medicine

The bird of death, the bird of love

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When I went to see B for the last time, his parents were in the hospital bed with him, his mother beside him, his father squeezed crossways at the foot of the bed. They were all barefoot and his father had one hand on his wife’s foot and the other on B’s foot and I could see how similar they were, these two sets of feet. Genetics alone do not a parent make but there is something about the uncanny likeness of parent and child that always catches in my throat. I felt tentative, worried about interrupting this intimacy, but his father waved me in, smiling. I had just finished my first call as a supervising resident on another floor and I was exhausted, pungent (can other people smell the post-call smell?), still roiling from the overwhelming responsibility that had abruptly been mine overnight. I was wearing one of C’s sweatshirts, several sizes too big, and an old maternity shirt, the middle deflated around my no-longer-pregnant belly, for luck. “Your first day as a senior resident and that’s what you wore?” B’s father quipped. I had to laugh. He had taken an unusual interest in me and his other providers and the workings of the hospital and as a result I had shared more than usual with him about myself and the challenges of residency.

It was to be the day of B’s death, the day his parents had decided to withdraw the care that was keeping his lungs expanding and his heart beating but doing nothing to reverse the irreversible damage to his brain. It is a cruel and unwarranted term — “withdrawal of care” — and it’s more politically correct cousin “withdrawal of support” is not much better. A better term might be “the hardest thing you’ve ever done or will ever do in your life” or “the ultimate act of putting your child’s needs before your own” or at least “releasing your child from the pain of futile interventions.” I was expecting the mood in the room to be very dark but B’s parents’ tears were intermixed with funny memories of their son, pride in B and in the family they had built together, and so much tenderness.  We took turns playing a little word game that B had liked to play. We talked about the course of his ICU stay, the milestones of hope and despair, the various providers they had interacted with along the way. We talked about their children, about my child, about parenthood. I could tell from our conversation that we might not agree if the topic shifted to politics (when they asked about my husband, instinct told me to go along with it instead of doing the whole “actually I have a wife” thing), but they were the kind of parents I aspire to be — thoughtful, generous, loving, engaged. As we talked, I held B’s hand. It was the first time I had touched him without a clinical purpose.

There is an inherent asymmetry to the relationship of doctor and patient. I touch my patient’s bodies along their entire length, examining their cavities and contours. I witness their tears, their anger, their caresses, ask them questions about their families, their diet and personal habits, their sexuality, whereas they neither touch nor see nor know almost anything about me. There is also an uncomfortable power dynamic related to knowledge, whereby I often understand the context and trajectory of their illness better than or before they do.  Try as I might to communicate the facts and my impressions, there is often an unbridgeable gap that is the product of the sheer complexity of the medical situation or the emotional context which causes patients and parents to receive information in a particular way. There is a certain trading back and forth of significance and anonymity. Sometimes I walk into the room of a patient I care deeply about, about whom I have spent a lot of time thinking and talking with other doctors, and it is clear to me that they have no idea who the hell I am (“I’ll have to call you back,” they say into their phone. “The nurse is here.” Proving that gender is still complicated here in 2013.)  I am one of the dozens of faces that are passing through their lives at a stressful time. On the flip side, sometimes I am stopped in the elevator or the hospital lobby by a parent who tells me I took care of their child on so-and-so floor and I am disturbed to realize that I have no memory of them. They are one of the dozens of patients that have passed through my life at a stressful time.

Then there is the awkward question of love, which I feel toward my patients but which cannot be spoken. I wanted to tell B’s parents how much I admired the strength of their love and care for each other in a time when guilt and blame could just as easily rule the day. I wanted to tell them how deeply I mourn for their son and for them. Holding B’s hand I wanted to whisper, “Go in peace, beautiful boy.” But instead I just said, “I have been thinking of you all” and hoped that they would somehow understand that I was feeling for them and with them, beyond the blood pressures and infusion rates and MRI findings.

The moment came when it no longer made sense for me to linger. I said goodbye and then we talked a little more and then I said goodbye again. I was halfway out the door when B’s dad called back to me “Be the best parent you can be.” I turned to him and nodded and awkwardly put my hands over my heart. There was nothing more to say.

I once heard a Zen saying: Live as if death is a bird always on your shoulder. No one likes to talk about death and certainly not the death of a child, but I think it’s bound up with love, especially parental love, in ways that people don’t acknowledge. The passionate, euphoric, desperate love of a parent for a child contains within it the terrible awareness of how much might be lost. If I were to face that loss, I would want to be able to say to myself, to my partner, to my child: I loved with my entire self, as well as I could.

