

“How about grandchildren?”

“Two,” she replied, tersely, “two… a boy and a girl.”

“Do you ever get to see them?”

“No,” she said, somewhat forcefully, still looking out the window, and then softened when she realized her tone, looking down at her hands again, “uh… well… no.  My son…  My son, you know, he’s very busy with his work, so busy.  And they live in the city… no place for me to stay if I were to visit.  Real estate, you know… so expensive there, right on Lake Michigan.”

I went on with the “medical” interview at this point, asking her a series of questions about her condition, and then examining her.  Outwardly, there was really nothing of notice – her medical profile wasn’t too bad for a woman her age – except, of course, for the lung cancer.

I had reviewed her CT scan and other X-rays before coming in to see her.  She had a large tumor, about the size of a softball, in her upper left lung.  The size of the tumor wasn’t the thing that worried me; however – I had removed larger ones.  The thing that I was most concerned about was how close it was to her aorta – the body’s “main” artery.  The aorta is a inch and a half wide blood vessel that leaves the left side of the heart, and is the conduit through which all of the newly oxygenated blood flows to the organs – more than three liters of the life-giving fluid every single minute.

I couldn’t tell on the CT scan whether the tumor was just jammed up next to the aorta, or actually involving it – or in other words, whether it was touching, or had invaded, or grown into the wall of the body’s most important vascular thoroughfare.  However, there were two other potential problems.  The first was the fact that the tumor was high up on this vessel, near to where the large branches to the left arm, and left side of the brain originate, and in addition, the vessel itself wasn’t normal.  Some patients at this age develop atherosclerosis of the aorta – a condition whereby the wall gets thickened with debris, and can become layered with rock-hard calcium.  Her aorta was badly diseased in this way.

So, the conundrum would be what to do if the aorta was in fact involved.  In a younger patient, we would consider cutting a piece of it out and repairing it if necessary to get the tumor out.  However, trying to remove a segment of her aorta and repairing it would likely not be possible.  Imagine trying to sew together the ends of a wet toilet paper tube that is lined with a thin layer of porcelain back together, after the wall has been cracked in a thousand places, and the tube torn into two separate pieces.

I suggested that we order another test – an MRI, to see if we could get a better idea of whether or not the tumor was actually invading the vessel wall, and she agreed.  The test was obtained, and we still weren’t sure.  I asked her to come back into clinic to see me to discuss this several days after our intial visit.

“I still can’t tell whether or not your aorta is involved,” I reported to her, “the MRI isn’t conclusive, but it is suspicious – the tumor may be growing into the wall of the aorta – the big blood vessel that comes out of the left side of your heart.”

“What does that mean?” she asked.

“Well, we won’t know until we get into the operating room, but if your aorta is involved with the tumor, we would either try to leave a little tumor behind as possible, to radiate afterwards, or simply stop if necessary, and not try to take the tumor out at all.  I hesitated for a moment, and then continued, “the other issue that you need to be aware of, despite how difficult it is to consider, is that if we were to injure your aorta badly in the process, it would likely not be something we could easily fix, or maybe even fix at all.”

She unclenched her hands, and smoothed her pants legs down to the knees and back again with her palms, “You mean I could die, right?”

“Yes ma’am…” I tried to soften my voice, to lessen the impact, knowing that it probably never really softened the blow of this information, “yes, that’s a possibility.  I don’t think there is a really high risk of that, but I just won’t be able to tell until we are in there.  How do you feel about all of that?”

She lifted her purse off of the floor, placed it in her lap, and began to absentmindedly fiddle with the straps.

“I was thinking about that discussion we had about my name the other day,” she said.

I thought that perhaps she was trying to change the subject, or that perhaps she was a little senile?  Did I miss that the first time we met? This was a bit of a right turn, considering what we were discussing at the moment.

“Yes?” I inquired.

“I told you that I have only been called Anne a few times in my life, and that my father called me Annie.”

“I remember,” I answered, ceding her what time she needed.  Perhaps she was just stalling – my previous comments, and the open-ended question of what she “thought about all of that” too difficult to respond to immediately.

“Yes.  Well, my husband called me my favorite name, and that’s Anne-Marie.  Would you consider calling me that instead of Ms. Johnson?”  She looked at me hopefully, and for the first time I noticed how pretty her eyes were, a light blue-green color that radiated out from the center like a child’s pinwheel.

“Sure,” I said, and waited silently for several seconds before returning to the question of whether or not to go ahead with the operation – still hanging in the air like a gnarled garland between us, “so… what do you think about proceeding, knowing that we might not be able to fix that blood vessel if it were injured.”

“Doesn’t seem I have much choice, does it?” she asked.

“You always have a choice,” I replied gently, “this is a decision that I am willing to help you make, but it has to be yours.”

“I wanted you to call me Anne-Marie, like my husband did because I like the way you are honest with me.  Bill… my Bill, was one of those rare honest lawyers,” she chuckled, “and he was honest with me too.  We were honest with each other.”

The skin on her face was wrinkled appropriately for a septuagenarian, especially around her eyes and mouth.  For a moment; however, I caught a glimpse of her as a younger woman, Bill’s young wife, perhaps, or her absent son’s loving young mother – her features softened, and her grey hair, for a moment in my mind, became brunette.

“Thank you, Anne-Marie,” I replied, “I would be happy to call you that… thank you for the honor of allowing me to call you that.”

She smiled, and reached out and took my hand between hers.  Her hands were wrinkled as well, and dry, but warm.

“I’ve done everything I want to do here,” she said softly, but very confidently, “but would like some more time if I can have it…  No one wants to die, but we all know we have to, at some point.  Let’s go ahead, and you do what you think is best.  If it comes down to something questionable or difficult, just you do what you think is best.  I am ready for what ever comes.”

“Will your son, or anyone else be coming on the day of surgery,” I asked.

She drew her hands back out of my loose grasp, put them in her lap together, and began to knead the stiff dough of remembrance once again.

“I’m not sure…  I don’t know,” she said, “I… I will have to let you know later.”

“It’s fine,” I replied, “I’ll check in the waiting area afterwards, and speak to whomever comes – family or friend.  No big deal.”

Anne-Marie’s case was scheduled for two weeks later.

I walked into the operating room where my resident trainee, and the nursing staff had already positioned Anne-Marie, prepped her skin with an antiseptic solution, and placed disposable paper drapes on her body.  A two-foot square area of skin was exposed where we would make the incision.

The CT scan was up on the big screen monitor in the room, and I manipulated it, looking at the tumor from as many angles as possible – I was looking at Anne-Marie’s chest in cross-section, ten times its normal size.  I always looked one final time at the images in the operating room before starting – in this case looking one more time at what we were going to be up against – perhaps hoping that the picture would look different from the last time I viewed it.  The fact was; however, that the images never looked any better in the operating room – and at times, worse.

“That’s a big one,” my resident, a young promising woman that was considering vascular surgery as her career path after general surgery training, “and in a rough place.”

“That’s right,” I replied, and asked the circulating nurse to call one of my cardiac surgery colleagues into the room – I knew he had a case down the hall from me, but hadn’t yet started.

He entered and I explained Anne-Marie’s case to him.  He looked up at the CT scan.

“What would you do if you found the aorta involved in that area?” I asked him, “would you be willing to do a resection and some sort of repair?”

He shook his head and rubbed his hand on his chest, absentmindedly, as if he were contemplating his own anatomy beneath.

“No…, impossible,” he replied, “You would have to replace the entire thing, including those arch vessels branching off to the head.   She probably wouldn’t survive it, especially in addition to a big cancer operation.”

I thanked him, and he left to go and deal with his own challenge for that particular day.  The resident had been standing nearby and listening.

“What are our chances?” she asked.

I replied, chuckling a little but not smiling – a nervous response with no associated humor whatsoever, “our chances are excellent… but we’ll see about Ms. Johnson’s in a little while.”

The familiar drumbeat steps that start any case began – the first few moves were almost always the same first verse of the same song, with a predictable rhythm.  We made a large incision under the left shoulder blade and down through the muscles of the chest wall to the ribcage.  We then divided the muscle between the ribs, and placed spreading retractors between them, cranking them open slowly to expose what lie beneath.  This is where the tune always changed – each patient had a different second verse once you were inside, and at times, the music became unfamiliar, and unpleasant.

The tumor was large, as expected.  The resident placed her hand into the upper chest and felt it.  “It doesn’t move,” she said, “it’s at least stuck to the aorta,,, but I can’t tell if it’s invading.”

I took my turn palpating the area, and agreed.

“Let’s see what we can do,” I said, confidently.

I wasn’t confident.

We started at the front of the tumor and in a short period of time, ran into a place where the tumor and the wall of the aorta were fused, and our progress stopped.  One of the things you learn in cancer surgery is to keep moving – if your advance is stopped – don’t retreat, just try to move troops in on the flanks, as you might be able to weaken the opposing army by coming from a different direction.  We tried from the top – initially we made progress, but eventually we again met the same resistance.

“Let’s divide the upper lobe from the lower one,” I suggested, “see if we can come from bottom up.”

The lung has two lobes, or anatomic subdivisions, on the left side of the chest, and there is often some tissue attaching the two in the area where they separate – an area that we call the “fissure”.  In some people, the fissure is “complete”, and the two lobes separate with no effort, exposing the arteries and bronchi, or breathing tubes, branching to each one.  At other times, the two lobes can be completely fused, requiring that we divide the tissue to expose the structures beneath.  Anne-Marie had a small amount of bridging lung tissue holding the two lobes together in one area.  We used a surgical stapler to divide that, exposing the bottom side of the tumor.

Although we were both leaning in over the incision, I was working from an angle, standing in front of the patient, that made it difficult for the resident to see exactly what I was doing.  She pulled the lung gently upward, toward Anne-Marie’s head, from her position standing at the patient’s back, and I worked with my scissors beneath and below.

Suddenly, there was a large, forceful gush of blood onto the back of my hand – it felt as if someone had been crimping a garden hose near it’s open end, and had suddenly let the kink out.  I quickly shoved my entire hand in over the area, and when I did so, the resident pulled a little harder on the lobe, thus the tumor, and the aorta – and the calcified fragile vessel cracked open like an egg.  I grabbed the suction device and shoved it into the now garishly large opening.  The resident knew what it meant.  She stared at me wide-eyed and unblinking as our gaze met for what seemed like several minutes, but in reality was less than a second – a great deal of information and emotion can be transmitted by the eyes, and quickly, despite the fact that all other facial features are obscured in the operating room.

“The suction canister is filling up with blood, rapidly!” the circulating nurse yelled out.

“Send for blood, stat!” the anesthesiologist at the head of the table replied, “Blood Bank! Stat!”

“No!” I yelled back, and then, more softly, as the room became completely silent, “no… don’t send for blood, please.”

I looked over the curtain at the anesthesiologist.  He had both hands on the paper drape, suspended between two IV poles, the “curtain” that separates the anesthesiologists from the operative field, pulling it down and leaning anxiously in toward me over Anne-Marie’s head, ready for my next request.  His body was like a coiled spring – still reacting to the shocking sight of a liter of blood escaping into the suction system in a matter of seconds.

The suction catheter vibrated in my hand, due to the large amount of fluid flowing past at such a high rate… her blood, her life, and perhaps her soul moving swiftly and efficiently out of her body, through the clear loops of rubber tubing, across the operating table, off the bed, and into the large plastic canisters which were attached to the wall suction source nearby.  My resident stared silently at the tubing, and the nurses – at the filling canisters.

I looked past the anesthesiologist at the electrocardiogram tracing displayed on the anesthesia machine.  Anne-Marie had already lost enough blood that her heart was beating abnormally – an arrythmia.  It was already failing.  A symphony of beeps and alarms had begun – sounds that usually were life-saving rather than death signifying.  They were signaling the arrythmia, in addition to the dropping level of oxygen in her blood, and her plummeting blood pressure.

“Just turn off the monitors, Tim, please… just turn them off.”

After we had closed up the incisions, and cleaned Anne-Marie’s spent body, I went down to the operating room waiting area to take care of the inevitable, and at times dreaded, next task.  I walked over to the receptionist, and asked for her to call the family of Ms. Johnson.

“Excuse me, doctor?” she replied

“Ms. Johnson…, Anne Johnson,” I said, “Annie? Anne-Marie Johnson?”

“Oh yeah, doc…” she replied, taking a sip from her soda can, and looking at the computer screen in front of her, “we’ve been looking for someone all morning for that patient, but no one’s come around.  Looks like she came in alone.”

(Fiction)

ONE

You often come to me in the twilight, when I can’t tell if I am awake or sleeping, and when I can’t tell if it is really you, or simply a dream of you.

You have been gone for so long, sister.

I have never spoken to you, or kissed you, but I have felt your touch, and I have looked into your eyes, and I know that at times you have been with me.

I don’t dare mention it to family or friends, as I fear that such a departure from my usual staid reality would be received badly – and I mean really badly, especially now.  That being said, it certainly isn’t one of those dark secrets that rots one from the inside out, due to its need to be expelled and forgiven.

How would they understand?  How can I explain, or ask them to understand when I cannot?

It’s not that you’re actually here, because you aren’t – you can’t be.  But you do exist, and have existed for me since I was a young child, even though we have actually never lived, and never will live, in the same space and time.  Of course, you understand all of this, sister.  The story isn’t news to you either, but I feel the need to share it with the others.

You were born five years before me.  Your hair was an unusual shade of red, the color of a “new copper penny”, as I was told as a child, and your eyes were exceptional as well  – at first that ubiquitous transparent deep baby blue, but becoming emerald green by the time you were a month old.  Our Aunt Raye Beth was fond of telling me the story of the doctor’s reaction… “In all the years that I’ve been in practice, I’ve never seen a baby with such green eyes at this age, just doesn’t seem possible,” he laughed, “if that don’t beat all – she sure is a pretty thing.”

Our mother and father both lived with abuse, neglect and poverty as children, but despite that our mother was a strong, and positive force.  She was in love with life and our father, and he with her – but you already know all of that too, I know.  They needed something; however, or some one, perhaps, to help them get to another place.  You were that someone.  All babies are a gift, yes, and a miracle, but for them, you represented new life – literally.  You were tangible proof that nothing bad lasts forever, and that context and circumstance and struggle can change, even if it takes a generation.

There are those that say that time heals, and is the best poultice to place over wounds, but a baby is much more powerful medicine – a baby is a chance for your family’s story to begin again, to start over, a baby is a possibility, a regenerative force.

You were named Penny, in part due to the beautiful color of your hair, and also for the song “Pennies from Heaven”…  a song that was introduced by Bing Crosby in a movie that our mother saw as a child.  The list of those that recorded “Pennies from Heaven” is a virtual who’s who of music – Crosby, Sinatra, Holiday, Getz, Martin… but my favorite version, and I suspect our parents’ as well, was Louis Armstrong’s – Mother loved him so much… his sweaty, smiling face beaming that impossibly broad smile that no one else can smile, or ever will, trumpet in his hand, leaning into the audience as if his shoes were nailed to the floor… that unmistakable gravelly staccato delivery…

“Every time it rains,…. It rains… Pennies from heaven…
Don’tcha know… each cloud contaaiiins…  Pennies from heaven…

Trade them for… a pack-aaaage of… sunshine and flowaaahhhrs…
Don’t you know… the things you love…  you must have showehhhrs…
So when you hear it thun-da…  Don’t run under a tree…
There’ll be pennies from heaven…  for youuuuu… aaaand meeeee…”

And then… that wonderful trumpet…

Unfortunately, however, the music would fade.  It was still there, but it became a tinny sound in the background – one that was almost imperceptible.  It became a tune that our parents hummed only every now and then, and with little enthusiasm, because it reminded them…

You were a precocious baby at first, but you began to lose your momentum – it slowed and slowed and then – it seemed as if you decided to begin to develop in reverse.  You were crawling and reaching and motoring around on the furniture – but suddenly, you couldn’t stand up… then… you couldn’t crawl… then you couldn’t even lift your little head up off of the blanket – and… your head… your head looked different somehow, an unusual shape – larger than normal.

The doctors said that they were worried about a muscular condition, or a nerve problem, or an incomprehensible “this”, or an unintelligible “that”… and then a diagnosis was pulled out of a shopping bag of words that meant nothing in particular, but on which everything depended, and that word was stuffed down our parent’s throats like a piece, no, a chunk, of dry stale bread.  Take it!  Swallow! Quickly!  Swallow, or you’ll choke!  Swallow!!  Hydrocephalus?  It was big word.  It took up a lot of space, and sat sickly undigested in their stomachs once it made its way there.