B passed away a few hours later as peacefully as possible. I will probably never see his parents again but I think of them almost every day as I kiss E’s neck  and tumble with her on the bed and listen to her breathing from the door at night and try like hell to do a good job at being her parent. On one shoulder the bird of death, on the other the bird of love.

Resonance (magnetic and otherwise)

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It’s the holiday season once again. I am in a Starbucks enduring the overdriven cheer of the Starbucks Christmas album. As sometimes happens, I am struck by a moment of gratitude for my job. There’s lots to complain about, but I don’t spend six straight weeks listening to synthesized sleigh bells and Frank Sinatra wannabees crooning about the most wonderful time of the year. When it’s my turn to order, I try to share a moment of fellow feeling with the employee behind the counter who is wearing a baseball cap from which two plush reindeer antlers emit. “If I had to listen to this album over and over again, I would go insane,” I say. “Oh, it’s not so bad,” she says, cheerily, “I love Christmas!” It occurs to me that she may be wearing the hat by choice. As often happens, I am struck by a moment of personal disorientation: Am I a huge Scrooge who needs to lighten up  and feel the spirit or a lone prophet screaming truth into the wind as human civilization crumbles? I am neither. I am a very tired person, about to enjoy a mocha latte in the middle of the afternoon as a group of undergraduates beside me discuss the precise definition of usury for their take-home final. In other words, it’s the most wonderful time of the year: vacation.

Some people spend their vacations in places like this:

woman bikini

(Note: this is exactly how I look in a bikini, only not as good.)

Whereas, I am spending my vacation here:

physical therapy 1

in physical therapy.

It’s a long story, but I’ll make it short: Sometime during pregnancy or after, my left sacroilliac joint became too loose. You don’t really notice your sacroilliac joint in the course of life until it’s too loose and then every third or fourth step becomes excruciating. The pain started at the end of May during our move and has slowly chipped away at my ability to function at life’s core tasks — picking the baby up, carrying the baby, and working, to name a few. Up until several weeks ago, I had the full expectation that this pain would resolve on its own if I just didn’t think about it (note: denial is up there with gravity in terms of forces that are strong). Then I started needing a cane to walk at the end of the day, at which point C gently informed me that it was time to seek medical attention. (As I have mentioned before, marriage saves me from myself again and again.)

The calculus of life being what it is, the total breakdown of my physical vitality happened to coincide with the most challenging rotation of intern year: the neonatal intensive care unit or NICU. I had been dreading the NICU ever since I chose pediatrics. The schedule is grueling, the knowledge base is totally foreign to the rest of pediatrics, and the ethics are complicated. Babies are being resuscitated as young as 23 or even 22 weeks gestation now and many of these babies go on to have a number of chronic medical conditions, including cerebral palsy, blindness, chronic lung disease, developmental delay, and hearing impairment. Then again, some percentage of them go on to be normal, happy children and there is no way to tell in advance which babies will have good outcomes. Even for those who don’t, it is impossible to objectively determine what level of quality of life merits investment. Where is the line between the mercy of sustaining life and the mercy of letting go? Millions of dollars are spent sustaining these fragile lives in their first weeks and months. From afar, it seemed like an ethical quagmire best avoided. But the calculus of life once again being what it is, it turns out that I love the NICU. As in: I think I may become a neonatologist, the one thing I absolutely knew I would never become.

What I didn’t realize about the NICU is that when you work there, you attend deliveries. When there is any concern about a baby that is about to arrive — a maternal fever, a concerning fetal heart tracing, a mother who did not have prenatal care — pediatricians are called to be at the delivery, receive the baby, assess and rescuscitate them as needed, and decide whether they need to be admitted to the NICU or not. In our hospital, pediatricians are present at about 40% of deliveries, which works out to 2,000 deliveries per year, or an average of 5.5 deliveries per day. That’s 5.5 babies per day who are delivered into the arms of a pediatrician. What greater honor, what greater work could there be than to be that pediatrician? The delivery room was the site of my first contact with the world of medicine as a doula and it was that experience that made me decide to become a doctor. So things have come full circle. For me, it’s been one of those rare moments when the narrative of life seems to make sense after all.