Hydrocephalus.  They listened to the doctor, and watched his face carefully.  He looked very serious, and his tone was ominous.  “Hy-dro-ceph-a-lus.”

“It means water on the brain,” he said, “and it’s bad.  There’s some experimental treatment… but…”

Even though you were sick from that time onward, and spent most of your time in rooms filled with people you didn’t know – people wearing white clothes and white masks covering their smiles, and always rushing around as if late for something important – you were a joy to our parents.

Your precocity for the physical, no longer possible, was transferred to speech, and intellect.  You talked incessantly, and on a range of topics that most ten, much less three year olds, would find daunting.  You laughed easily, and told simple silly jokes.  You told them that you “wuv’d” them, and kissed their faces every time they bent down, to help reposition, or place your increasingly large and heavy head on a pillow.

Our mother and father laughed and laughed and cried and laughed, and told each other that you were such a blessing, and that “we can get through this”, and that “she might get over this… she is so strong.”  But, you didn’t know how to tell them how tired you had become, very tired.  You didn’t know how to tell them that you knew somehow that your little body was just not able to fight much longer.  You didn’t know how to tell them that God was talking to you.

You didn’t even know what an infection was, really, but knew nonetheless from him what had to happen, and where you had to go.  It found its way from a nurse’s healthy child onto her hand one morning as she lifted him out of his high chair, and then onto the outside of her dark rubber glove in the clinic, and then onto the plastic tubing that was inserted into the fluid filled cavities around your brain to drain and drain and drain – to ease the pressure on your little brain – so you left.  Eighteen operations and two and half years later, your tiny corpus was spent.  You knew that you had other things to do, despite how desperately our parents wanted, and needed, you.  You knew how important it was.  He had told you.

You hovered for a time overhead, curious.  It looked strange to you, seeing yourself lying there on the bed below, in a cheap, plain wooden-slatted crib – the large heart-shaped head compared to the tiny body, the worn stuffed animals, and the thick hospital-issue faded pink thick cotton nightgown pulled down just so around your thin limp legs.

You thought for a moment how you might miss your “babies”, as you called them – the little fuzzy blue elephant, Nuffie, was your favorite.  You had a momentary urge to return, to touch them.

Then you thought about how those wooden slats felt up against your body, or your feet as you lay there unable to move or reposition yourself these last few months – cold and hard.  At times your little foot would be trapped between the slats and you would struggle for hours trying to move it enough to dislodge it, focused on that small freedom, to no avail.

Now you were free, and you were holding up your own head, without the need for pillows or rolled up blankets or nurses aseptic hands.  It didn’t feel heavy anymore.  Nothing was heavy, nothing hurt.  You reached up to feel the “tuby”, as you had come to call it – the tube running into the water around your brain that you had lived with for so long, and it was gone as well.  It was then when you realized that you didn’t want to go back, ever.

This was better.  He was right.

The door to the room opened, and our mother rushed in to the bedside.  Her mouth was open wide, but you couldn’t hear any sound.  It really was time.  You closed your eyes then, and in a moment, the room disappeared, and you were with him.

TWO

“I gotta go to the bathroom”, I cried, a little too loud, squirming in my seat at the busy restaurant.

My mother and I had come down to Austin, the capital, about three hours from our tiny hometown in the Panhandle, with her sister and my cousin Paulette, on a shopping trip.  Paulette and I were four years old.

“I REALLY have to go, Mommy!”

My squirming took on the appearance of someone that was being possessed by a demon, or at least about to require a change of underwear.  She whisked me up, fork in my little hand trailing a single long strand of spaghetti, wagging, in my fascinated opinion, back and forth like the tail of a dog as we took off. She maneuvered deftly around the big, round crowded tables to the bathroom, situated at the far side of the large dining area.

She placed me down on the floor when we reached the door with the funny-looking dark picture of someone else’s mommy in a dress, with stiff arms and legs and some letters above her head.

“Mark,” she implored, “give me that fork honey.  Did you carry that all the way over here?”

I turned and looked at the tables between ours and the door – at all the other mommies and fewer Daddies, and wondered, “where are all the Daddies?”

“Where are all the Daddies, Mommy?” I asked her.

“What?” she replied, “give me that fork, honey, before you stab someone with it.”  I quickly tried to get that last strand of spaghetti into my mouth, but she gently twisted the fork from my hand.

“Where are the Daddies?  Why are there mostly Mommies here?”

“Oh,” she laughed, “its Monday, sweetie, most of the Daddies are at work.”

“Oh”, I replied.  I thought about my Daddy, and watching him tie his narrow black tie that morning before he left for the day.  She jiggled the doorknob.  It made a metallic jangly sound, like the doorknobs at my grandma’s house.

I suddenly remembered that I needed to pee, put my knees together and squatted down, wincing.

“Just a minute honey… there, I got it.”  She pushed the door open with one hand and grabbed my arm gently with the other, pulling me into the tiny room.  I looked around as my shorts and underwear were tugged down magically around my ankles.

“Go ahead honey, go potty.”

I turned my attention to the toilet, aiming the stream at the center of the water in the bowl.  I noticed an uncomfortable feeling; however, a tingly sensation on my skin – starting at my stomach, moving up and around my chest to the center of my back, and then up to the nape of my neck.

It always started this way.

“Mommy, this room is… really little…” I started softly whimpering.

I looked up at the ceiling, and missed the toilet.

I could hear the mild anxiety in my mommy’s voice, as she suddenly remembered my fear of tight spaces, like this one.  She was so deep in conversation with my aunt, and we were in such a hurry to get across the room that it had slipped her mind.

“Oh Lord…  Okay… Okay honey, it’s okay, honey, really, mommy’s here… focus on what you’re doing.  Pee in the potty, honey.”

A couple of years later, I would hear her discuss this with our doctor.  He called it something that sounded really weird – I would later ask her what “closet toadie” meant.  She laughed and said, “claustrophobia, you mean… it’s nothing, really.”

“Are you finished?” she asked.

“Yes,” I replied – my heart was racing now, and my voice trembled as I answered.

“Listen, honey, mommy has to go to the bathroom real quick too.  Can you wait just a minute?”

I couldn’t, but I told her I could.

This was an old, historic building, with two-foot thick limestone walls, situated at the corner of two of the busiest downtown thoroughfares.  The bathroom was legitimately tiny – likely a closet of some sort or a small storage room in the past.  It was about four foot wide, and perhaps eight foot long.  It’s bumpy rock walls were covered in several layers of dark blue, almost black, paint.  The toilet was situated at one end of the rectangle, and the hand sink at the other.

She gently moved me back away from the toilet and pulled up my pants.  She patted me on the head, “you okay?”

“Yes,” I replied.  I wasn’t.

She pulled down her pants and sat on the toilet in front of me.  I nervously looked around the room.  The only sources of light were a little slit of a window up high on the wall above and to the left of the sink and a single bare light bulb hanging down from a thick black frayed fabric-insulated wire from the middle of the ceiling.

There was an old wooden door on the wall opposite the entry door.  By the sounds of traffic outside, this door opened directly onto the street.  It looked ancient – perhaps an original wooden door, reinforced with metal bands running at right angles to the wood, with old, painted-over hinges and locks.

My anxiety worsened. Everything felt tight.  I couldn’t swallow.

“Are you almost done, mommy?  Are you?.. Are you?”

I started sobbing, and shaking.

“Am I gonna die in here?”

“No honey,” she chuckled under her breath a little, “It’s okay honey, it’s okay…”

I looked up at the ceiling, repeatedly, at the entry door, and the old door on the opposite wall, over and over again.  The walls were dark, and moving inward.  It felt too tight, too tight… TOO TIGHT!  I panicked, wheeled around and began banging on the old door on the outside wall, with both fists, over and over, and over again.

“OUT!  OUT!  OUT! OUT!,” I screamed, at the top of my lungs, “OUT! OUT! OUT!…”

My mother was literally trying to wipe her undercarriage with toilet tissue with one hand, while reaching out to grab my flailing arm nearest to her with the other.  I yanked away.

“HONEY!  STOP!,” she implored, “IT’S OKAY!”

As I banged on the door harder, the rusted and long-deteriorating bolt lock made a cracking noise, and broke in two – iron dust and blue paint flakes exploded onto my face and clothes as the door flew wide open.  I ran out.  My mother screamed.

The door opened, literally, immediately onto the street.  There was no sidewalk, just a small curb.  There were three lanes on each side and many cars moving rapidly in both directions.  I ran right out – directly into the traffic.

Its been suggested that our childhood memories are all manufactured, based on our meager remembrance, coupled with snippets gleaned from photographs, conversations with relatives and our fictional internal continually revisionist dialogue with ourselves regarding who we were, are, and want to be.  Perhaps this is true of all memories – there are those that can accurately recreate everything in their past, but they are rare, and if you remember too much, it can supposedly be debilitating, overwhelming the present.

I don’t have that problem – at least not the general ability to accurately recreate everything.  As a matter of fact, at my age there are increasing gaps in my ability to recall most things from my past.

However, what happened next, on that day, I remember clearly.  So clearly, in fact, that when I close my eyes and think about it now, at age seventy, I am literally there.

I smell the mixture of gas and asphalt and oil.  I feel the hot summer air moving on my skin.  The only thing is that there is no sound.

I couldn’t hear anything then either, at least not at first.  As soon as I left the room, my mother’s scream was cut off as if someone had hit a mute button – nothing.  No sound – no wheels screeching, no horns… nothing.  And… everything slowed down.  Not just a little, but way down – not really moving at all.  I had time to see the checkerboard pattern in the glass of a headlight three feet away, and the smudged chrome housing surrounding it, on the front of a car that was evidently about to unavoidably hit, and probably kill me.  I looked up and saw the panic and fear in the face of the driver, a chubby woman with a blond bouffant hairdo, and a pink and blue chiffon scarf wrapped around her neck.  Her fingers were gripping the steering wheel so tightly.  I wondered if she was someone’s mommy, and if she would be sad afterwards.

I moved my head a little to the left, and looked at the back driver’s side door of the car that was almost past me in the adjacent lane – the paint was metallic red, and there were little chipped areas where it had been “doored” repeatedly by other cars.  Mommy always told me to be careful getting out of our car, not to do that.

Then, I heard something.  The sound is hard to transmit in words – perhaps more of a feeling and a sound combined.

Wha-wup!…  Wha-wup!… Wha-wup!…

With each of these strange sounds, there was a sense of being buffeted by a forceful, pressured gust of wind – on both sides of my body at once…

The sounds slowed…  Wha…  wup!…   … Wha… wup!  I still felt the wind move about me, but not as forceful.

I felt myself lighten, and lift up, up and off of the ground.  There were hands, or arms, or something around me.  The sounds were really loud now, and faster.  Wha-wup! Wha-wup! Wha-wup! Wha-wup!  Now slowing again, and softer… Wha… wup…  Wha… wup.  It reminded me of something beating, wings?

I was on the ground again, on the sidewalk and somehow on the street opposite the restaurant.  It seemed like I should be scared, but I wasn’t scared.  Everything was still slow, but I could hear faint sounds, and detect movement, at a very gradual increasing timbre, and pace.  I turned around, and I saw you.

It was you, sister.

You were older, older than me, but not as old as mommy.  You were a young woman.

I looked into your eyes… deep green and beautiful, tender and knowing – our mother’s eyes.  Your hair looked like fine spun copper, like the new pennies I had seen at the bank – so pretty that you can’t quit looking at them, rolling them around in your hand, letting the sun reflect off this way, and that, and so perfect you don’t want to put them in your pocket, for fear of scratching them up.

Everything was bright and clear-yellow white around you, and yes, there were wings, but not at all like the pictures in my Sunday school class – much larger, and blurred, as if they were still, yet constantly moving.  You smiled and touched my face, I felt warm, and safe.  I felt happy.

Then you were gone, and I could hear mommy’s screams, and horns honking, and the cars were moving again, and there were people rushing up to me, and someone I didn’t know was hugging me, and some mommies were crying, and I started to cry too.

THREE

Shortly after the bathroom episode, I started to remember my dreams.

Not all the time – what six-year old remembers all of his dreams, or can even articulate what they are?  But I knew that I was dreaming, and I also knew that on occasion – you were involved, or at least, my images of you were.  It was my secret, but it was killing me to keep it so.

“Did you have any dreams last night, sugar?” our mother asked.  I sat in my white brief underwear at the kitchen counter, sleepily spooning up malt-o-meal out of my favorite orange plastic bowl with one hand, my other supporting my head, elbow on the olive-green formica counter.  I didn’t answer, but looked up warily, eyes only, keeping my head down and taking another bite.

I had dreamt of you again the previous night.

“Uh-uh… I mean, no… no mommy,” I replied, somewhat unconvincingly.  I looked back down at the malt-o-meal.

I imagined that it wasn’t a warm breakfast cereal at all, but rather a vast desert.  I heaped some up in the middle of the bowl, like a giant dune.  In my mind, I shrunk myself down immediately to the size of an ant, and hid behind it from my mother.

Mothers have a sixth sense about lying.  Its not that they can read minds, because they can’t.  However, by the time you are four or so, and have been talking to them on a daily basis for a couple of years, they are like amazingly expert linguist-detectives.  They develop the ability to catch even the tiniest of tonal changes in your voice, and know immediately that you are being dishonest, or at least that you are unsure about what you are telling them.

She stopped scrubbing a dish in the sink, and casually looked over at me.  I peered over the malt-o-meal dune, sheepishly.  She looked casual, but I knew she was on to me.  Like some sort of truth-shark, she had smelled a few molecules of false in the water around her, and now was ready to circle.

“Really?” she asked.

Oh no,”I thought to myself, how does she do that?

I sunk further down behind my imaginary sandy barrier.

“Did you really not have any dreams?  You don’t sound so sure, honey.”

Why does she say honey when she thinks… no, KNOWS, I am lying to her?

“Honey?”

“Yes mommy?”

“Did you?  Did you have any dreams last night?”

She wiped her hands on a dishtowel, and took off her apron.  She then walked in my direction, stopping at the radio to turn down the local country channel that she liked to listen to each morning, and pulled up a chair across me at the counter.

Now I’m in trouble

I didn’t answer.

“Do you dream every night honey, or just some nights?”

She’s trying to trick me

I looked up at her, and assumed my normal size again.  “I don’t know, mama.”

“Oh c’mon,” she said gently, placing her hand on my arm, “don’t  you?”

I started sweating.  I wanted to tell her, but I couldn’t.  I couldn’t tell her because in my simple way, I knew that she wasn’t over losing you.  I knew that she would never really be over losing you.

The front room, where your picture hung, was like a shrine of sorts – a holy place.  I wasn’t allowed to go in there.  No one was.  It was a curiosity to me in some ways, so every time the babysitter was there, of course, I investigated.  I didn’t understand why the room that had the nicest furniture was one that we never used – the big tweed couch with its dark brown and black rich, but itchy material, and the shiny red velvet chair.

Some of your things were displayed on a small dresser – a tiny blue and white plastic rattle that I was told not to touch, and a small ceramic duck with a bright orange beak and scary big blue eyes.  Our mother and father rarely set foot in that room, and I can’t remember them ever looking directly at your portrait on the rare occasions when they did, or mentioning it in any way despite the fact that it was the most imposing and noticeable feature in there – a life-sized professional black and white “color-tinted” photograph of you sitting up on that same tweed couch, shortly before you left, looking beyond the camera with your beautiful curly hair framing your heart-shaped head.

Your eyes were fixed with the classical hydrocephalus downward gaze, which made you look as if she were perhaps playfully feigning shyness, but actually was only a manifestation of the disease, as the ability to look upward, and at times from side to side became impaired in later stages, toward the end.  I wondered at times if you were looking down because you were listening to God.  I know that I would have looked down if he had been talking to me.  Your hands were in your lap, fingers intertwined – perfect and pale white, like little alabaster carvings.

But, I know that you know all of that already – I’m just sharing with the others again, because they don’t know like we do.

“Are you afraid to tell me because it was scary?  A nightmare?”