There are other things I love about the NICU. One the one hand, there’s the acuity and the pace of an intensive care unit. The actions you take as a doctor there have the potential to be lifesaving in real time and that feels satisfying. On the other hand, a percentage of the babies at any given time are just feeding and growing, and might spend anywhere from days to weeks to months in a stable state as NICU patients, so there is the opportunity for a longitudinal relationship. It’s like doing intensive care with a little side dish of primary care. There’s also the opportunity to interact with parents in the most fragile, nascent stage of their parenthood. As a recent new parent myself, there is a river — a huge, gushing river — of empathy and tenderness for these parents, whose entrance into their new role is not made easy by the NICU environment. I can’t pretend to know what they are feeling, but I imagine it is a mixture of gratitude that the child is alive and mourning for the normal course of things that was expected. I want to be one of the people who help to ease this time for them. Mostly, though, I just love the babies, with their impossibly tiny yet perfectly formed fingers, their totally distinct and individual faces, their resolute presence in this life against all odds. I am reminded of a speech by one of my favorite authors, Haruki Murakami, as he accepted the Jerusalem Prize. He was speaking, bravely, about the Palestinian cause. “If there is a hard, high wall and an egg that breaks against it, no matter how right the wall or how wrong the egg, I will stand on the side of the egg.” I’m not sure the analogy is perfect, but it’s the closest to describing how I feel as I peer into the isolettes each morning at these little humans whose life is a complicated gift: I will stand on the side of the egg.

But back to the pain in my ass (which is, by the way, the technical term for the sacroilliac joint). So by day I’ve been, you know, helping to save the lives of babies. By, night, I’ve been hobbling on a cane, barely able to climb stairs, writhing every time I have to lie down or get out of bed. I went to a specialist who got X-rays that showed osteitis condensans ilii, a non-specific benign sclerosis of the sacroiliac joint which happens in women who have borne children as a consequence of the stresses of pregnancy. Aka: things I already knew. She sent me to another specialist who ordered more X-rays, an MRI, some labwork, and physical therapy. In regards to the MRI: let’s just say it was not something I was looking forward to.

I scheduled the MRI for a Sunday, my only day off. The hospital was quiet, stripped down to only essential staff and essential activities. Weekends and nights are my favorite times in the hospital for this reason: less hierarchy, more just taking care of people. The radiology reception area was dark with just one light behind the employee assigned to register patients that day. She took my information and handed me a gown. I stripped down to my bare skin then signed a form swearing a blood oath that I wasn’t harboring metal anywhere in my body.

I was almost to the MRI waiting area when I realized I was still wearing my wedding ring. It’s not a thing I like to be without, especially when faced with 30 minutes in a tube, but off it went, leaving behind a dent in it’s sacred spot on my finger. When the tech came to get me from the waiting room, I was in fending-off-anxiety-with-cheer mode. As I chatted (how can something bad happen to you when you’re being charming?), the tech scanned my consent form and paused over the only “yes” answer. Are you claustrophic? Yes. Yes I am. Not so much claustrophic as claustropanicdisordered. Claustro-catastrophically-freaked-out. “You’re claustrophic?” she asked, weary. “Yeah,” I said, “but I’m thinking I’ll be fine.” She got me situated on the narrow metal table and gave me a plastic bulb to “squeeze if you need me.” She started to roll the bed into the tube and my entire field of vision was engulfed by beige metal, only three inches from my face in every direction. “Get me out,” I squawked in the most controlled voice I could find, “Get me out!” She rolled me back. “How about we turn you around and put your feet in first,” she suggested. “Jesus Christ,” I wanted to shout, “Yes, fucking yes. Who wouldn’t choose that option?!” But instead I said, “Hmmmm, yes, let’s try that.” My body went into the tube and as my neck approached its mouth, I shut my eyes and resolved not to open them for the duration of the test, which turned out to be harder than I thought. The human organism is not a fan of constraint.

Lying in the tube with my eyes closed, I could not escape the thought: “We are born alone and we die alone.” In the interest of full disclosure I will say that I have this thought with relative frequency (normal? abnormal? unsure) and it is a source of both anxiety and comfort. But lying there, holding my emergency bulb and willing my eyes to remain closed, it felt closer than ever, the irreducible reality of every being’s solitude. There are things, moments, feelings that are unshared and unshareable. Naked under my gown I thought of all the babies I have seen emerging from their mothers this month, equally unprotected.

The machine began to make loud rhythmic sounds — buzzes, vibrations, fizzes, and clangs. It was beautiful. I wanted to record it, to play it for C at home, but then realized no recorder would make into this metal-free room. (See above: re: the unshareable.)

“You OK?” the tech asked. “Fine,” I said, watching the fractals behind my eyelids.

I was afraid to fall asleep, for fear of waking up and opening my eyes by accident. So I just experienced the time passing. I thought of C who has spent time in a sensory deprivation chamber and loved it. Um, no, I thought. No thank you. Sensation is much to be preferred as far as I’m concerned. But I was doing ok. We are born alone and we die alone. And nobody knows (tiddly pom) how cold my toes (tiddly pom) how cold my toes (tiddly pom) are growing. Between scans, I turned the emergency bulb over in my hand to make sure my hand was still there.

Then it was over. I’ll say this: I wouldn’t do it for funsies, but it’s not as bad as I feared. Just make sure they slide you in feet first.

The MRI was normal — no spinal tumor, which is what I thought I might have all along and which is what I think was secretly preventing me from going to the doctor all that time. I’m embarassed to admit it but it’s true. So on to physical therapy or rather on to three weeks of waiting for my vacation so that I could have physical therapy, which only occurs during business hours. Meanwhile, I attended deliveries, did my first, second, and third lumbar punctures, intubated a patient, placed two central lines, rounded and rounded and rounded and rounded and rounded, fell more in love with neonatology, barely saw my own baby, didn’t have a day off for 17 days in a row, and finally came out on the other side: vacation! So now I’m here in the Starbucks after my daily physical therapy session with my mocha latte. I can’t really remember life before now, but I think it’s the best vacation I’ve ever had. (Actually, I do remember some of life before now and I have had better vacations (ahem, Paris) but this sounds good and brave so I’ll leave it in.)

It turns out, my core is very weak. The muscles of my core are not stabilizing my pelvis and so one tiny muscle, the piriformis muscle, is doing all the work and has become too tight and is pulling the sacroilliac joint even farther out of alignment. It’s a vicious cycle of core weakness and pain. As a poet for whom language is allowed to expand and expand, I am of course concerned that this reflects a weakness in the core of my being, rather than just the core of my pelvic floor, but I don’t have time for psychotherapy in addition to physical therapy, so we’re sticking with the pelvic floor for now. Maybe the one will take care of the other. My therapy consists of a series of exercises involving subtle contractions of my abdominal muscles, a few stretces, and one exercise in which I sit on a huge exercise ball and pretend to unsheath a sword and fling it high in the air sixty times on each side. Also, before my exercises, I spend ten minutes on a treadmill walking backwards (if that’s not a metaphor, what is?) and then the physical therapist gives me a butt massage. It’s not the Bahamas, but it is covered by insurance.

It’s 1:16pm now and my parking meter expired 16 minutes ago, so I guess I’ll go home now and tidy up the house (aka put everything in the closets) because the cleaners are coming, then I’ll go pick up my daughter from day care (pure bliss! pure bliss!) and we’ll play and eat and bathe and go to sleep. I’ll say this for intern year: it robs me of my life but then, for three weeks of the year and assorted weekends, it gives it back to me as the sweetest gift imaginable. And so this is my holiday wish this year for you: that you too will know your very own life, in all its banal details, to be the sweetest gift. (No ninety-hour work week required.)

Happy merry hannukahkwanzaamas!

Fracture Lines, Suture Lines

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E broke her arm last week. That’s not entirely accurate. She didn’t break her arm. Her arm was broken. But no one broke it. The most accurate way to describe the situation is: There is a fracture in E’s left forearm. Yes, our ten month old is currently sporting the world’s most tiny cast.

How did it happen? The truth is: we do not know. C dropped her off at day care one morning and she was fine. When she picked her up that afternoon, she was refusing to crawl. No one could offer us any history of trauma or episodes of unusual crying. No one noticed that she couldn’t crawl. Did it happen hours or minutes before pick up? We have no way of knowing. In the day care’s defense (just for the record, there is no defense), she was using the hand for all the usual eating, playing, grasping, and pulling up, just not crawling.

For several hours on the way to the ER and awaiting the X-ray results we wondered whether someone had hurt her. I knew a new kind of hysteria: the hysteria of unfocused rage. But the fracture turned out to be of the type caused by falling on an outstretched hand, most likely from some height. So no one hurt her, but someone did not supervise her adequately, someone did not catch her as we catch her 20, 50, 100 times a day.  She is lumbering around on her first legs and a set of capable arms needs to be constantly at the ready.

When I tell people what happened, there is a shocked pause. I can actually hear the person on the other end of the phone processing a moment of deep doubt at our parenting abilities. Even those who love us most cannot get on our side on this one.  “I’ve just never heard of this happening to a baby before,” they say. “Oh, it’s actually quite common,” I say, in my pediatrician voice. But the truth is, I’ve never heard of it either. I’ve read about it, seen it in older children, but it’s never happened to someone I know at such a young age. What can I tell them? We love E beyond all bounds of imagining. We took her to day care and something happened there. We are doing the best we can.

Maybe no one is judging us. Maybe it’s just me that is judging us.