“No mommy”

I had experienced some nightmares…  there was that one where the big brown dog down the street chased me up a mountain, and when I got too tired to climb any more, and he was real close, I woke up.  Another time, I dreamed that a bad man broke into the house, and blew up the refrigerator – the noise of the explosion so real that it woke me up and I went running into our parent’s room, screaming. Another time, the worst one I could remember, our mommy was sick, real sick, and I knew that she was going to die because of her skin – her skin was the color of the Wicked Witch of the East on the Wizard of Oz.

Interestingly, my dreams of you, sister, were never scary.  I don’t know how many times I had dreamt of you by then, but I could remember many.  Usually, I just saw your pretty face hovering over me and smiling while I lay in bed sleeping – at least I think I was asleep.  Other times you would talk to me, but I couldn’t understand what you were saying, all the while those giant wings moving and not moving, blurred somehow even though your face was so clear.  Sometimes, when I woke up, for a few minutes I could still see your green eyes, even though everything else had faded. It felt so good to look into your eyes that I would often lay there for a long time, until I couldn’t see them anymore, mommy telling me two or three times -“get up, honey, time to get up!”

“So, no dream last night at all then, good or bad, right?”

“I mighta had something…”

“Really? What?”  She put both of her elbows on the formica and rested her face a few inches from mine.  She was smiling, and she had me, but despite that I wasn’t going to tell her everything.

“A girl.  I dreamed about a girl last night.”

She sat up suddenly, and put her hand over her mouth, covering a little laugh, “really?  A girl?”

“Yes mommy.”

“Me?”

“No, but pretty like you?”

She crinkled up her nose, “really? How so?”

I blurted it out, as if I no longer had control of my thoughts or what I was saying, “she had red hair, like yours and green eyes.”

“Hmm,” she replied, “was she a mommy, or younger?  Is she a girl at school?”

I was getting really nervous.  The truth-shark was getting closer and closer, the circles were smaller, and smaller, the scent of disingenuous words stronger, and stronger, the prey almost in her grasp…

“No, just a girl – she sort of looked like Penny.”

There was a brief look of confusion on our mother’s face, and then – blank.  Nothing.  I looked carefully at her to try to understand, but she was just – blank.  It was terrifying.  I had never seen that look before.  I had never said your name before to her. My heart started to race, and I felt like crying.  Why did I say that?

“Oh,” she said, more of an utterance than a word.  She got up from the table, and walked out of the room, with quick, stiff movements, like a robot I thought to myself.  I suddenly felt very sad, and very guilty, sitting there in my white underwear, in the corner of the kitchen, hovering over a now frigid bowl of malt-o-meal, congealed around the spoon such that it stood up in the middle of the bowl by itself, where I left it, behind the dune.

I wanted to say I was sorry, but didn’t want to make it worse for our mother, and I didn’t think fast enough to say anything before she disappeared.  I could just make out Roger Miller’s country song on the radio…

“Dang me, Dang me, they oughta take a rope and hang me…, hang from the highest treeeeeeeee…  woman would you weep for meeeee… doo-doo  doo-doo doo doo-te-doo-doo-doo…”

I got up from the counter, walked over and reached up and over the edge of the counter, and put my orange plastic bowl in the sink, like our mommy always liked for me to do.  I listened as it rattled around for a few seconds, then stopped.

I never mentioned you again, sister.

FOUR

As childhood passed into adolescence, and stumbled into young adulthood, you came to me less often.

You still came, yes, but my dreams had become much more crowded.  I had found my way into our father’s Playboy magazine stash, hidden away under old newspapers in the right hand bottom drawer of the dark oak roll-top desk that he and I built and painstakingly hand-finished when I was ten.

Even though the newspapers weren’t replaced or updated, becoming yellowed and smelling of a mixture of musty wood and old ink, new issues, as my rummaging determined, of this now suddenly very interesting magazine came like clockwork each month.

I was also playing the usual spate of sports that any fourteen-year old would, sister – you know, baseball in the summer, football and basketball during the school year.

I wasn’t the best player on any of the teams, but I played, and at night, I dreamed of hitting booming home runs – the ball going up and up and up until you couldn’t even make it out against the light blue sky  - our mother standing up and cheering and our father’s, “that’s my son” proud smile beaming… of making impossible swivel-hipped runs from deep on my end of the field, opposing players falling away like stiff toy soldiers wearing football helmets… of ridiculous and overly dramatic off-balance half-court shots to win the basketball game at the buzzer, to the delight of the cheerleaders arrayed courtside who interestingly looked like, well – those girls in Playboy.

I had all but forgotten about the episode at the restaurant in Austin – it had been pushed to a distant corner of my mind by all the pubertal cacophony and confusion taking up space there.  I wasn’t even sure it had happened.  Had it?  I had never asked our mother about that day, and she never mentioned it.  If she had seen something, wouldn’t we have talked about it?

So, you still came to me when I was sleeping, but those episodes seemed infrequent, compared to all the other activity.  I really didn’t remember whether or not you spoke to me – I never really understood what you were saying before, when I was younger – it was always some unintelligible whisper, like the rustling of dry leaves.

I figured dreaming about someone, or something like you was just, you know, normal.

It wasn’t.

I sat transfixed, at the small wooden desk in the corner of my room – one that I had outgrown a few years before, my knees rubbing and bumping up uncomfortably against the small pencil drawer beneath, as I sat in the chair that was also now at least one size too small for my growing frame.  Every time I shifted, the wooden pencils bounced around in the wooden confines of the drawer, sounding like a tiny percussion group warming up.

There was a small spider’s web at the corner of the window the desk was facing, and I noticed that a fly, which had been buzzing around the room earlier when I woke up, was now caught there.  It struggled desperately, but to no avail.  As I watched the fly’s jerky but futile efforts shake the web violently, there was another, unrelated movement at the periphery – the spider.

It had evidently been flattened down, compacted and in hiding over at the far left corner of the web where it was attached to the surface of the windowsill, The spider’s light grey coloring blended in remarkably well with the faded, once-white paint.  However, the fly’s desperate movements and agitation of the network of interconnecting and communicating strands had brought it to life, now standing on all eight legs, its body twitching, arched into the shape of a spindly dome.

It took several, tentative, slow-motion steps toward the fly, as if trying to discern whether or not it was safe to get any closer.  Its movements were beautiful – each leg independent, but all somehow coordinated, and with an impossibly light touch, the web beneath neither deformed nor moving in any way in response.  I leaned forward.

Then, the spider moved forward, leapt forward, onto the fly.  The ancient imperative of killing another to survive, woven into the chemical bonds of DNA over the millennia, was fulfilled, and almost immediately the prey was motionless.  The spider then without hesitation began wrapping it, over and over and over, with a silken death-jacket, spinning it around and around beneath it’s body with those impossibly agile legs.  The whole thing took no more than a few seconds, and then the spider moved slowly and deftly back to its hiding place, once again without engendering even a quiver from the web, pulled its legs beneath it, and flattened itself back down on the faded wooden surface of the sill.

“We’ll do lunch later, buddy” I imagined the spider whispering to the fuzzy cocoon, before moving away.

My eyes focused now on the corner of the window glass, and noticed the ice crystals that had formed, in a repeated branching geometric pattern, thicker at the corner, and becoming thinner and more filamentous as it extended outward – random, but yet not random, in shape in form.

Looks a little like the spider’s web, I pondered.

When you spend a lot of time outdoors in this part of the country, as we did, you learn that Texas panhandle winters are colder than one living elsewhere might predict.  They don’t achieve the impressive low numbers that you get in places like Minnesota, but it’s still really cold.  It’s a different kind of cold, actually – a painful, wet blowing cold that starts out by sticking to your skin, penetrates, and ends up in your sinews and bones.

There are really only two seasons there – summer, and winter.  Fall and Spring aren’t so much seasons as they are hyphens, separating summer-winter-summer-winter, lasting a few days at best.  The flowers bloom during the winter-summer hyphen, and then shrivel up a short time later as if someone had put a blowtorch to the tips of the petals.  During the hyphen that comes between summer-winter, the weeds turn from green to brown and the leaves do the same and fall to the ground, overnight, right before the wet winds come down from the high plains to the immediate North.

It was on a cold Texas panhandle Sunday that two of my buddies from down the street (two who I would never have hung out with at school, but who were good when there was no alternative for allaying the occasional neighborhood boredom) decided to check out the new church being built a few blocks away.

Sundays were boring in general, especially at age fourteen.  We had long since stopped going to church – involved here were our mother’s illness, our father’s Saturday night drinking, and my teenage indifference regarding the preacher’s message – warning me about the dangers of things I was just beginning to consider interesting.  It wasn’t that we weren’t believers, because we were – well, at least our mother and I, but we just weren’t that pious.  Mother had been a Sunday School teacher in years past, as you know, but our father had not attended any form of worship since, well, since you left them.

Our father was a strong man, as I am sure you remember – one of those men that could manipulate the world around him by sheer will, or by brute force, if necessary.  Your illness; however, was something that his thick, muscled forearms, and large calloused hands could not shape, or bend into the form and outcome he desired.  Will and force were useless, so, for the first time in his life, he tried something he had never done before, and likely would never try again – he begged.

He went to the little dark brown brick Baptist church down the street from the hospital in Galveston, where a preacher had laid his hands on our father’s head as he cried uncontrollably, encouraging him to ask God, to pray – to beg.  So he did, day after day for weeks on end, for months on end, he walked down the street each day during your naptime, and prayed.  When, like Sampson, he realized his mortal strength was useless, he went begging God there, on his knees every day, for a miracle.  When the miracle didn’t come, when it couldn’t come and you left, he simply lost his faith.

The new church was a big and newsworthy project for our small community – supposed to be the biggest Catholic Church in the entire Panhandle when complete, “one of the biggest in Texas!” our mayor had proclaimed, during the past summer’s fourth of July celebration and annual community update.  They had actually brought in cranes in a month ago to top off steel and wooden sanctuary dome, a good four stories above the ground.  No one in our home-town ever remembered such a thing – cranes?

There had been a couple of ice storms during the last week or so, and so the work at the site had temporarily ceased – and therefore it was a perfect time for us to nose around without fear of being discovered.

The reason I didn’t hang out with these two much at school was that they were, well, different – they ran with a different crowd.  It wasn’t that they were bad kids – they just seemed ambivalent.  They had long hair, and wore old army jackets, white t-shirts, and rolled-up jeans.  They skipped class, and smoked cigarettes after school in the corner of the parking lot, over by the band hall.  I was an A-student and a jock, and had won the attendance award the year before in the eighth grade, to my morbid embarrassment.

At school we avoided one another like a communicable disease, one that you are afraid you might catch if you got close enough to breathe the same air.  However, here in the neighborhood on a Sunday afternoon, as I said before, we were just bored, and boredom and risk were the two bookend ancient facilitators of teenage camaraderie.

“Hey, there it is,” Jack said, “there’s the fucking Astrodome of churches!”  “HEY MAN!”, the other one, Bill, fired back, “take it easy, God might strike us down, you know, a lightening bolt or somethin’ cool like that!”

I was walking about three paces behind them, not talking.

I stopped and looked at the structure, now a half-block away.  It thought it looked amazing, a skeleton of a building before the muscles and skin were applied.  The front of the church was clearly visible, its mostly wooden and infrequently interspersed steel framing taking the shape of an entryway, with the huge dome, also just framed out, immediately behind.  There was a thick coating of ice on all of the wood and steel, and the setting sun and the colors of the Texas sunset horizon reflected off the linear structures in various places, giving off glowing orange and blue colors.

“Beautiful,” I whispered under my breath.

Neither of my neighborhood companions had noticed the esthetics; however, and both were already in the center of the structure, swinging on door frames, and running and skidding on the iced-over concrete foundation.

I walked in through the entrance, and looked up at the center of the dome-to-be.  I tried to imagine what the final structure would look like.  Suddenly and to my right, I heard a loud, banging noise, steel on steel, and looked over.

Bill had found a huge long-handled sledge hammer, and was banging away as hard as his lanky, thin arms could muster at one of the few steel girders connecting the frame above to the foundation.

“Fuck yeah, man!” Jack screamed, “HIT THAT SHIT!”   He was jumping up and down, excitedly. I smiled, and thought briefly about walking over and joining in – but then, a large piece of ice fell right next to me on the ground, from the structure high above – SPLACK!!

I looked up, anxiously.  With each strike of the sledgehammer, the frame of the dome overhead shook, and swayed rhythmically.  The shape and the movement reminded me of something – what was it?  It was as if something inanimate, something that was hiding itself in the beams and boards above had awakened, had come to life in response to the agitation below.  It was cold, but I now felt a different chill, moving up my spine.

The spider

Two additional large pieces of ice were dislodged from more than forty feet above, and fell to my left, and to my right – “SPLACK!!… SPLATACK!!…

I glanced back over at Bill and Jack – Jack was jumping up and down howling now, steam rising from his mouth and from his shoulders in the cold, his long stringy wet hair hanging in front of his face, and Bill had choked up on the sledge hammer, so that he could hit the steel post more often, and with more force.  His face was twisted and his mouth was half-open and contorted with determination and morbid glee.

There was now an increasingly louder and louder humming sound coming from the frame of the church – some sort of harmonic had been created by the rhythmic impact.

“HEAR THAT MAN?!!  COOL!!  COOL!! HEAR THAT?!… DO IT!! DO IT!!, Jack screamed, “KNOCK THE SHIT OUT OF THIS GODDAMN THING, MAN!!”

They were completely oblivious to the falling ice, and the worrisome movement four stories above.  I looked up again, just as the first few pieces of the dome’s frame came loose, and began to fall, toward the ground where I was standing.  I couldn’t take my eyes away, and couldn’t move.  The pieces fell fast at first, then began to slow, and then stopped falling in mid-air, half-way down.

What?… I thought to myself… how the hell did that happen?  Why did the pieces stop?  DID that happen?

Then, something enveloped me – a sensation that something was moving, yet not moving, around me, embracing me, holding me in place.

I knew I should move away – that I should run, to try to avoid the falling wood and steel, but the will to do so left me.  I felt comforted, safe.  I noticed that I was no longer cold.  I fell to my knees.

Where was the noise?  Something should have hit the ground by now…

Nothing.

Am I dead?

Then, I heard something.  A whisper?  It sounded like a soft sheet of paper being wadded up, or dry leaves rustling, I couldn’t tell.

And then, the sensation, the embrace, was gone.

I noticed that I was cold again.  Judging by the fading light, more time had passed than the few seconds it had seemed – it had to have been at least a half-hour.
My eyes began to adjust – there was just enough light for me to make out the frame above, in silhouette.  More than half of it was missing.

I looked now down at the ground.  There was metal and wooden debris everywhere, some of the metal girders were bent and there were pieces of large wooden studs haphazardly piled on one another, many split, broken, or in splinters.  The concrete foundation was cracked in areas and there were chunks of concrete gouged out of the smooth surface, like divots on a golf course.

From the impact, I pondered, and looked up again at the remaining frame more than forty feet above, must have made a lot of noise.

Noise.

Noise?  I noticed now that there was no noise.  There were no voices.

“BILL?” I called out, and looked over to the area where he and Jack had been earlier.  ”JACK?! BILL?!”  All I could make out in the darkening distance were the remains of the framed walls – a lot of which seemed now to be missing.  I noticed for the first time as well that there was a cloud of dust hanging thickly in the air a few feet above the debris, also making it difficult to see.

My heart racing, I started moving toward where they had been, tripping repeatedly over large chunks wood, and bent metal.

Maybe they… yeah… maybe they left.

I scraped my knee on a sharp piece of broken sheet metal, and a large splinter of wood pierced my right shoe.

“SHIT!” I yelled, “that hurt”.  I continued over to the area where I remembered last seeing them.

They must have been right about here, I thought to myself.

I tripped over a large piece of wood, and stumbled forward off-balance, breaking the fall with my outstretched palms.  They hit the concrete surface below, hard.  I started to get up, and noticed that my they had come into contact with some dark, sticky fluid, covering the foundation over a large area, for several feet around me.  It was too dark now to make out what it was, but it was sticky, I put my right hand up close to my face and sniffed.

Smells like metal… Oil?

I took another couple of steps, and realized it wasn’t oil at all.

It was blood.

I found Bill, lying on his side on the ground, an impossibly huge pool of blood emanating from the place where his head should have been.  It had been severed cleanly and completely from his body by one of the steel girders, as well as his right arm, its hand still clutching the sledge hammer on the ground behind his body.

“Jesus!”, I muttered to myself, my voice cracking… I began to rub my hands on my jeans, feverishly.

Next to him was Jack, face down.  One large wooden stud had entered his chest from the back, and gone right through him.  Another large wooden support beam, now resting on his right shoulder, had crushed his skull.  There was spongy, light-colored material coming from the large open crack in the back of his head.

Is that brain?

I turned my head away, fell to the ground again, right into the congealing blood, and vomited.  As my watering eyes cleared, I looked over in the area where I had been standing when this all started.  A three-quarters moon had just come up over the horizon, and the concrete surface was illuminated, the stacks of debris all around casting long shadows toward me.

The clouds of steam coming from my mouth slowed, and grew smaller as my breathing became more normal.

Where I had been standing when the metal and wood support structures fell was an oval area, four foot or so in greatest diameter.  It was completely surrounded by debris; however, there was nothing in that oval area, not even a splinter.

I stood up, unsteadily, and looked up at few stars that were now becoming visible through what was left of the frame above me.

FIVE

Our parents left me within year and four days of one another when I was eighteen.  You would have been twenty-three, sister.

As you know, mother died of a brain tumor and our father simply drank himself to death as quickly as he could afterwards.  I have wondered often if you had anything to do with their departure.  If so, perhaps you were protecting me – they were never going to recover from losing you and the life that they thought they were going to have, were they sister?

What would have come of me if I had struggled with them, and their unremitting and caustic grief, for years on end?  Would it have been a distraction?  Would I have been consumed by it?  Would I have accomplished what I have?  Did you do this to me, or for me?  Were you involved?  Was this liberation, punishment, or random chance?

I was angry, but at this point, I wasn’t sure that you “existed”, so how could I resent you?  I simply forged a sharp instrument out of the emotion I felt, and plunged it into other things.

School always came easy.  I walked through college, and got a graduate degree in physics, too.  With no support, I either had to work full-time, or seek another funding source.  I decided to join the ROTC, and accepted Uncle Sam’s generous offer of cash and travel.  In 1968, at the height of the Tet offensive in Vietnam, I got my chance to pay him back, as a Marine.

In Vietnam, sleep didn’t come easy, or for extended periods of time.  It is amazing how little rest you need to keep going when you are young, and worried constantly about dying.  One of the things that you learn when you are sleep-deprived for long periods of time is that you dream more, or at least you remember more of what you dream – I certainly did in Nam.  Evidently, the sleep the body needs the most, is associated with dreaming.  When you are only getting a few hours here and there, every time you go to sleep you fall right into that stage, bypassing all the ones that come before.  Its as if your brain is starving for it.

Many of my dreams in Nam included you, sister, or an image of you.

It was always the same – you hovering over me, with your beautiful face a few inches from mine.  Your green eyes are what I remembered the most vividly.

Interestingly, green, in general, was not a favorite color over there.  Vietnam was hot, wet, and green, and you grew to hate all three.  We used to joke that we all wanted to go back to the States and move to the mountains of Alaska – someplace that was “cold, dry and with no goddamned plants.”

I would always remember your eyes upon waking, and that sound – a rustling sound, like a whisper.  Your mouth didn’t move, but it seemed like it was you whispering – it was hard to tell.  I started to think you were actually trying to tell me something in these dreams, and the one word that I thought I could make out was “important”… “important”…

After about 6 months, I stopped thinking you were a figment of my imagination, and started believing that I was just nuts.  Between the drugs, the death, and the futility of what we were doing, a lot of guys went crazy over there.  I tried talking to a Chaplain about the dreams, but I didn’t dare tell him everything – like the episode in the street as a little boy, or in the church as a teenager.  It was just too fantastic to believe that it all hung together in any way – it didn’t really cross my mind.

“Son,” the Chaplain asked, “are you hooked on drugs, you know, dropping acid?”

“No,” I replied, “I smoke a little pot every now and then, but that’s it.  I’m not really into that scene, father.”

“Well,” he answered, his face serious and drawn “perhaps God is in this… perhaps this is part of your plan – the plan God has for you, son.”

I got the feeling that he had launched into his “standard issue” speech, one that he had given a million times over here, to young men, scared senseless.

“What plan?” I asked angrily, “Is Vietnam part of my plan too?  Is killing part of my plan?”

“Don’t be upset with me son,” he went on, “I am just the messenger, and I am just saying that you have to trust God – he is the weaver all tapestries.  HE is weaving your tapestry as we speak, but you don’t see it, can’t see it – WE can’t see it.  We only see the backside – the knots and cut ends of the yarn, and the multi-colored, indistinguishable pattern.  God sees the other side – the pattern that he is weaving for you, the beautiful pattern of your life.”

He was beaming now, his cheeks were red and his eyes were wide open, almost wild.  He had placed his hand on my shoulder, and was squeezing it – hard.  Toward the end of his comments, his voice had begun to take on the rehearsed, plastic rolling pitch and timbre of a revival-tent evangelist.

“Bullshit,” I replied.

My best buddy over there was Carl Jenkins.  Carl was from South Carolina – the “great-great grandson of the best slaves money could buy,” he used to tell me, sarcastically.  Carl was, in my eyes, the perfect Marine – smart, loyal, fearless, and a remarkable physical specimen – at least six two, and over two hundred pounds of lean muscle.  He had started at a black college back home as a football player – a running back, and was exempted from the draft initially.  However, he was the oldest of eight, and when his Dad had a heart attack, he had to go home.  In doing so, he lost his scholarship, and ended up in hell, here with the rest of us.

“Wasn’t much chance for a college dropout in my hometown to stay out,” he said, “and you know that there ain’t any black folks on the draft boards in South Carolina.  I saved ‘em the trouble, and just joined up.”

“Why the marines,” I asked.

“Listen college boy,” he answered, laughing, “I didn’t need no degree to tell me that if you have to fight, you might as well fight with some motherfuckers that know how to fight – know what I mean?  I mean, if I am fightin’ next to a goddamned killin’ machine, instead of some regular army dude that spent as much time learnin’ how to peel a potatah as shoot his gun – I got a better chance of gettin’ out of here.”

In 1970, there were about 50,000 marines on the peninsula, and we heard rumors that some units were being pulled out, as the South Vietnamese Army were taking control of increasing areas of the country.  My recon unit, which operated in the Happy Valley region, south of Da Nang, and numbered between 20 and 30, depending on who was coming in and going out, had lost about twenty killed and more than forty wounded since I had arrived, about 20 months earlier.

We were responsible for keeping the V.C. away from the nearby Da Nang airbase.  We patrolled daily, walking in a “V” formation from one lousy, hot, wet, green place to another – usually without a plan, other than to shoot and kill Charlie, or anyone that might have looked or smelled like, or reminded us in any way of Charlie.

Every now and then the C.O. would tell us that we were going to check out a village for Charlie, or sympathizers, and gratifyingly that would break up the monotony of trudging around in the rain forest, mostly trying to avoid booby traps.

We were on our way on this particular day in July of 1970 to do just that.

The C.O. said that it was just another village, maybe ten to twelve shacks and a wooden fenced-in area at its center where the few remaining livestock were kept.  They all looked pretty much the same.

Carl and I had earned our spots in the middle of the recon formation (making it less likely an ambush or a sniper from would surprise, and kill you where you were exposed at the front or back of the “V”) by staying in, and staying alive.  Another one of our original group that had earned a good place was Jim Cruse, from Jersey City, and he walked near us.

Cruse was an alright guy, but a little reckless.  He liked drugs, and when he was high, I swear that he was convinced somehow that he was Jim Morrison, the lead singer of the Doors.  His voice sucked, but he loved to sing Doors songs, especially as we walked into villages – “let’s ‘em know we’re here, you know?  Freakin’ Americans, Jack!  What the fuck does Charlie know about the Doors, man?”

As we approached the perimeter of the dwellings, he characteristically burst into “Hello I Love You”:

“….Hello, I love you
won’t you tell me your name…
Hello, I love you
let me jump in your game”

The “point”, as the poor bastard on the tip of the “V” formation was termed, usually the newest guy and therefore the most expendable, spun around, waving his hands above his head.

“Shut up Cruse!”

Unfortunately, Cruse was really high this time, and the admonishment only emboldened him.  He stopped, pushed his helmet back on his head, flipped the point off, and started again, yelling…

“HELLO! I LOVE YOU
WON’T Y…  tatat tat tatat – Ssssuuuummmp!

When a high velocity bullet strikes human flesh and bone, it doesn’t just make a hole – the area it hits explodes…

The unmistakable report of an AK47 was followed by Cruse’s lower jaw, in a horrific fine aerosol of blood and bone fragments, being blown right off of his face, mid-chorus.  Carl and I were looking right at him when it happened, hearing a millisecond before the familiar whine of bullets passing by us, from the direction of the village,.

We all jumped off of the dirt road, and down into the high vegetation grown up next to it.

Tatat tat tatat tat!
Tatat! tat tatat tatat!

Bullets ripped through the tall green plants above us.  I felt little pieces of grass falling from above, sticking to my sweaty face.

More green shit…

“Those came from the other direction, man!” Carl murmured, lying about fifteen feet away from me now, “it’s a fucking ambush…”

One of the marines down the line noticed this as well and hollered out to the C.O. – “BIDIRECTIONAL FIRE SIR – AIR SUPPORT!, AIR SUPPORT!”

Too close, I thought to myself, a truly sickening realization… that AK fire from no more than 50 yards, and less than a hundred to the village, where the first ones came from… to close, not good.

Charlie had learned well over the years, to respect and fear our air support – planes that could scream in on site in less than 15 minutes, and rain down fire and death from above.  He had learned to get in real close and personal with us, sister, figuring that a few extra casualties from coming in tight was worth it to avoid having an entire regiment blown away, or burned to a crisp by napalm.

The C.O. knew as well how close they were – no call would be made, and no support would be coming – an air strike would kill us as well.

A concussion wave blew me off my stomach and onto my back, violently. I didn’t even hear it – the wave of pressure struck my eardrums and temporarily rendered me deaf, my ears ringing loudly, before my brain had time to register any sound.  I looked over at Carl – his mouth was wide open, like he was screaming, but I couldn’t hear anything.

A grenade, or something, had blown off both of his legs, way up high.  I propped myself up on one elbow and looked across the road – more than a hundred V.C. were now running toward us, stopping every few feet to fire their weapons.  I glanced hurriedly over my shoulder at the village – another fifty or so were emptying out of the two closest huts.

I tried to get up, but my balance was all screwed up, the blast had done something to my inner ear as well, I fell clumsily onto my back, my head now spinning uncontrollably.

I closed my eyes, and waited for what I knew would come in the next few seconds.

Then, the ringing stopped.

And then came the familiar rustling whisper, barely discernible…

“important”… “important”… “important”…

“Hey, marine, good to have you back.”

A woman’s voice?

I blinked my eyes and focused.  A nurse was leaning over me.

“Hello,” she said, smiling, “what’s cookin’ good lookin’?”

A feeble “what?” was all that I could muster.

The nurse plopped herself down in a chair next to the bed in which I was laying, and lit a cigarette.  She put her head back and blew a stream of smoke toward the ceiling, then looked back down at me.

“You,” she said, “must be the luckiest Marine in the goddamned universe… or something.”  She shook her head and took another draw.  ”What do you remember, soldier?”

I raised up on an elbow, and looked over at her.  I hadn’t seen a white woman in a couple of months.  She wasn’t pretty, but not too bad either. “We were on recon, approaching a village,” I swallowed, hard, “and I think we were ambushed.  I… I don’t really remember much else.”

“That’s probably good,” she replied.

I put my head back on the pillow, and looked up at the dark green, waxed canvas ceiling of what I now assumed was a M.A.S.H. tent.  A cloud of smoke slowly drifted overhead.

I wriggled my toes, still there, I noted, thankfully.  I felt my abdomen and chest under the sheets, no bandages…

“How long have I been here,” I asked.

“You came in last night,” she replied, as she put her cigarette out into a little ashtray, fashioned from the bottom of a beer can, “you were unconscious.”

“Hey, listen,” I continued, looking over at her again, “I’ve been with that unit a long time – my friends?”

She suddenly looked nervous, and stood up, smoothing her olive green cotton field operating room dress down in the front, self-consciously.  ”Um, none of them… are here.  You see, Charlie must have had somewhere else to be, because after they, well… after they did what they did, they got out of there pronto.  The chopper boys came in about two hours after the fight was over, to try to evac the casualties.  Thing is, technically, there weren’t any.”

“What do you mean?” I asked.

“What I mean is,” she hesitated, “is that they were all dead, all of them.  Some all shot up, some blown to bits, and as an extra bonus, some hacked all to hell with machetes or somethin’.” She stopped, and wiped her moist eyes with the back of her hand, as if dismissing a familiar intrusive mental image of death.

After a few seconds, she produced a thin forced smile, “thing is, they found you there too, just laying right out in the open, like you had, you know, just slept through it all.  We checked you real good last night.  We didn’t find anything wrong with you, nothing – not even a scratch.”

SIX

I lay in bed in the hotel with my suit and dress shoes on, tie cinched up tight, exhausted.

“What a year…  Way, way too much activity… for a seventy-year old… ”

The voices from the next room were numerous, and animated, but thankfully muffled to some degree by the closed door of the suite.

I tried to sleep, but it wouldn’t come.  I was a little nervous about the upcoming event.  The team had been prepping me for months, but I had never done anything quite like this before.

I had become used to the attention, yes, sister, but this was a little different.

“Who would have thought that I would have figured it out?  A boy from the pahhandle of Texas?  A hick!”  I chuckled under my breath, and shook my head, eyes still closed.  The improbability of it all seemed ridiculous at times.

My mind drifted back to to the MIT campus, in Boston, where I had landed a postdoc position in experimental biophysics after I returned home from Vietnam.  It had struck me while over there that the one thing that could have saved more lives wasn’t American bombs, or pacification, or a certainly not a new democratic government.

It was water, fresh water.

I saw children dying from cholera, literally crapping themselves to death on the laps of their crying mothers – entire villages sick and dying from fouled river water.  The goddamned plants in Nam kept growing, they didn’t mind, but in many places there was just no water fit for human consumption, and no way to get it to the villages during the war.

Over the coming decades, I would dedicate my career to trying to determine how to deal with this problem, and as I worked, the problem increased in magnitude, globally.  More than thirty percent of the world’s rapidly, too rapidly, growing population was desperately in need, and wars began to break out as a result – not for gold, or land or oil, but for water.  People started killing one another for water.

How did I do it?  I know that you know, sister.  I studied photosynthesis, how a plant makes sugar from sunlight and water.  After all that consternation about the heat, and the moisture and the ubiquitous “green shit” in Nam, that was, after all, the secret.  Let it suffice to say that after about 25 years, at age 50, I figured out how to reverse engineer that natural process – nature is the ultimate teacher, you know, sister.  Through a relatively complex methodology, with a ridiculously simple application technology, I figured out how to generate clean water from sunlight.

I was on the verge of patenting the process, and moving the project to the next level when I found out about the cancer.

I had undergone, at the urging of my wife, a screening exam, and a baseball sized mass was discovered in my upper colon.  The surgeon got it out, but it had already spread to my liver, and to several other areas in my abdomen.  I started the usual chemotherapy afterwards, but there was little hope for cure.  My doctor, at Mass General in Boston, a national expert, told me to “get my affairs in order.”

Up to this point, I still didn’t believe that you were real, and that the scattered events in my life that I couldn’t explain, that allowed me to live and to do this work, were coincidence, or manufactured memories.

And then, you intervened, and all doubt was removed.

About halfway through the chemotherapy, you came to me in a dream, once again.  I hadn’t dreamt about you in years, but I had not forgotten the sensation of being with you.  This time was different; however, from all that came before.

I dreamt that you had appeared in the room, and lay down next to me, your head on my left chest.  We remained there for a long time like that, and then you placed your hand on my abdomen.  I felt a warmth there that I cannot explain.  It did something to me in that moment… and it did something to the cancer.

“I can’t believe this, Dr. Robinson,” the oncologist commented, three months later.  He was rubbing his balding head with his hand, with a confused look on his face, “this is the best response I have ever seen from chemo – BY FAR.  There is simply no tumor on your scan – nothing, nada, nicht, anywhere.”

He stared at the computer screen for several more seconds,  “now, even though this is good news, miraculous news, exactly, you know that the chance of it coming back is virtually one hundred percent, right?”

It didn’t.

The next twenty years were a blur…  The company and its success, the spread of the technology around the world, the smiling faces of children in Asia, and Africa, and the Middle East, the international collaboration, and the stopping of wars… and – the prize.