Having to take your child to day care is a compromise. You can dress it up however you want—she loves being social (she does), she’s bored in our house all day (she is)—but the truth is that placing your child in the care of near strangers does not feel right. Added to that core uneasiness is the Herculean task of finding a spot at a day care and affording said spot. When we were looking, most of the places I called had a waiting list of 8-12 months or cost more than our monthly rent, or both. We needed day care in two weeks. When we visited the Day Care That Shall Not Be Named, I liked some aspects about it, but it seemed a little threadbare, glued together around the edges. But they had a spot and the director was a warm person. C was starting work in one week. We signed up.

In retrospect, it seems unimaginable that we settled for less than the best, but we were up against a reality that felt impossible. Every day these days feels like that old cartoon where the sailor is trying to keep his boat afloat by sticking a finger in one of the many leaking holes. Perfect is no longer an option. After the fracture, I sent an SOS email to a group of my fellow doctor moms asking for child care recommendations. I got twenty-five emails in three hours with stories of child care disasters, near misses, and last minutes switches. It made me feel a little better. We are all trying our best.

E is her usual sparkly self. She is crawling on the cast, continuing her quest for bipedal mastery, avid as ever for discovery, for novelty, for height. Every time I look at her little cast, two thought-sensations run through my head. How could I have let this happen? Followed by, thank god it wasn’t worse. The dual mantras of parenthood.

Needless to say, we are looking for a new day care. In the meantime, my parents are stepping up as they always do with extra days of child care each week and we are bleeding money through every orifice hiring our wonderful but expensive babysitter for the rest of the days.

It takes a village to raise a child, but sometimes you have to move to a new village.

*             *             *             *

Did I mention that things these days are pure desperate madness? Still there are these moments of grace.

I am on my way to present a poster at one of the national pediatrics conferences. The conference is happening in New Orleans. When I tell people about it, they are of course excited for me. “How exciting! You get to go to New Orleans!” What I am thinking is: “Can’t they plan the national meeting in a major air travel hub where people I know live?” Boston? Washington, D.C.? Chicago? It is clear that the planners of the conference are not interns with small children supporting a family on one and a half incomes. There are no direct flights. I got up at 5 a.m. to catch an early flight, will present my poster this evening at 5pm and will be up at 5am again tomorrow to fly back. My main goal for the trip is to get back to the hotel by 9pm so that I can get eight straight hours of sleep for the first time in 18 months. When I heard there was an evening cocktail party that I “should attend for networking purposes,” my first thought was: “Doesn’t anybody care about me at all?” Hard won wisdom: Chronic sleep deprivation results in irrational egocentrism. Don’t get me wrong: I’m honored to have been selected to present and there are always interesting things to be learned at these conferences and there are worse things than spending the night in a nice hotel.

In my prior life, I would never, never have planned a flight that required me to be up at 5am. These days, I am excited because will be no traffic on the way to the airport. This shift in perspective is one of the ways I know that I will one day die.  I browse the New York Times from 6:10-6:15am while eating my off-brand Greek yogurt. Me time! I throw the dental floss in my bag on the way out, imagining flossing my teeth in peace while watching HGTV on the hotel TV. More me time! On the other hand, I should probably use the time to catch up on overdue discharge summaries.  Work-life balance should be called work-life death match.

On the way to the airport, I listen to Shawn Colvin’s rendition of one of my favorite songs, Bob Dylan’s “You’re Gonna Make Me Lonesome When You Go.” It’s a live version. It’s not perfect. But it gets to me. Something in the strumming. Plus, heartache and bittersweet love loss is more convincing to me in a female voice. That’s just me. I lost my glasses somewhere—I think I gave the case to E to play with in the stroller at some point—so I have to slow down at each sign to decipher how to get to economy parking. The person behind me is clearly unhappy, but really, I am incapable of caring about it. Here is one thing that being an intern and a parent have given me, and pardon my language: I just do not give a fuck what other people think anymore.

For example, none of my clothes fit. I lose a size every 2-3 months since E’s birth and I’m not complaining about that, but my clothes budget cannot keep up. So I’m wearing the size 12 stuff until the weight loss plateaus and it’s safe to go shopping. My pants are constantly in danger of falling off mid-stride. Also, under my “loose-fitting” jeans, my legs are incredibly hairy. This might be TMI, but see above re: I’m kinda past that. I have not had an hour to get my legs waxed since mid-August. This morning I tried to shave them in preparation for the conference presentation — it’s going to be 80 degrees in New Orleans. Don’t these people understand that I’ve transitioned to the cold weather hair management schedule? (see above re: egocentric irritability) — but I discovered that the only razor in the house was dull. So there is just a single strip of socially-acceptable, hairless girl-leg on my left shin. No matter: I will wear black tights under my “loose fitting” dress. Problem solved.