The Nobel Peace Prize – how ridiculous…!

I smiled, and then winced at the memory of that evening in Stockholm.

That must have been the worst acceptance speech ever.

I sat up in bed, and rubbed my eyes.  My mind was just too active to sleep.

There was a knock at the door a few moments later.

“It’s time to go, Dr. Robinson.”

I got up and tightened my tie, and the young man whisked me past the crowd in the living room of the suite, where several other impossibly young-looking people were gathered around television monitors and tables with computer screens.  One of them was giving an interview to someone holding a microphone in his face.  Several smiling faces, most of whom I didn’t know from Adam, shook my hand and patted me on the back as I walked by.

“Good luck, Doctor!”

“GO GET EM!”

“No contest, dude!”

We got on an elevator with a couple of guys wearing dark suits and little electronic earplugs, and then down into a waiting car, where we all piled in.

I had been told that the auditorium was large at Dartmouth, and that it would be packed.  I had been on campus once before, delivering another one of my terrible physics visiting lectureships – after the prize everyone was much more interested in hearing from me, and I was somehow much more interesting.

My young escort walked me up to the back entrance of the stage, along a dark, unoccupied hallway.  I opened the door and stepped onto the stage.  The others were already there, standing behind little podiums to the right of me, positioned every few feet.  My podium was the first one next to the table and chair, and as I approached it, the crowd came to its feet.

There was a thunderous standing ovation – it was embarrassing… it must have lasted for more than ten minutes, sister.

The others looked at one another, and then down at their podiums, shaking their heads in disapproval.  The one nearest me was yelling at the guy wearing a larger microphone and standing on the front of the stage …

“Are you going to allow this?  Is this really fair?  C’mon, Bill!  Make them stop!  I mean, why the hell are the rest of us even here?”

One of the others walked off the stage, throwing his notes down on the floor in disgust.

The Dartmouth university president walked over and shook my hand, vigorously, followed by several other university dignitaries.  The moderator stood up and calmed the crowd, with difficulty.

There were a lot of students there, and on the front row, there was a young, beautiful red-headed woman wearing a Dartmouth sweatshirt, and holding a notebook in her hands.  Even from that distance, and despite the bright lights, I could see her pretty green eyes.

I thought of you, sister, then looked up at the bright lights above, and smiled.  I remembered an early evening when I was young, when I looked up at the stars through a demolished church dome-frame to try to find you – to try to understand you.  I didn’t know if I would ever see you again now, or fully grasp you and I, but wasn’t sure it was necessary any longer.

Important… I thought to myself.

“Welcome,” the moderator said, “to Dartmouth, to CNN Live, and… the first Democratic Presidential debate…”

(Narrative)

I pushed open the patient exam room door self-consciously and entered, with the strange feeling that I had somehow just learned how to walk a few seconds earlier.  The hard heels of my new dress shoes “clicked” embarrassingly on the tile floor as I cautiously moved forward.  Luckily, the patient was seated on the exam table facing away from the door, with her head down – she didn’t seem to notice me yet despite the noise.

I stopped halfway in, and reached up and pulled on my collar.  It was moist, and the dress shirt that I had purchased the weekend before for the occasion, the cheapest one at Sears, felt like it was made of unfinished raw canvas, rather than cotton.

This collar is too tight, dammit. 

By telling me to go in, it felt as if my proctoring physician had put her high heel on my chest, grabbed my tie (30 year-old vintage psychedelic print – from my late father’s collection) and pulled it tight around my neck right beforehand.  It occurred to me that they did something similar to bulls at the rodeo right before they come out of “the chute”, or the little mini-corral in which they are placed right before release into the arena – cinching up a leather band around their hindquarters to piss them off and get them to try to buck the cowboy off.

I had nothing to buck off, but it did feel as if something was sitting squarely and heavily on my back.

Did I tie this damn thing this tight?

I can’t breathe.

 So uncomfortable…

I was a second year medical student, and I was about to do my first history and physical exam on an actual patient.

My classmates and I had all been looking forward to this.  Finally – a respite from the classroom.  We had spent four or more years as undergraduates there, and an additional one as first year medical students, sitting and listening to lecture, after lecture, after lecture… now, finally, a chance to be a “real doctor”.

In the second year curriculum, we spent Tuesday afternoons in local “primary care” clinician’s offices, where we were taught the mechanics of interviewing and examining patients, and organization of our thoughts into written “History and Physical Exams” (H&P’s) which were graded for organization and accuracy – sort of documentation “practice runs” for what we would be placing on patient charts a few years later.  As it turned out, like everything else we had been learning, there was a science involved, and by no means an intuitive one, to organizing one’s evaluation and subsequent thoughts about a patient and his or her presentation of some particular disease entity.

No less important, we had been coached that there was an art that had to be mastered in the interaction with the patient – how to approach another vulnerable human being, how to question in a manner that transmitted concern and not just data acquisition, and how to tactfully invade someone’s intimate space, and manually examine his or her body.  There was painting, yes, but there were also the technique – the million brushstrokes that made up the final product, and there were colors that had to be carefully mixed on a palette as well, before applying them.  It seemed as if there was little intuitive about this – but my intuition did tell me that this latter set of skills would take more time to acquire than the mechanical aspects of the H&P.

Crap…, why does my first one have to be a woman?

We had “practiced” on a few occasions with professional patients, individuals who for pay subject themselves to scripted interviews and all manner of physical examination.

One of the more uncomfortable moments of the first year of medical school was when two young men stood in front of the classroom and dropped their pants.  We formed two lines, literally like the local hot dog stand, and did penile and testicular exams.  Several in line, namely female students, were unfortunate targets of – “hey ________, are you in line again?”  At least the “standardized patient” female pelvic exams that we would do later in the year were performed in a more private setting – I worried about that as I stood in the “hot dog” line, and waited to take my turn.

I walked up to the bedside in the exam room.  I hadn’t noticed until now that a man with a clouded expression on his face was standing on the other side of the table, holding the woman’s hand.  It wasn’t clear to me whether or not the look was fear, or loathing, but something was wrong.  I shrugged it off – there’s always something wrong, or they wouldn’t be here, right?

I also noticed that they both seemed young to be in an internist’s office – all of the patients in the waiting room outside were older.

I glanced down at the chart in my hand, my nervousness impairing my ability to do simple math, such that it took me several uncomfortable seconds to calculate her age from her birth date, and to absorb the other demographic information printed in the corner of the first page.

She’s a twenty-nine year old black female school teacher from Bryan, Texas, I thought to myself – imagining the discussion with my proctor when I finished later, providing her with what we had been told was the classic “five part introduction” with which we were supposed to begin every patient presentation.  I also thought that she was pretty, but noted that I probably shouldn’t relay that information as a sixth component.

She was wearing a loose white cotton sleeveless blouse, and blue jeans.  Her toes, with red-polished, carefully manicured nails were visible at the end of her brown strappy sandals, her legs dangling off the end of the exam table.  She had a shapely, athletic figure.  We had been told that we shouldn’t notice whether someone was attractive, or repulsive for that matter.  I wondered how many of these exams I would have to do before I didn’t notice.

How do you not notice?

We exchanged pleasantries, and I informed them that I was a “student doctor”.  I didn’t tell them that this was my first physical examination, or that I wasn’t actually a “doctor” at all yet.  I was anxious about what was about to happen, but I was more concerned that they might turn me away.  Thankfully, the fact that I was a student didn’t seem to faze them in the least.  The young woman continued to look down.  I noticed that the man’s hand, holding hers, was shaking.

I launched, with feigned cheeriness, into the scripted medical student H&P questions I had been taught previously, “so, what brings you to see the doctor?”  The woman looked up and over at her husband, and then at me, with what struck me as a blank expression.

“I just don’t feel well,” she replied, “I’m just really tired”.

This became my “Chief Complaint” – the single explanation of why the patient felt that he or she had sought care, and the first piece of information I was supposed to elicit.  I wrote this down, and immediately started a “differential diagnosis” in my head…

I wonder if she’s depressed, I thought…, blank expression, head down, monotone voice…, maybe that’s it?

I then launched into the “History” part of the interview.  Here I was supposed to try to find out more about the symptoms – how long they had lasted, how severe, how they were characterized, and whether or not they were associated with any other similar, or dissimilar complaints.

I felt good about things so far, I was moving along smoothly, asking everything in the right order.  I was relaxing.

“I don’t know”, she replied distantly, “how long I have been tired like this… a long time, I guess.”

There wasn’t much more forthcoming…, she had no associated symptoms, she didn’t know if she had felt like this before, she couldn’t remember whether or not it came on suddenly or slowly – she was just “tired”.  I was frustrated.  This was going to be hard.

Maybe it was actually depression after all…, we hadn’t learned much about the psychiatric exam yet…, we don’t talk about that until next year…

I decided to move on the “Review of Systems”.  This was a series of scripted questions, facilitated by a handy copied chart I had with me, with boxes to check.  The review of systems “systematically” (focusing on grouped body systems, for example, the respiratory system – “have you ever had asthma”, “have you coughed up any blood”, “have you been short of breath, etc…”) attempted to solicit additional symptoms or other problems or conditions a patient might have experienced recently, but that they didn’t remember to tell you about, or that they might have felt not associated with the primary reason for coming in.  Often, this information would provide clues to the diagnosis that the “History” did not.  I went down the list… neurologic – nothing, gastrointestinal – all answers were “no’s”, cardiac – negative, respiratory – nada, gynecologic – nothing, etc., etc…  nothing, nothing, nothing.

“I’m just tired, really, that’s all”, she said, once the questions stopped, “none of those things you asked me about are bothering me”.

I said that I understood, hesitated for moment and moved on to the next part of my carefully rehearsed script… “I would like to examine you now, would that be okay?”

“Sure,” she said, laconically.

I had asked the proctor earlier, Dr. Mukhopadyay, if I needed to do a pelvic exam, and she had told me that would not be necessary, noting that the patient had been seen recently by a gynecologist who occupied an office in the same building, but I knew that I would still need to ask the nurse to come into the room when I examined the patient’s breasts.  However, I decided to save that for last, as I was worried most about it, and didn’t want to have the nurse watching me the entire time.  I had just met the nurse in the clinic, and had no idea what sort of person she was, but I imagined for some reason that she would be behind me, tapping her fingers loudly and impatiently on the metal instrument tray – with pursed lips, and squinty, disapproving eyes.

I asked the patient to change into a cotton gown, and that I would be back in a few minutes.

I walked outside and shut the exam room door to find Dr. Mukhopadyay waiting.  She was about sixty years old, and had been a proctor for hundreds of students before me.  She was pleasant and seemed to be engaged in this activity, one that obviously added a great deal of inefficiency to her busy day, but was also very matter-of-fact, all business.

She held a sheaf of papers in her hand, and didn’t look up at me when she asked, “so, about to do physical exam?”

“Yes ma’am,” I replied.

“Your differential based on the interview?” she asked, turning pages in her hand, and adjusting her reading glasses.

I fidgeted, and looked down at my notes.

“Well?” she asked again, impatiently.

“I’m not sure, I think she might just be clinically depressed,” I replied, with an obvious lack of confidence.

“Hmmmm,” she said.  I sounded and looked like she had a bad taste in her mouth,“that’s a waste basket diagnosis…, did you characterize the complaint?”

“I asked her everything, but she kept saying that she was just tired,” I replied.

“Are there any causes of fatigue that aren’t depression, young man?” she asked, sarcastically.  At this point, she looked at me for the first time, over the top of her glasses. She dropped the papers to her side in her right hand, as if exasperated, and placed her left over her mouth.  I wanted to know if she was hiding an amused smile, or perhaps her disgust – there was no way to know.

“Uh, yes,” I replied, embarrassed, “lots of them, anemia, chronic infection, neurologic disorders like multiple sclerosis, many others…”

“Better,” she snapped, “go back in and see if you can figure it out.  I haven’t seen this patient yet, so let’s see how good you are…”  She then turned abruptly, and headed to another exam room, her high heels striking the floor with sharp staccato reports.  She didn’t see me shake my head yes.  I moved away quickly, before she could come back and grab my tie.

I knocked on my patient’s exam room door, and opened it a crack.

“Are you ready?” I asked.

“Yes”

I walked over and told the patient what I would be doing, starting with a neurologic examination, and “checking her all over” for anything abnormal.  She shook her head up and down.  I looked over at the man, and he looked back at me.  His hands were now in his pockets, but he was standing in the same place.

“I’m sorry,” I said to him, “I didn’t ask earlier if you were related, or if it would be okay with Ms. Smith for you to stay in the room.”

“I’m her husband,” he replied, nervously.  His voice sounded shaky as well.

“It’s fine, doctor,” she said.

I put my cheat sheet of the steps required to complete the physical examination down on a table behind me, so that I could turn and look at it if need be, and reached into my pocket to grab my reflex hammer.  I was going to start with the neurologic examination, which included tapping the joints to test for reflexes.

Like all other medical students, I had been duped into buying several hundred dollars of “stuff” that I was told I needed to examine patients, and an expensive black leather bag in which to put them – feeling sheepish about carrying the small suitcase-sized bag around, I had stuffed all the things I had purchased into the few pockets of my short white coat – stethoscope, ophthalmoscope with otoscope fittings, tongue depressors, tuning fork, reflex hammer, portable blood pressure cuff, etc., etc… As I fumbled for the various devices in my pockets during the exam, I became aware of how silly it looked, and how all these things “clanged” together whenever I moved.  It struck me that I sounded like some sort of medical “tinker” – those people that in the past carried around with them on a rolling cart a load of cooking utensils that needed fixing, all banging together as they traversed bumpily early american cobble-stoned streets, rather than someone that should be working at fixing patients.

After what seemed like several hours, we got through most of it, with me dropping the device I had purchased to look into patient’s ears, the otoscope, on the floor – relieving it temporarily of batteries, and a spring that held them in place.  I had to get down on my hands and knees, feeling incredibly professional in the process, to retrieve them from underneath the exam table, and the spring as well – it had miraculously bounded away into a corner ten feet away.  Another notable moment was the point at which I was unable to remove the stethoscope from my left ear smoothly, where it dangled for a time, as I grappled with it for several moments as I tried to make small talk – like a garish, techno-fashion earring.

Everything was stone-cold normal, at least to my inexperienced eye.  She seemed like a very healthy young woman.  It was perplexing.

I began to worry about my next conversation with Dr. Mukopadyay, and remembered with a little spike in my baseline anxiety that it was time for the dreaded breast exam.

“I need to do a breast exam now – to be complete.  I’m going to ask the nurse to come in,” I said.

“Okay,” she replied, again, with little emotion.

I opened the door and poked my head into the hallway.  The nurse was waiting – she wasn’t a novice either.  She ambled down the hall, gave me a tired smile and a nod and came inside.  I asked Ms. Smith to lie back and told her that I would examine one breast at a time, again, as I had been taught to do.  She lay back on the table, and the nurse grunted at me, as she pulled out the sliding support for the patient’s legs.

“Ya know, she’ll be more comfortable this way,” she said, loud enough to let the woman and her husband know that I would likely never reach her level of compassion or expertise, despite my best efforts over the next several decades.

I gently guided the patient’s left arm up and placed her palm behind her head.  I pulled the gown up to the center of her chest to expose her left breast only, and palpated it in concentric circles, starting wide and finishing by examining her nipple for discharge or abnormal thickness – all normal.  I moved to repeat the same steps on the right, telling the patient as I moved forward what I was doing, I placed her left hand back by her side, and pulled the gown away from her right breast.

I leaned over, and caught a whiff of something unpleasant.

What’s that smell?

Something was wrong.  Her right breast, hidden earlier by her own loose blouse and now by the examination gown, was twice, almost three times the size of the left, and there was a gauze pad covering an area just lateral to the nipple on this side.  It had some discolored dried material on it – reddish brown.  I lifted the gauze gently off the surface of her breast – there was an open weeping wound, about the size of a golf ball, with heaped up edges, and crusted with dried pus and blood.  I reached down and felt of the breast around the wound – rock hard.  There was a grapefruit-sized mass in her right breast, and it had eroded through her skin.  I was mortified.

I glanced over at her face, and she looked back at me – with no change in her expression.  The husband, who had backed away to the wall a few feet away during the breast exam, inched toward the table.

“Something wrong?” he asked.  His voice seemed calm, but I could tell it was higher-pitched than before.  He had been expecting this.

I looked at the nurse, standing at the end of the table.  She looked back at me with both eyebrows arched, and her eyes wide open. My heart was racing.  I tried to speak, but my voice didn’t come out right.  I cleared my throat.

“Ma’am…, how long has this been here?” I asked.

I gently repeated the positioning step, placing her right palm under her head, her elbow out.  When I did so, the mass looked even bigger, and there were several nodular densities that I could see under her skin in her armpit.

Lymph nodes, I posited silently, that’s bad.

She turned her head toward her husband, away from me.  “A while”, she replied, “I know I shouldn’t have waited, but I was just too scared…, too scared…”

She started sobbing.  Her husband moved in, and took her hand again.  He looked down at her, and didn’t look up again.  He was breathing hard, his chest moving in and out, and his shoulders up and down, convulsively.  I gently covered her right breast back up with the gown, moved her arm back down to her side, and cleared my throat again, trying to seem as calm as possible.

“I’m going to ask Dr. Mukopadyay to come in, okay?” I said in a soft voice, “she’ll be right in.”

Ms. Smith continued sobbing, looking away from me, and her husband didn’t move or answer.  I looked at the nurse who nodded to me, and then at the door.  I went out and found Dr. Mukopadyay.

“I think you should come in and see her,” I said, “there’s a problem.”

“What problem?” she asked, but didn’t wait to hear my answer, brushing past me to go into the room, the bottom of her lavender sari billowing out beneath her long white coat as she moved.  She motioned me to follow.

I sat at the clinic nurse’s desk a couple of hours later, waiting on Dr. Mukopadyay, who had spend a good hour or so with Ms. Smith, and then had made several phone calls to arrange for her to see a surgeon and a medical oncologist.  Everyone had left the office except for us.  She came over, and plopped down into a chair across the desk from me.

“So sad, so sad…,” she said, wearily.  She was looking at the bell on her stethoscope, as if she had never seen it before, rolling it back and forth between her thumb and index finger.  Her glasses were pushed up on her forehead, the chain attached to its arms dangling behind her head.

“I have seen this before, this waiting…, this waiting until it’s too late.”

She hesitated for a moment, then continued, “you can turn in your H&P to me, and I will read it later. I’m too tired to discuss this with you right now, to be honest.”

“What will happen to her?” I asked.  I thought I knew, but wasn’t sure.  “Was that a breast cancer, a tumor?”

“Yes, yes it was,” she said, still not looking up at me, now tapping the bell of the stethoscope gently on the desk in front of her.  “I am virtually certain.”

“So, what are her chances, you think?” I asked.

She looked up, and then back down at her stethoscope again, squeezing it tightly in her palm now.  The fluorescent lights above glinted off of her glasses as she moved, the chain dangled behind her head.  It was very quiet in the office, as everyone had left – the electric wall clock on the wall above her head ticked ominously for several seconds.

“Chances?” she laughed, without smiling, and shook her head from side to side.  “Her chances came and went months ago.” She paused for several more clicks of the wall clock, which seemed even louder now, and then took the bell of the stethoscope and whacked it hard, down on the desktop – “BANG!!”…

“It seems like we are too far along for this, we are TOO FAR ALONG for this thing to happen, you know, this THING, this WAITING thing to happen to a woman…, a young…, woman.”

I felt as if I should say something to acknowledge her, but nothing seemed appropriate.  I shifted uncomfortably in my chair.

“Now she is dead…, dead,” she added, deflated.  She plopped back in her chair, letting the stethoscope fall into her lap, and waved her hand in front of her face, as if to dismiss the entire episode.

She looked back up at me, took her glasses off of her forehead and put them into her large side coat pocket.  She took the stethoscope, folded it neatly onto itself, and placed it into the other one.

She closed her eyes and rubbed them with the back of her hand, hard, and asked, “so…, how was your first day as a real doctor?”

(Narrative)

“I – am – doctor – from – United – Arab – Emirates!”

A short, stocky and heavily black-mustached man, dressed in a tan linen suit, was speaking to me, emphatically, as I approached the exam room of my next clinic patient.  He was standing outside the door, almost as if at attention, his legs stiff and held close together, his expertly polished brown wingtips pointing away from one another, at forty-five degree angles beneath the wide cuffs at the bottom of his pants.

“Um…, okay…, nice to meet you,” I said, “are you with this patient?”

“YES!” he replied.

“Are you related to the patient?” I asked.

“NO!” he replied again, a little too loud, smiling broadly.  He offered his hand and I reciprocated.  He grasped mine firmly and jerked, rather than shook, it violently up and down.  I looked down the hallway to see if anyone else had witnessed this exchange, and might provide some explanation, but we were alone.

“Do you have permission to come in with me…, to see the patient?” I asked expectantly, worried about the delay this discussion might provide, with a long list of patients waiting to be seen.

“I – AM – DOCTOR – FROM – UNITED – ARAB – EMIRATES!” he replied, looking at me as if I was supposed to know why he was there, or what my next move was supposed to be.  I looked down at the patient’s chart in my left hand, my right one still in his grasp.

Arabic name, female, dysphagia, R/O cancer of the esophagus.  I looked up and at the man’s face again, for a long awkward moment.  He continued to smile, raised his bushy eyebrows, and squinted.  He then shook his head up and down as if he had affirmed something with me, or that we had agreed to share some secret during our very brief, and very odd, encounter.  I slipped my hand with some difficulty from his grip, and grabbed the doorknob.

“Excuse me, please,” I offered, smiling with clumsy, feigned politeness.  I opened the door and slipped into the exam room, leaving him standing there as I shut it behind me quickly.

When I entered the room, there were two women waiting.  I was immediately struck by the fact that they looked as if they were from completely different worlds, and if not, at least from very different parts of the same one.  An older woman, whom I assumed was my prospective patient, was sitting on the exam table.  Her size and shape were difficult to discern, with what appeared to be several layers of loosely fitting black thin cotton garments covering her body, from a tight head-dress that covered everything except the area of her face between forehead and chin, literally to her toes – numerous blouses with long sleeves, and multiple skirts.  Her dark figure stood out in sharp, stark contrast to the white walls, and the standard medical exam room light pastels.

The only exposed areas of skin were her face and hands.  They were dark brown and leathery, looking more etched than wrinkled.  Her eyes were an unusual, actually striking color – an amber background, with gold radiating out from the dark center. I hadn’t noted her age when I looked quickly at the paperwork outside, but she seemed ancient – both in dress and general appearance.  I glanced again at the chart, “only sixty-six”, I thought to myself, “wow, no sunscreen I guess.”

I held out my hand expectantly, attempting to smile my best disarming smile, as I always did when first meeting a patient, and addressed her, “hello, I’m Doctor Smythe”.

“NO!” came the other woman’s voice from behind me, “she will not shake your hand, it is…, I’m sorry…, not possible.”

I turned to view the other woman.  She was much younger, about thirty or so, wearing a blue short-sleeved polo shirt, jeans and well-worn Nike tennis shoes – the expensive kind a serious runner would wear.  Her hair was short, dark and styled in a modern way that would be indistinguishable from any other woman that I might pass on the street in this major American city.

“She is Bedu,” she said apologetically, with a pleasant French accent, “she cannot touch you, and you must not touch her without permission.”

“Okay, I’m so sorry, does she speak any English?”

“No, but I am her daughter, and I can translate for you.  I’m a psychologist, I have a doctorate.”

“Great,” I replied, introducing myself again to her.  I started to offer her my hand as well, but thought better of it, and placed it uncomfortably back in the pocket of my white coat.

Out of curiosity, I asked, “where is Bedu?”

She quickly replied, “Oh, it is not a place, it is her life, her heritage, she is Bedu…, Bedoiun, you know, from the desert”.

“Oh, okay, I understand. Say, um, before we get started, can you tell me anything about that man outside?”

She laughed, “Yes, he is from the embassy, but we never met him before today.  He is supposed to be here to help with our arrangements, I guess.”

I sat down on the rolling stool next to the exam table, lowered it so that I wasn’t looking down on the daughter sitting next to me at the desk, and told her that I would like to ask her mother some questions.

“Of course,” she replied.  She then spoke to her mother in Arabic, I assumed explaining to her he interview process to come.  The older women turned and looked at me again. literally with disgust, her eyes gleaming like gold coins in the center of her suddenly even darker-appearing face.  She then closed them and with palms down, waved the back of her hands toward her daughter as if to dismiss her comments, and it seemed, to dismiss me as well.

I proceeded with the daughter’s help.  Initially, it went well, with the exception of the usual inconvenience related to the use of an interpreter.  I asked the daughter questions, while alternating between looking at her, and then at her mother.  The patient kept her head down and only occasionally glanced up at her daughter to answer her entreaties with what seemed to be as few words as possible.  She did not turn to look at me as I asked questions, or as her daughter responded to me in turn.  I started in with the usual questions that I would of anyone being evaluated for a possible cancer of the esophagus.  At one point, after we had gotten through the first few parts of the history, her mother suddenly looked up at her daughter and barraged her with pressured, angry speech, waving her hands and repeating, almost yelling, phrases over and over again in Arabic.  Her daughter tried to interrupt several times, but to no avail.  I sat silently, and waited for them to finish.  Eventually, the older woman stopped, turned her head and again glared at me.

Her daughter took a deep breath and spoke, “she wants to know what good this is if she is going to die anyway?  She says that if she has the cancer in her chest, that this is meaningless, that these questions are meaningless.”

The old woman now watched my face as I spoke.  I stared back at her, but with some difficulty, as it occurred to me that her eyes looked a little frightening.

“Tell her that we don’t know whether or not she has cancer, and if she does, that it may be treatable…, that she might not die from the cancer.  There is no way to know what to do; however, unless we finish here first, and then do some tests. Tell her that I’m only trying to help her.”

Her daughter translated.  This time, the woman didn’t take her eyes off of my face as her daughter spoke, as if trying to catch a small change in my expression that might tell her something that the words her daughter were relaying did not.  Once her daughter was finished, the patient looked down again at the floor, and we resumed.

She related classical symptoms of an obstruction of her esophagus of some type, including the sensation of “food sticking” in her chest when she ate.  I was suspicious that it might be cancer based on her story, and on the X-ray, a barium swallow, that she brought with her from a hospital in the Emirates.  This test involves the patient drinking barium, a liquid metal dye with the color and consistency of thick milk that can be seen on the X-ray images, and then taking films of the fluid as it traverses the back of the throat, the esophagus, and finally down into the stomach.  Any abnormalities along the way appear as a change in the normal pattern of the dye filling and giving shape to the structures as it passes through them.  Her study suggested that there was a partially obstructing mass about two-thirds the way down her esophagus.

The remainder of her history was surprisingly benign, despite her age, and what I assumed must have been significant wear and tear secondary to having possibly lived her life in the desert.  Her overall health was quite good – exceptional actually – she was taking no medications, had no other complaints, and was very active.

When it came time to perform the physical examination, I stood up from where I had been sitting and asked the daughter, “I’d like to examine her now, will you ask her if that is okay?”

“She probably won’t let you,” she replied, shaking her head.

“It’s important,” I continued, “it will be hard for me to know what to do for her unless I do this.  Didn’t the doctors in her country examine her?”

“No, just X-rays,” the daughter said, “but okay…, I will tell her.”  She then drew in another deep breath, looked over at her mother with a look of great trepidation, and spoke to her sternly in Arabic.

Her mother responded immediately by yelling back at her, almost shrieking, and waving her hands over her head violently, the layers of fabric undulating back and forth on her forearms like black warning flags, letting everyone within sight know of some impending danger.  She was yelling so loudly in fact that I was concerned one of the clinic nurses might barge in, or call security.  I walked over to the door and stuck my head out, signaling with a wave to the nurse that had stationed herself expectantly down the hall a few steps away that all was okay, shut the door and sat back down as they continued to exchange verbal blows in a language for which I had absolutely no comprehension.  I looked at my watch and shook my head, contemplating the four other patients already in other rooms waiting to see me.

As I watched the mother arguing, I thought about how different I must have seemed to her – she dark dress, skin and even darker demeanor, and me in starched white labcoat, red-haired complexion, and, for the moment, attempting to be cheerful.  I considered the fact that I had avoided exposing my own integument to the sun religiously since medical school – my family frequently embarrassed by the straw hats, long sleeved shirts and hospital scrub pants I so attractively sported on vacation while they cavorted in bathing suits on the beach.  Finally, the heated discussion between them tapered off.  After a welcome pause, the mother said something quietly to her daughter, then turned her head toward the wall, away from both of us.

Her daughter spoke to me once again, “She will allow you to examine only small parts of her body – but only areas that she exposes herself.  She will not disrobe.  I am sorry, but this is what she is saying she will allow.”

“Sure,” I replied, still optimistic, “let’s take a look.”

It became obvious very quickly that my idea of taking a look, and my patient’s were just as disparate as our appearance.  Over the next fifteen minutes or so this became distressingly obvious.  During this time she exposed two to three centimeters, at most, alternating areas of her chest or abdomen with one hand by peeling back layers of her garment carefully, but then slapped at my hand or stethoscope with the other when I attempted to palpate, or listen to the small area that I thought she was allowing access to.  During this frustrating game of medical examination peek-a-boo, she continually muttered something repetitive in Arabic, and looked away from me.  If it weren’t for the fact that I had other patients waiting to be seen, it might have struck me as funny – but I did, and it didn’t.

I glanced up at her daughter repeatedly and paused with exasperation after each small patch of skin was comically and cursorily examined, at which time she and her mother would begin yelling at one another once again.  This forced me to continually back away from the table – for fear of being caught by one of the mother’s frenzied waving black arm-pennants.

Finally, impatient and worried about getting too far behind, and concerned as well that the commotion might be too much for some of the waiting patients in nearby rooms to bear, I decided to stop and move on.

“Okay, okay, we’re all finished,” I said, trying to maintain a positive expression and an air of authoritative finality, despite the discomfort I felt with the overall interaction and how thoroughly I had actually examined her.

For all I know, she could be hiding another damned person under there, I thought to myself miserably.

I explained to the daughter what would come next, “I’m going to order a couple of tests – an endoscopy and an X-ray.  The endoscopy involves putting a lighted flexible tube in her mouth and esophagus, while she is partially sedated, and the X-ray is a CT scan, where she will just have to lie still on a table while a machine makes pictures of her chest and abdomen.”

“Doctor…, will she have to remove her clothes for either of these tests?” her daughter asked, with a look on her face that suggested an anxious plea for a negative response.

I found this question interesting, as most patient’s family members ask about the potential complications of tests and procedures, rather than whether or not disrobing was involved – but then remembered our physical examination adventure moments earlier.

“I don’t think that she’ll have to remove all her clothing, but the doctors in those areas will tell to you what to expect”.

I actually knew full well what she had to expect, but didn’t want to risk sharing that with them now – she would have to disrobe, and would also be asked to wear a hospital gown.

The basic design of that article of clothing (“clothing” being considered here a very generous designation), the hospital gown, has been unchanged since the turn of the previous century – a dangerously thin cotton garment that one places on the front half of the body, leaving the more posterior “elements” exposed.  It comes complete with two little cotton or rayon string ties in the back to secure it, one upper, and one lower.  These are usually only tied at the top by normal people struggling to get them on, with the lower tie reserved for those that are actually able to tie them – Olympic gymnasts, and Circ Du Soleil contortionists.

My mind wandered…, there’s only one other situation that requires you to wear clothing that only covers the front half of your body.

As my patient and her daughter gathered up their things to go, I recalled a discussion from my past.  I was eighteen when my father died.  My mind often stumbled unwillingly to my own parent’s untimely deaths whenever I was seeing a patient and his or her grown child in my practice, such as these two.

“I guess I’ll take those,” I had told the funeral director sheepishly, choosing from one of the several shirt, tie and coat combinations he had set out for me on the counter.

He wouldn’t really have worn any of these things, but I guess I should pick one, I thought, as I surveyed his offerings.  I started to ask if they had a Sears brown and black houndstooth polyester sport coat, and a clashing striped open collar dress shirt – my father’s usual “nice” attire.  What I was forced to choose instead was an sophisticated-looking charcoal-colored jacket, with white dress shirt, and a grey, red and black paisley tie.

“Hey…, why don’t these have a back part?” I asked, “there’s a big open area in the back of this jacket,” as I lifted it up, and then the shirt as well, to inspect them more closely.