Anyway, I pull into economy parking and this beautiful song is playing, and the sky is just turning from black to blue. The airport shuttle pulls up to the nearest stop, but I decide to finish out the song (see above re: me time). I allow myself to imagine getting on a random plane and ending up somewhere else, but the fantasy holds no appeal. My two loves are at home in bed and that is where I most want to be. I start to cry. Why? Because I am so, so tired.  Because in that moment I remember the dreamer traveler that I used to be and I miss that person. Because I am alone but never really alone. Because I am so grateful for my little family. Because I fear losing contact with the sublime forces in the world but I haven’t yet.

*             *             *             *

I’m working in the newborn nursery this month. What this means is that every 5-90 minutes a brand new human being is delivered into my temporary care. Day of life zero! No amount of mindless bureaucracy (so. much. paperwork.) can dull the wonder of it. Here are some of the observations I have been able to make:

1) Every human being grew inside a women. This is self-evident, but cannot be too-often noted and celebrated. Even more amazingly, the majority of us emerged through a vagina. Crazybeans!

2) A person’s unique selfhood is present from the very beginning. You need only examine twenty newborns a day to begin to feel that nurture pales in comparison with nature in determining life’s trajectory. Each of them is so resolutely themselves already! Here is what I take away from this: Relax, my fellow parents. Keep your children alive and they will largely do the rest. Ok, don’t let them have everything they want. But go out to the movies once in a while! Our children’s lives are intertwined with ours but they are also separate. In the first few minutes, hours, and days of life, you see this best. The mother is trying to recover, awkward, exhausted, labile, high and bereft. The baby is awash in sensation, ravenous, and knows no clock. The needs of the mother and the baby are at odds but yet they are uniquely suited to fulfilling each other’s needs. This complicated dynamic continues for life as far as I can tell.

3) Evolution works. Evolution is majestic. How else to describe the skull sutures that remain unfused to allow the baby’s head to pass through the birth canal? Every time I examine a new baby’s head, the pulsing spaces between the skull plates shock me anew.  Sometimes the plates even override each other like the tectonic plates deep beneath the ocean beds. Evolution found the point of intersection between the maximum brain size and the minimum pelvis size and so our skulls mold to fit the exit tunnel. You can always tell a baby who was born by planned C-section because their heads are perfectly round. I wonder if this creates a new existential category of human: people who have not had to yield in order to come into this world.

4) There are too many babies being born. Too many people have too many children. How will the earth support so many people? I’m not sure what to do about this. I guess we’ll just have to wait and see what happens. Meanwhile, maybe I’ll have another one. What’s one more?

Which brings me to the most disturbing side effect of working in the newborn nursery: it makes me want to have another baby. Not at some point in the future, but now. This is proof positive that the reproductive drive is a subcortical process. Or a mental illness. Thank god C and I cannot get pregnant “by mistake.” On the other hand, I wish we could get pregnant “by mistake.” But thank god we can’t….. and so on.

The newborn physical exam is one of the most important tests a human ever takes. It is the test that asks the question: Were you made correctly? It contains a number of check boxes that need only be checked off once in a person’s entire life. Once you’ve verified that a baby’s anus is patent, it’s a question that never needs to be asked again. Ditto with the cleft palate. Five fingers and toes. Closed neural tube. I love examining a brand new baby. They are a text that has never been read before.

When I examine the babies I catch myself calling them by E’s pet names. “Hi smoosie boosie,” I say. They cry and undulate and then suddenly open their eyes and regard you with an expression of sober contemplation. Are these a phalanx of anthropologists from another dimension, you wonder? Then they are back to rooting and burping up milk. “Hi boose boose,” I say as I run my hand over an oddly shaped head. “Who is gorgeous?” They all are.

*             *             *             *             *

Once in every ten days or so, E forgets entirely what is supposed to happen in the middle of the night. What is supposed to happen is that she awakens crying, drinks a bottle, and effortlessly falls back asleep. What happens on these fluke nights is that she awakens, but instead of crying she gives us the biggest smile you can imagine and starts clapping your hands. How can one gesture evoke such delight and at the same time such desperation? Hand clapping is the sign that you are basically screwed from a sleep perspective.

Last night was one of these nights. Ordinarily, we try to put her back asleep. This process can take 1-2 hours, is accompanied by lots of crying and dramatic thrashing about, and leaves you feeling more exhausted than if I you simply stayed up all night. Last night, after several rounds of unsuccessful rocking in C’s arms, I decided to just go with it. Was I secretly excited at the chance to spend some stolen time with E? I was. I work a lot of hours and my time with E in the evenings is all tasks. Dinner time, then bath time, then bed time.