The funeral director looked up from his notepad where he had been gleefully adding up all of my choices, including in addition to the attire – piped-in music, artificial flowers, and of course, color and style of coffin, with a sad, questioning expression.  His mouth opened partially, but he checked whatever he was going to say and stopped.  I suddenly noticed how quiet it was in the room.

“Oh,” I said, tears welling up in my eyes, and reaching up to rub my nose as an attempt to distract him from that fact “…okay, yeah, I get it, sorry.”

I returned to the present moment as my patient and her daughter stood to leave, and winced when I thought about the upcoming interaction between them and the nurses in in the testing areas who would be charged with encouraging my Bedouin patient exhange her current dress for the open-backed gown.  I asked the daughter to report to our front desk, where the tests would be scheduled, and said my goodbyes.  I looked over at the patient, but she turned her head away from me once again to stare at the wall at the back of the exam table as I left the room.

My physician’s assistant, Julie, was standing outside an adjacent exam room with a chart in her hand, and motioned to me toward her as I shut the door.

“Who was that little dude in the tan suit?” she asked.

“Oh yeah,” I chuckled, “evidently he was some doctor from the United Arab Emirates embassy, where this patient is from.”  I shrugged my shoulders shook my head and frowned, “and I have absolutely no idea why he was here…”

“Really?  Weird.  Oh well, you better come on in and see this next patient, she’s pretty mad about the wait”, she said, tapping the door with the corner of the chart in her hand, “what took you so long in there, and what was with all the commotion?”

“That’s a long story,” I replied, “let me just go on record to say that I hope that I don’t have to operate on that patient,” I nodded my head toward the closed door, “taking care of her in the hospital might be, uh, challenging”.

So of course – I had to operate on her.

The endoscopic procedure demonstrated that the patient had a mass in her lower esophagus, and a biopsy indicated it was a cancerous mass.  Interestingly; however, it had been determined by the pathologist looking at the microscopic slides to be a rare type of cancer – one that is caused by a previous infection with the Epstein-Barr virus, and called a lymphoepithelioma.  More than ninety percent of the world’s population has been infected with the Epstein-Barr virus at one time or another, and most will recognize one of the more common manifestations of these particular viral infections as “mono”, or mononucleosis.  For the overwhelming majority, the virus comes and goes, but in rare individuals, especially in certain parts of the world, the virus proteins interact with normal cells to change them into cancer.  This patient’s esophageal tumor was so rare, in fact, that it had never been reported in the United States, only in some countries in Asia.  Most patients with the “usual” type of esophageal cancer undergo chemotherapy and radiation prior to surgery, but for this unusual variety, the determination of the team of doctors involved was that immediate surgical removal was the best option.  Thankfully, there was a very good chance of cure.

“Great,” I said to myself sarcastically, murmuring under my breath as I read the email from the medical oncologist that had seen her after the biopsy results were obtained, “this is going to be interesting…  I wonder if I can do this operation through little areas of exposed skin while she slaps the scalpel away?”

Julie called the daughter, and asked her to bring her mother back to the clinic for a preoperative consultation.  Gratifyingly, they were both somewhat more subdued during the return visit, and didn’t seem to be in the mood to argue with one another, as if some truce had been called.

The mother sat silently from her perch high on the exam table, like a giant black raven puffing out her feathers, looking down at the floor, and only nodding in response as her daughter spoke to her in Arabic.

I explained the procedure in detail, which involved removing the esophagus and replacing it by making a tube made out of her own stomach, and putting this tube up through the chest to the lower neck, where it would be attached to the small amount of esophagus left behind.  I drew the daughter a series of pictures to explain the steps of the operation, which she showed to her mother, who barely gave them a glance.  The older woman simply nodded once more after her daughter completed her explanation, and the daughter signed the consent forms.

“She is illiterate” she had informed me as she signed, “there was no value in learning these things in the desert.”

As they were walking out the door of the exam room ahead of me to leave, the daughter turned and said, “my brother will be here tomorrow.”

I told her that I would look forward to meeting him.  She stood for a moment or two after I said this with a strange expression on her face, and then turned her head and looked down the hall.

“Yes, yes,” she mumbled, and then turned and ran after her mother – who was moving fast, already half-way down the hall, her long black tresses trailing behind her, undulating back and forth in a way that reminded me of the reverse image of a B-movie matinee ghost.

Modern memory theory suggests that we learn to do things in a predictable way with repetitive effort – that mastery and efficiency follow in a fairly reproducible fashion as our acts move from stumbling conscious trial and error, to more perfected “unfocused” activity, and then to an almost involuntary state.  At this level, we may be very expert, but no longer have to think much about what we are doing, and may even actually forget the details once an activity is completed – driving a car is the example most would identify with.

This happens to surgeons as well.  During the training period, and for the first few years in practice, the act of “doing surgery” requires a great deal of conscious effort, but as you progress, things become more and more “automatic” in the operating room.  In time, you infrequently “fret” about the minute details of what you are about to do before the start of the case – the invariable (but seldom admitted) muted fear, indigestion and tachycardia, and the heavy, tight spring-coil of nervous tension that accompany the practice of complex surgery during the first few years of practice gradually diminish and mature into concern, rather than worry.  So it follows, as I walked into the hospital the morning of my Bedouin patient’s case, I wasn’t thinking about it a great deal.  I had performed cases similar to this many, many times before.

I rode the elevator up to my department floor and unlocked my office door, where I dropped off my briefcase, and glanced at my email inbox.  I then walked down a couple of floors of stairs, and traversed the few polished tile and aseptic-smelling corridors to the locker room adjacent to the operating room, where I changed into a set of scrubs, and grabbed my “working bag” from my locker.  This containing my headlight, loupes (magnifying glasses), some tape to keep my mask on my face and prevent those glasses from fogging, and few other items.

The repeated reports of metal on metal, the sounds of locker doors opening and shutting, signaled the beginning of the operating room day.  I exchanged pleasantries with a few other surgeons dressing nearby, and walked out into the hallway, past the doors marking what we call the “red line” (where one must wear scrubs, shoe covers, mask and hat) and into the operating room area proper.

This was the repetitive, routine beginning of another day in surgery.

The first part of the day was the busiest time in the operating room area, as everything later becomes naturally staggered based on the varying types and lengths of cases.  However, all first cases start at roughly the same time.  At this time of day, the operating room floor might remind one of busy train station – like 30^th Street in Philadelphia, or Grand Central in New York, at morning rush hour.  Everyone is moving purposefully, into and out of the doors of the operating rooms, like into and out of the doors of subway or train cars.  Stretchers are being guided around people and corners, IV poles being adjusted up and down, equipment is being moved from place to place, and a few people are running down the corridors and bumping into others, trying to catch patients before they “leave the station”.

I stopped at a corner near the main desk, and glanced up at the flat screen monitor to see where I was operating.  I walked down the hall, and absentmindedly pushed open the door to the operating room.  I stepped in as the door swung shut behind me, looked over at the operating room table, and then literally froze where I was standing.  The thin nylon bag slipped from my hand, and it hit the floor at my feet, the hollow wooden box containing the magnifying loupes striking the hard tile floor on one of its flat sides, just at the right angle for maximum sound – “WHACK!”

Everyone -nurses, residents, anesthesiologists and technicians stopped, and looked up at me from their tasks.  I didn’t respond.  The preparation of the patient had reached the point just before her body would be “draped” – covered with sterile paper sheets, so she was lying on the operating room table nude.  I stared at her, my now open mouth hidden by the mask I had put on earlier.

The patient, lying on her back, was covered with hundreds and hundreds of nickel-sized, and slightly larger, pigmented spots.  Some appeared to be randomly placed, but others were in unmistakable patterns, both linear and undulating.  They were everywhere, on her chest, abdomen, arms and legs, and even her forehead, just above where her headdress had been situated.

I moved forward, compelled to understand – not so much as physician, but as any other human being affected subconsciously with curiosity and attraction to things odd and salacious – the compulsion that attracts people to the side show at the circus, or encourages well-paid and highly-educated executives to pick up and read copies of the National Enquirer while waiting in line at the fancy gourmet grocer.  Although perhaps not one of our more enviable traits as homo sapiens – morbid curiosity is one of the things that doctors actually rely on – an ancient inclination to “nosiness” when it came to other human beings.  It is involuntary, and instinctual, and therefore not situated in the outer cortex of the brain, where all the medical knowledge gets packed in during medical school and residency training.  It is much more basic – a curiosity that is lodged somewhere in a dark fold of the ancient hindbrain, right next to the areas that tell you to eat, breathe and procreate.

The others in the room quickly resumed activity, but I was now mesmerized, the clamor of voices and movement, the clanging of metal instruments against one another and as they came into contact with the metal trays where they were being organized for the upcoming procedure, and the rhythmic beeping of the patient’s cardiac monitor had all faded from my consciousness.  I focused only on the image of the patient before me, and the strange marks on her body.

The patterns, I murmured to myself, they must be man-made, not some disease process.  What is this?  I walked up, putting my hands on the edge of the operating room table, and leaned in close to her body – these look like burn lesions…, they are…, they’re all healed burns. 

I looked up again after a few seconds, as the circulating nurse brought me back to the noises and movement.

“Weird, huh?” she said as she tucked a sheet under the patient’s legs, “burns all over her, like she was abused or somethin’, you know?  It’s terrible, just terrible what people do to themselves, and each other.  I think I’ve seen everything down here, you know?  Not many secrets when you’re all splayed out like this in the operating room, right doc?”

I shook my head in affirmation, but thought otherwise, remembering the exam in the clinic a few days ago, and how she had obviously systematically hidden this from me.  Not abuse, I thought to myself, and not accidental either, I don’t think so,… something else, but something meaningful.

The case itself was a blur, but went well.

The esophagus had to be removed, as planned, but the tumor was small, making it technically a little less challenging.   I walked out of the operating room as the resident and his assistant closed the skin incisions.  I then checked in with the receptionist in the patient family waiting area down the hall, and met with my patient’s daughter in one of the small conference rooms that was “budded” off of the main common seating area.

“Hello,” I said, with as much of a positive tone of voice as possible, and with a reassuring look on my face.

I had learned years earlier that patient’s family members begin to make inferences about how things went in the operating room via non-verbal cues as you walk up to them, your posture – your expression, whether or not you make eye contact – all are pieces of data that they are collecting and analyzing carefully, even if they aren’t really aware of it.  The majority of those waiting expect bad news from a trip to the operating room, and are trying to prepare themselves for it.  The operating room is a black box for most, and is assumed to be a common portal to death by many, even though most modern elective surgical procedures are certainly much safer than cab ride in Manhattan.

“Everything went very, very well,” I said, “everything really as planned, no surprises, and she is doing very well so far.  The tumor was removed, and we put everything back together using her stomach, as we had discussed.”

“Praise God.”  The tension, superimposed onto her face like a tense, transparent puzzle, loosened and fell away in pieces.  She lifted her palms upward between her waist and shoulders, and her eyes looked up toward her heaven, “praise God, praise God, and thank you doctor.”  She looked exhausted, and although now happy, seemed suddenly very small, and very alone.

“I thought that your brother was going to be here today, was there a problem?”  I noticed the tension returning, the puzzle partially reassembling itself on her previously relaxed visage.

“No no, no…, just a cancelled flight, he will arrive tomorrow.”

I nodded, and stood to leave.

“Thank you doctor, thank you so much.  You are wonderful, may God bless you.”

I have never become comfortable, or learned how to avoid the squeamish feeling that came with accepting this sort of praise and thanks from family members.  I operated, literally, under the impression that my personal efforts were usually less important than what the disease, and the patient’s anatomy actually allowed me to do.  However, I understood from experiences with my own family members the relief that accompanied hearing that one of them had survived the very unnatural suspension of conscious thought, and corporeal invasion.

I smiled and replied, “You’re welcome.  Lets work together now, over the next few days in the hospital, to make sure that everything continues to go well.  Let’s get her out of here as quickly as possible.”

She took a tissue from her purse, and daubed her eyes as she sat back heavily into her chair.  I turned to leave, and then remembered, the spots…

I turned back around, and took a seat across from her.

“Can I bother you for a moment more?” I asked.

She looked at me expectantly, “is there something wrong?”

“No,… I’m sorry.  I just forgot to ask you something, if you don’t mind.  Can you tell me anything about those marks on your mother’s body?” I asked, “It was hard not to notice them.  Was she hiding them from me in the clinic?”

“Marks?  Oh…, oh yes, they are maqua,” she replied, “maqua.”

“Maqua,” I asked again, “what is maqua?”

“It was healing – a form of healing that was used when she was younger, in the desert.”

“Are they…, burns?”

“Yes, burns from fire.  It was usually administered, if I remember correctly, by the tribal elders.”

“Did it work?” I asked, not mocking her in any way, but out of a my desire to understand this very modern and educated young woman’s opinion – culturally connected to, but one generation removed from, her mother’s nomadic life.

“No,” she chuckled, “of course not”.  She then looked contemplative, and more serious, “But the belief in this treatment in the desert was very strong in the past”.  She paused for a moment, as if thinking about her next response.  “Yes, she was probably ashamed for you to see them.  I think she is ashamed of many things about her life, you see.  Her children, and her people…, we are… we are very different now.  But the belief was very strong in the maqua, I think, and as a result, perhaps…, it had value.”

After rounds, I made my way up to my office.  It was just getting dark, and after checking my mail and signing some charts, I stared out the large square window to the right of my desk, dominating that wall of my small space.  Although we were in a large city, the medical center was in an area that was more residential than metropolitan.  My office, several stories above the ground, looked out and away from town, into an area without much light on the horizon at night.  I stared out the window at the dark blue void, and daydreamed about the day’s events.

Her body looked more like some sort of antiquity, or museum piece, I thought to myself, than a patient.  And why would she subject herself to those burns?  It seems crazy…

It was as if she were a living relic, a relic that had been literally imprinted by history, history and beliefs dating back for tens of thousands of years, as long as Bedouins had roamed the Negev, and beyond.

I rested my chin on my hand, and continued to stare, unfocused.  The dark blue rectangle of my office window gradually became dark blue over brown, and I then imagined a golden glow at the center, where the two colors met.  My mind moved in closer to the light.  It was the desert at night, and the glow was a small fire.  Orange and yellow tongues of flame leapt from a small spot on the ground, and the breeze intermittently blew tiny grains of sand past and into them, becoming sparks.

I “saw” the figure of a young girl, her back to me, dressed in layers of white and light brown garments, struggling in the grasp of an old man, who was squatting by the fire and holding her arm, the only exposed limb, above the elbow.  There were others about, in a loose semicircle around the fire, but they seemed disinterested, talking among themselves.  The old man placed a stick into the fire, and then removed it – embers glowing hot at the tip.  He then methodically, but quickly placed it directly onto the young girl’s arm, as he chanted something rhythmic, and unintelligible.

She didn’t scream, or cry out in any way, but turned her head away quickly from the site of a small tendril of acrid grey smoke arising from her skin.  Her eyes were my patient’s  –  amber and gold, a burning color, the color of fire.  Heavy tears welled up in them, but she willed them stay there, and not fall down onto her cheeks.  She stared past me, out into the desert, expressionless, silent.

The next day on rounds, in the intensive care unit, I met my patient’s son.

I glanced up through the sliding glass doors which made up the entire front wall of the patient’s room, designed so that no patient in the intensive care unit would ever be “invisible” to the nurses outside at any time, and noted that the daughter was sitting in the far back corner.  Standing in front of her at the bedside was a man who appeared to be at least ten years younger, if not more.  He was handsome, with short black hair and an immaculately groomed, close-cropped black beard.  He was wearing modern western-style clothing – a red and blue tightly-patterned plaid long sleeved shirt, and jeans.  I walked into the room, and he immediately rounded the bed and reached for my hand.  He moved quickly, almost jumping, with a manner somehow reminiscent of a cat.  He shook my hand vigorously, and spoke in staccato Arabic to his sister, without turning to look at her.

“My brother says he wants to thank you, and he praises God for your efforts.”

I noticed that compared to my previous interactions with her, which were animated and cordial, she was speaking in a quiet monotone voice, and not looking up at me.  The brother continued to speak to me, Arabic phrases and words literally spilling out of his mouth – terse, and rapid.  At one point, he turned and shook his index finger at his sister, as if scolding her.

“He wants to know if she is going to live, and if it was cancer.”

“Sure,” I replied, “you spoke to him about this, right?”

She sat silently, looking down at the floor.