I took E downstairs, turned on the light, and sat down with her in front of her toy box. There were still tears on her cheeks from the sleep attempts. She took a few seconds to adjust to the light and then spent several more seconds with her mouth open, trying to figure out what the hell was going on. Then slowly, she figured it out—Playtime! No more sleep attempts!—and her face was transformed into an enormous, electric grin that I hope is the last thing I remember before I die. She lunged into my arms, so grateful, so excited. We turned to the business of stacking blocks and using them as eyeglasses. I brought a pot in from the kitchen and she played a new game: Earnestly Filling a Pot with Objects. She is capable of an astonishing degree of attention and she spent 20 minutes exploring the buckles on her stroller, every so often looking at me as if to say, “Are you seeing this total and complete awesomeness?!” and “Is everything I’m doing ok with you, Ima?” I got to watch her, tickle her, laugh with her, catch her as she tumbled about with her little purple cast clanging against the sides of things.

The nice thing about parenting is there is just so much time for things to happen. It is the most time-intensive relationship in life. You spend hours upon days upon months in the constant company of your child. Every once in a while, at an unexpected moment, your orbits go into perfect phase. It’s like you’re on the best date of your life, where everything you say is funny and everything the other person says is smart. That was us last night, just enjoying each other in the pool of a lamp’s light in the otherwise sleep-silenced night.

I may not always be winning the work-life death match and but E and I are still what we are to each other, two people who were at one point separated by the thickness of only one cell. We are separated now by time, by my responsibilities, by her curiosity about other people and other things and that is how it should be. Her life is her own. I’m just here to catch her when she falls.

Long time no

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I haven’t posted in over a month. Every day, after I have worked from 6-6 or 6-7 or 6-9, driven home, bathed and put Little E to bed (on the days when that is possible), I am faced with a “decision”: stay in bed or get out of bed and try to do something. Invariably, E has placed her tiny hand across my arm as I hum our bedtime song over and over again and I am so deeply exhausted that there is really no decision. I slip into the comfort of sleep leaving the rest of me fallow for yet another day. The sleep I get from 8:30pm-midnight beside my baby is the sweetest and the only reward I have these days and I am reticent to give it up, even for just one day, to get my shit together in life’s other domains. And so: no writing. No responding to emails, no exercising (I am about as strong and vital as a bowl of tapioca pudding these days), no doing writing for the research projects that I am still ostensibly participating in. Just sleeping, waking, working, and doing whatever small amount of mothering I can do in the hours between.

It is hard to know whether to tell the truth about internship. Doing so seems like a betrayal, but of whom? As in any hierarchical culture (think: the military), there is an unspoken taboo against speaking out about how it feels to be at the bottom of the pile. We instinctively identify with the system that we are trying to enter and to speak about its flaws is to risk being exiled from it. The first rule of intern year is: You do not talk about intern year.

But, I did not join the military or fight club. I decided to become a doctor, a healer, a person tasked with the care of those who are suffering. And right now, I am exhausted, uninspired, and in an unhealthy place physically, spiritually, and emotionally. I find myself wondering about the merits of the current culture of medical training, whether it produces the kind of doctors we want caring for us, whether it is the system or me that requires reform.

So here’s the truth about internship: It’s really, really hard. I have never felt so exhausted, so consistently pushed past my limits. After a lifetime of working to cultivate an open heart that is strong enough to face suffering, I find that I have to encase it is armor just to survive the days. There is just no time to process and integrate everything that I am experiencing. Instead of being wiser than ever about people, I am less and less wise, harsher, more judgmental, and less patient. I am in constant physical pain, unable to do the exercises and get the rest that I need to keep my back healthy. I resent my job every day because it does not allow me to be the kind of parent and spouse that I want to be. I began this path hoping to become a strong warrior, guide, and advocate for those who are suffering and now find that I am the person who is suffering, who is in need of guidance, of compassion, of healing and recovery. Perhaps this is the deeper intention in this training model?

Medical residency was at the start designed for unmarried men who committed to live in the hospital for the duration of training, hence the term “residency.” There is much nostalgia in medicine for the time when the ardent mission of medicine was all-consuming. There is certainly precedent for this kind of professional training. In prior times, apprenticeship in many fields required a period of servitude to a master, often of a live-in nature. Perhaps the gravity and complexity of medicine requires a period of complete 100% commitment in order to master. In which case, perhaps 32 year old people who are also parents and spouses are simply ill-suited to the acquisition of this profession.

But then I think of all the other people in the hospital–nurses, psychologists, chaplains, radiology technicians, the list goes on and on. These people are all protected with respect to the amount of time they are expected to work. In fact, it would be considered unsafe for many of these people to work more than a certain amount per day or per week or per month. How exactly are doctors different? Are we immune to the effects of chronic exhaustion and life deprivation or do we just think we are? I get that doctors are the people who have to made difficult decision and judgements in the toughest moments for very sick people. I get that some training under pressure is necessary to be able to rely on people to consistently make these decisions correctly. But does it have to be so relentless for so long?