After I waited a few moments in vain for her response, I replied, “yes, as you know, it was cancer, but it was removed completely, and she is doing very well so far.”

The son turned to the daughter, and motioned his hand toward his chest impatiently for her to speak.  She spoke to him in Arabic, looking down the entire time.  He replied to her, in angry, pressured speech.

“Is everything okay?” I asked.

The daughter, still looking down, shook her head up and down, signifying “yes”.

I said that I would be back the following day, and that their mother might be able to be transferred from the intensive care unit to the regular inpatient floor if things continued to go well.  As I was turning to leave, the brother again spoke to me, with what seemed like great concern, and building anxiety.  I looked at his sister.

“He wants to know if it was really cancer,” she asked.

“Yes!” I said, a little more emphatically now, “we are sure, we looked at it under the microscope, it was a form of cancer.”

He finally looked begrudgingly satisfied, and so we left.  I looked back and saw him pacing in the room, like a big cat does at the zoo when the enclosure in which it is housed is a little too small.  At the end of each few steps, and prior to turning to pace the other direction, he would look up at us as we walked away, through the transparent sliding doors.

Over the next several days, this pattern of interaction with the son continued.  We would come to see his mother on rounds, and he would stand at the bedside and ask us questions through his now passive and somewhat muted sister, often repeating the same questions three, four or more times, as if we weren’t being truthful, or trying to determine if we were going to change our minds, or our explanations, under pressure.

At times, he would focus on inconsequential or minor issues, such as on one occasion asking us five times whether or not the intravenous fluids were necessary, and occasionally, he would return to the cancer interrogation, repeating the same suspicious questions over, and over again.

He spoke absolutely no English, and his sister would initiate no conversation, nor return any directed to her when they were in the room together.  Although she served as my interpreter, she would only answer questions from me when they were directed to her brother.   I noted on a couple of occasions as I sat at the nursing station, and I watched the two of them leave the room together that she walked several feet behind him, and that she initiated no conversation when they were alone, waiting for him to speak to her.

Throughout this period their mother simply lay in bed when we were in the room, and moaned.  The son would hover over her, occasionally leaning in and yelling something to her in Arabic, but she would only respond by moaning more loudly.  Although I considered myself a patient man, I began to silently calculate how much longer she would be in the hospital.  I assumed that we were going to be able wrap this all up soon, and that I would be sending the patient on her way in the usual period of time associated with this sort of operation.  However, this would not be the case.  The patient, despite steady improvement, proved to be refractory to hospital discharge.  She initially developed a series of small problems that delayed her mobilization – a small wound infection, some abnormal blood work, a little fluid around the lung on the chest X-ray…, during which the daily sessions with her son and daughter continued in a repetitive fashion.

A little over a week post-surgery, as I walked onto the hospital floor to make rounds, I found the daughter standing outside her mother’s room alone, almost on her tiptoes, appearing very nervous.

“Can I have a moment doctor?  I must hurry,” she said, trembling, and speaking just above a whisper, “I am sorry, but my brother thinks I have gone to the bathroom.”

“Sure,” I replied, “is there something wrong?”

“No, no, but I have to tell you that I am leaving tomorrow.  I trust that my mother will be discharged soon, and cannot thank you enough, or God, for all that has been done for her.  My…, my brother will remain until she leaves.  He cares a great deal for our mother, and I hope that it is no trouble.

“No, it’s no trouble,” I replied, “I’m sure that we have some good interpreters, and that we’ll be fine.  We take care of many patients from other countries here, and a fair number from the Middle East, as you know.  Please travel safely.”  I took out my card and handed it to her, “hopefully your mother will home soon.”

She looked at the card quickly, and then stuffed it hurriedly into the front pocket of her jeans, smoothing her hand over the area, as if to hide the fact that she had placed it there.

“If you will excuse,” she asked anxiously, “I must return, my brother will come and look for me.”  She forced herself to smile, turned on her heels and rushed into the room, taking care to open the door only enough to enter, and then shutting it immediately.  I could hear her brother shouting at her inside as I walked past to another patient’s room.

The next day was my first with the patient and her son alone.  The head nurse on the unit where she was staying called me early in the morning, and informed me that there was, to my substantial delight, no on-site Arabic interpreter, and that we would have to call one by phone when I came by to see the patient on rounds.  She suggested a time later in the day when the interpreter would be available.  I arrived on schedule, and the now familiar sequence with the son started, minus the daughter’s involvement.  He met me shortly after I entered the room, shook my hand smiling and began to talk to me in Arabic, as if I understood him – in a low, seemingly friendly voice.  The head nurse came into the room, and we reached the interpreter on the phone in the room.  I spoke to her for a moment, and explained the situation from my perspective, warning her of some of the issues we had experienced with the family dynamic up to this point.

“No problem, doctor, she said, “I am very experienced, and grew up in the Middle East.  I can handle these issues easily for you, don’t worry.”  Her voice sounded very similar to my patient’s daughter’s voice, but much more confident.

I felt momentarily relieved, this might work out after all.  We then proceeded to go through the usual progression of questions from the son, including five separate rounds of him asking if his mother really had cancer.  Within ten minutes or so into the interaction, he was yelling at the top of his voice at the interpreter and stomping his feet, while he frowned darkly at the phone in his hand, holding it intermittently in front of his face, and shaking it.

At the end of an hour-long session, I spoke to the interpreter again before hanging up the phone.  She was still very calm, and reassuring.

“This is not that bad,” she said, “he is just scared, and is not happy that I am a woman.  He asked for a male interpreter, but I told him that would not be possible, and that I was very good, very experienced.  It will be fine, don’t worry, I know what I’m doing, he will get better with me talking with him, you will see.”

Over the next several days; however, the exchanges between the three of us grew longer, and more contentious.

The comments from the interpreter to me after our discussions rapidly transitioned from the previous confident proclamations of “no problem”, to the confused and irritated – “I don’t know what is wrong with this man.”…  “He repeats the same questions over, and over and over.”…  “I am losing my patience”….  “He is demeaning, and says insulting things to me”…  “He has called me in the middle of the night, and disturbed my family, to ask STUPID questions we have discussed earlier.”

Thankfully, as all this unfolding, my patient was steadily improving.  However, when all of us were in the room, she simply lay in bed and moaned, even though the nurses reported that when she was alone, she seemed, “fine”.  Over the next couple of days, I informed the son repeatedly, through the interpreter, that his mother was ready to go home, but he dismissed the concept, or ignored it, focusing on things such as “is there medicine in this plastic (intravenous fluid) bag?”, “are you sure that this was cancer?”, and “is my mother cured?”.

I knew that like most patients from other countries, this family, or at least someone on their behalf, was paying cash for this admission, as the American version of health care insurance was either not available, or didn’t cover treatment outside of the home country.  In addition to trying to get the patient out of the hospital for safety reasons (the hospital is a dangerous place, if you don’t actually need to be there), I was also concerned about the cost to whomever was paying for this.

Another two days passed, and immediately following the most heated exchange yet between the son and the interpreter, she got on the phone with me, her anger transmitted through the receiver like shrapnel after a bomb blast, wounding anyone within range – in this case, I was the only bystander, and I was in range.

“I cannot deal with this man any longer!  NOT…ANY…MORE!  DO YOU UNDERSTAND ME?  NOT ANY LONGER!” she screamed into the phone so loud that I had to hold the receiver out away from my ear an inch or two.

“Uh…, ma’am,” I replied, trying to speak slowly and without any emotion, “I’m on your side here…, I appreciate how difficult this has been for you, and understand, but please just help me to convince this patient’s son to allow us to discharge her.  If we can do that, we’ll all be better off, and I can leave you alone.”

She paused as if considering my request for a moment, and then replied. “I cannot.  I just cannot.  I am sorry.  I can’t.  I CAN’T!  THIS MAN IS IMPOSSIBLE!  THIS MAN IS THE REASON I LEFT JORDAN!  You must understand this… I LEFT MY HOME, AND MY FAMILY BECAUSE OF MAN LIKE THIS!  I cannot do this… I CANNOT LIVE IN THAT WORLD ANY LONGER!  DO YOU HEAR ME!  WE – ARE – FINISHED!”  (Muffled noise of phone being moved around…, then rattling on the receptacle…, then CLICK!…, then dial tone…)

I looked over at the son, across the patient’s bed.  There were little beads of sweat on his brow.  He was breathing quietly, but heavily – I could see his ribcage rising and falling under his dark t-shirt.  He literally looked crazed.  It was as if he was about to jump over the bed and grab me, or at least grab the phone from me.  He was slowly clenching and releasing his fists at his side, and he was leaning forward slightly, back arched.  He reminded me of a big cat again, but this time one that was threatened and dangerous – I fleetingly recalled the uneasy feeling that I had as a child standing next to a tiger’s cage at the zoo as it paced back and forth and looked at me, with cold ancient animosity and silent feline rage.  His mother lay in bed between he and I, moaning.  I noticed her eyes were only half-shut, and that she was watching me.  I also noticed after a few moments that I was still holding the phone up to my ear even though there was no longer anyone on the other end, so I smiled at them, hung it up, and left the room.

The next several days were almost indescribably frustrating.  I spent more than an hour in her room each day when I came by to see her, despite the fact that she had been ready to go home for several days, and I had other patients to deal with – patients that actually actively required the services of a surgeon.  She continued to lay in bed moaning and watching me out of the corners of her partially shut eyes, as I tried to mime words and concepts for the son, and drew ridiculous stick figures for him – of people getting out of bed, and getting onto airplanes, shuffling on board them in my pictures like ridiculuos little inky skeletons.  I even drew the United Arab Emirates shape for him (after looking it up), a sort of reverse “L”, with one of the stick airplanes landing there, full of little stick people, including one that I tried to make resemble his mother. Understandably, he just looked at me repeatedly as if I were nuts, and shook his head.

The nurses on the floor, no longer able to call the interpreter when the son became agitated, began calling me two to three times in the middle of each night.  “I’m not sure what to do,” I replied sleepily, “I’m sorry, I don’t speak Arabic either.  I’m really sorry that you’re having to deal with this, but I’m trying to discharge her, really, as soon as possible.”  At times, I could hear him yelling in the background somewhere nearby, yelling across the room and into the phone at me, it seemed, as if I would understand him.

I began having dreams, actually, no, actually nightmares, about the situation, likely fueled by a combination of sleep deprivation and frustration.  One particularly unnerving and memorable one involved the son actually turning into a leopard.  During the transformation, he snarled, as spots were appearing on his face and arms, “I am going to EAT YOU!” in Arabic, and ironically, this time I was able to understand what he said.  When fully leopardized, he leapt over the bed (where his mother lay, laughing) at me while I was on the phone trying anxiously to reach the interpreter.  Just as he was clamping down on my neck with a suffocating cat-bite, I woke up struggling to breathe – the phone on my nightstand at home was ringing again.

Eventually, my concerns about my patient’s prolonged stay and the costs associated were noted elsewhere.  The discharge planning coordinator for our inpatient floor, her supervisor, and the Chief Medical Officer for our hospital all weighed in, sending me a number of emails asking why I was “extending this patient’s hospital stay beyond what is medically necessary.”

“Because I am enjoying it so damn much!” I replied, not in writing, but yelling it out in my office alone, as I read his very tactfully worded, but thinly veiled accusatory email.

The patient had now been hospitalized for about three weeks, more than ten days beyond what was truly necessary.  During clinic, I explained to Julie the events of the last week or so.  She didn’t often get to see the patients after surgery once they were hospitalized, as she was busy with the outpatient part of the practice in the clinic.

“Jeez,” she said, “that’s really crazy… what are you going to do?”

“I was thinking of moving in the middle of the night, and under the cover of darkness to another city,” I replied.

“That seems a little extreme,” she laughed, “say…, what about that little stocky dude, you know, the doctor that was here when they first visited?  Has he been around?”

I had completely forgotten about him.  “No, not to my knowledge, but if he had been during the last few days, I would have noticed it because I would have asked him to interpret, and I would have gotten a hell of a lot more sleep.”

“Do you think he could help get her discharged?” she asked, “why don’t you just call the embassy, see if he is around, and can do something.”

I called our hospital’s International Relations Office the next morning and was given the embassy number, as well as a person to ask for – not the doctor himself, but someone I was told would know how to find him.

I thought I would go by the patient’s room, and try to communicate my plan to the patient and her son before I called, just on the off chance that things moved quickly.  I wasn’t particularly optimistic that I would be able to do so, but thought that regardless the problems with communication, they still deserved a chance to know that they might be discharged soon.  As I walked over, I contemplated whether or not I would be able to draw a stick embassy, or perhaps a stick figure short stocky doctor with a giant mustache, and almost turned around and went back to my office.  It was much earlier in the day than usual for me to see patients in the hospital, and when I walked into the room, I found my patient alone, for the first time since she was admitted to the hospital.

She was sitting up in bed watching television, but when she saw me, she quickly switched it off with the remote, closed her eyes and began moaning.  I walked up to the bed and stood there.  I realized that with the language barrier, her obvious mistrust, and the family dynamic that I really had never really connected with her as a patient.  For some surgeons, this is the actual goal – not connecting.  It is admittedly emotionally safer that way, and more efficient.  The existential ramifications of the death of a stranger, even if your patient, is easier to deal with than someone you know.  That being said, I had never really been comfortable with that approach.  I had always found the human connections with patients to be the most rewarding thing about being a cancer surgeon, and therapeutic for me even if the only thing that really mattered to the patient was whether or not the tumor came out.  In actuality, I didn’t believe that any patient actually felt that way either.  We are all social animals, and the need for human touch, interaction and understanding, always present, is heightened during the vulnerability that accompanies illness.

This may be my last chance, I thought.

I reached down, and gently touched her arm.  She reflexively drew away, shook her head from side to side, and moaned.  I tried again, and this time rubbed the back of her arm, gently with my thumb, directly over some of the burn scars.

“Maqua?” I asked.

She stopped moaning, opened her eyes and looked at me, but didn’t pull away.  She seemed stunned.  It was the first time we had held one another’s gaze since that day in the clinic, when she had eyed me so suspiciously.

“Maqua?” I repeated, pointing to the spot on her arm.  Then, I had an idea.  Worth a try, I thought.  I pointed again to the spot, and then to my own chest. “Maqua…,” I said to her, “maqua”.

Her expression softened, and she looked down at her arm where I was touching her, and back up at me again.  I noticed again the amazing color of her eyes – like reflected fire in the desert, no longer ghoulish, but beautiful.  For a moment, I saw the face of that young girl again, the young girl from my imagination I had “seen” in my office that night after her operation, now several weeks ago.

There was a faint smile, the first one I had seen on her face, as she looked up at me and repeated, almost at a whisper, “shukran…, shukran…, shukran.”

When I returned to my office, I called the embassy, and in a few moments heard the familiar voice of the doctor from weeks ago.

“Ah! Doctor!” he said, happily, “how is it going for you?”

“Okay, thanks,” I replied, “this is Dr. Smythe, the surgeon that operated on the woman from the Emirates with an esophageal tumor.”

“Yes, yes, of course, of course!” he replied, “I know you, we are good friends!”

I hesitated for a moment, and then went on to explain the dilemma I was having getting her discharged from the hospital, and hopefully, on her way home to the Emirates. Although I didn’t go into detail, I mentioned that there had been some communication challenges.

“She is ready?” he asked, his voice suddenly sounding very businesslike.

“Yes,” I replied, “she could have left some time ago, actually.”

“DONE!” he confidently replied, “DONE, DONE and OVER!”

“Really?” I asked, incredulous.

“YES, OF COURSE, OF COURSE, DONE!” he emphatically repeated.

“Okay…,” I said, trying to sound upbeat, “Say…, by the way, can you tell me what the Arabic word ‘shukran’ means?”

“Sure,” he replied, and laughed, “it is what you will be telling me tomorrow, my friend!  It is, simply, “thank you”.”

The “Bedu” have developed, in literature and legend, a romantic legacy of graceful restlessness, as well as harmony with their desert surroundings, despite a lifestyle that was demanding and unforgiving.  In modern times, almost all of them have abandoned this mode of living, and although millions in the world are of Bedouin heritage, the majority have been assimilated into more sedentary modern society.  It is fair to say; however, that the fame that they garnered in past times was deserved – an uncanny ability to move great distances, from one locale to another, and to then somehow disappear, leaving no trace of having been there, no marks in the sand.

The following morning, she was gone.