I challenge myself to think of a better training model, but to be honest, I am simply too tired. My brain is in survival mode. I guess the best thing to do is to keep my head down and keep going day after day, and hope that when it is over, the person I was is still in there somewhere, ready to care and feel things deeply again, ready to find a sustainable balance between service and self-care.

Work/life

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I have not posted for a while. I have been up to my ears in the work of intern year. Really, intern year is over my head and I’m trying to swim towards the top. Overwhelming doesn’t begin to describe it.

Amidst this slow-motion drowning/birth, I frequently encounter the phrase “work-life balance”. It’s en vogue these days and everyone seems to be striving for it and I have no idea what it means anymore. I begin my workday at 6am and finish anywhere between 5-10pm, with a so-far average of 7pm. That is 13 hours a day. Given that I sleep and commute, I am left with between 2-4 hours a day of “life”, if you buy that these two entities exist in dichotomous opposition to one another.  13:2-4. Can this ratio ever equal balance? Does thinking about life in these terms even make sense? When I work, am I not also alive?

Let’s turn to the original arbiter of this = that: the dictionary. Merriam Webster offers nine definitions of the word “balance”, each with sub-definitions. Scanning these definitions, two jump out as being most relevant: “equality between the totals of the two sides of an account” and “physical equilibrium, or the ability to retain one’s balance.” If you accept the first definition, then I am doomed. For the next three years, and probably for the rest of my working (ahem) life (ahem ahem), I will “work” more than I “live”. The scales will never be even. The second definition seems more forgiving, balance defined subjectively, by the internal sensation of equilibrium.  Yes, I can work with that.

On to “work”: “the labor, task, or duty that is one’s accustomed means of livelihood” (there’s life again) and “energy expended by natural phenomena”. Can we fit work into a box defined by what we are paid, or is work simply the natural extension of each breath we take? Should work be a distinct entity with boundaries around it, or should each aspect of life be seen as an part of the larger work of our movement through space, time, and each other’s lives?

Finally “life”: “the quality that distinguishes a vital and functional being from a dead body”; “spiritual existence transcending physical death”; “the sequence of physical and mental experiences that make up the existence of an individual.” Here is where the discussion catches in my throat. I’m glad I chose a profession where I am constantly challenged to act in others’ best interests. I think the majority of the work I do as a doctor ends up in the positive or neutral columns on the cosmic spreadsheet and I love my patients with a practical and non-grasping kind of love. But I do not feel like medicine is why I was put on this earth. When my physical body stops one day and whatever remains of me is free to roam, I don’t think it will be wearing a white coat.

What distinguishes me from a dead body is something else that I can’t fully articulate, something to do with observing the world, the thread of poetry in everything, and my love for the people I love. As I write, I am realizing that this is my “life”, my spiritual existence transcending physical death. I am here to watch, experience wonder, and love.

The good news, I guess, is that I can do these things at work, though I have to make a concerted effort (there is just so much computer work involved in doctoring these days). The bad news is that there is so much more to these things than work. I miss the quality of light that streams through the windows at 4:30pm on the west side of the house after a nap. I miss cooking myself a sweet little breakfast and eating it with tea. I miss traveling and people watching and writing letters and wondering what a given day will hold. Most of all, I miss meeting my child’s gaze eleven thousand times a day. So much laughter and understanding and surprise has passed between us and there is still so much more there…..

Maybe work is like light, both particle and wave. On some days, it’ll exist in it’s box and I’ll gratefully leave it as soon as possible to return to my life. On other days, I’ll let it seep all the way into me and me into it and there will be no separating us. Maybe I’ll just have to live in a state of tension between a desire to dive in and a desire to escape. Maybe that’s its own kind of balance.

First day

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First day of internship: 6am to 9pm. Dickens was on my mind all day: it was the best of times, it was the worst of times. Never have I understood the phrase as I do now.

I didn’t see E awake at all. See above re: the worst of times.

Here are some things I learned today:

— As an intern you spend almost no time with patients. I spent 10 hours of front of a computer, 3.5 hours rounding, one hour in lecture, and a total of one hour in the presence of patients. I have, however, trended their LFTs and perhaps this can replace conversation. (P.S. What did doctors do before computers? How did they fill up the hours when there were no new results flags to clear?)

— You know how they say that matter is just empty space? Well people are just stories.

Too tired to continue writing…… More later.,,,, Gotta get up in seven hours for another awesome, awful day.