Paula's House of Toast

I know you've been pining to see them.

Here, dear readers, is visual proof that my father, the dear Raul Stanati, is as distinguished as Albert Einstein.

All living things are one seamless body
and pass quickly from dark to dark
(First Dedication)

The chaplain, our office manager said, was in the clinic. Did anyone want ashes ? I asked whether taking ashes was strictly Catholic, and, if so, was it, like communion, closed to Protestants. My colleagues were vague on the theology. One, chagrined, did not know that she was not allowed to share communion in a Catholic Church. I tried to explain the theology as I understood it: transubstantiation effected only by priests in lineage with the Pope. A Catholic colleague chimed in: but lay ministers give the Eucharist all the time ! Hmm. The discussion lapsed. There were no takers for the ashes.

One seamless body. These branches seem to tango. And seem a pieta. In any case, they remind me of the kind of "love" that "seamless body" implies.

For Lent I will attempt to give up 15 minutes a day of discursive thought.

I was an intern when House of God came out. We didn't need a novel to tell us that being an intern sucked, and that ridiculous overwork sometimes desensitized us, but it was liberating to see that we were not alone in using black humor to get us through the night. Some of the book's phrases have fallen into a disreputable niche of the medical vernacular. An unfortunate one is GOMER, meaning a frail, elderly, often severely demented nursing home patient with multiple diseases all in various states of impending or actual decompensation. It's an acronym, and stands for "Get Out of My Emergency Room." It encapsulates the sense of frustration and futility that comes from having, time after time, to treat a patient whose quality of life can maybe be brought from miserable to terrible by treating yet another bout of CHF or aspiration pneumonia, only to have it recur a few days after discharge.

I got to thinking about "Get Out of My ER" this week after reading Spanky's Place, an ER nurse's blog. The writer is a nurse practitioner now, doing urgent care, but he obviously has worked in ERs for years. If Sam Shem offered us a tempered and deconstructed glimpse of the underbelly of health care providers' negative feelings in House of God, Spanky whips out the under-underbelly and proudly parades it with an almost contextless glee.

I'm trying to come up with the opposite of "Get Out of My ER" -- something like Humans Avoid That E R -- which works, but imperfectly. Because, in fact, it's only certain humans that need to avoid Nurse Spanky: female, obese, non-English speaking people of color on welfare.

It's possible -- even likely since he's apparantly still employed -- that Nurse Spanky maintains an impartial, non-abusive and professional demeanor at work. Nonetheless, the depth and breadth of his verbal animus is breathtaking. His comments bristle with sizist, sexist, racist, classist, and xenophobic phrases. Here are a few excerpts.

Is there some reason bipolar passive-aggressive corpulent women find the need to gravitate to the ER on Sunday nights? Are they so lonely they would rather come to the ER and get stabbed with sharp objects rather than stay home alone and run up their electric bill with their “back massager?"

You got that fat by yourself, why should I hurt my back and jeopardize my entire income and lifestyle because of your inability to control your appetite. One of the nurses I work with has a permanent back injury caused by an insensitive lard-assed pile of goo. This fat, lazy, shit encrusted pustule wanted to sit up in bed...

This particular (ambulance) call was for an enormous black mama, 500 plus pounds. Who had fallen between the bed and the wall, and was wedged so tightly they couldn’t budge her. Keep in mind this was at the back of a large projects building in a unit with no elevator.

Anyone who works EMS or ER knows when they hear a certain address, it’s going to be a bad call, and the ER is going to be overrun with toothless, tattooed, worthless consumers of oxygen.

The next three snippets are from his ER manifesto. The phrase "we hate you" recurs throughout his piece like a refrain.

1. Don't go, it's not really an emergency, and we hate you. No really, you think you have an emergency but it's really not. And seriously, we hate you. Just stay the home, or at the restaurant, movie, massage parlor, your lovers house, or even with your significant other, just anywhere but the ER. Have I told you we hate you yet?

2.         What is the most frequent reason for dragging Jose, Keneesha, Bryttynii, Boneki, Kristyan, Christiaan, Twannekaa, FeMolly, Miiho, and Sterling to the ER? Earaches. Now follow along closely ya hear. EARACHES ARE NOT EMERGENCIES, EARACHES ARE NOT EMERGENCIES!!! ...

14.       And for you fat middle aged psyche women with the psyche look (We know who you are). The best way for you to remain unimpressive to me, is to tell me you have fibromyalgia, mitral valve prolapse, and hypoglycemia. Ok, so one out of three diseases is real, the other are pure bullshit. Fuck-off, die, and get the out of my ER.

What is the value of putting extreme stuff like this "out there" ? Is it to somehow validate feeling this way ? Writing like this is way beyond satire. It is invective, screed.

As a woman who has had her share of body image and eating issues, I read his ugly, cruel, way over-the-top description of catheterizing an obese female patient with chagrin. It is the antithesis of the Buddhist concept of "right speech." It is harmful, hateful, aggressive speech. In House of God, empathic care actually triumphs. In the House of Spanky, it's not that clear.

But what's in the job description of health care provider IS crystal clear: compassion. And not selective compassion. I'm not just being cute or sentimental. Dale describes compassion better than I ever could as a cultivatable skill. A practice. It takes a simple maneuver, a little act of the imagination. A tiny leap out of the self. Imagine being very poor. Imagine, if you're white, being black. Imagine being obese and, on top of that, having to climb countless flights of stairs to your apartment in the projects. Imagine the humilation of falling and being unable to get up. Imagine being ill and smelling bad and seeing disgust on people's faces. Imagine being an obese woman needing to get a urinary catheter in the ER. Imagine being a poor single mother with kids. Imagine being a single mother whose child is screaming and tugging at its ear at two AM. Imagine trying to get care from providers who don't speak your language and who resnet you for not speaking theirs. Imagine being without health insurance or on welfare. Imagine having a a body that hurts everywhere all the time and disabling fatigue and a diagnosis that your health care provider believes, vociferously and scornfully, is not "real." Imagine (this one's for me) having severe, acute low back pain and no doctor and having to go to a walk-in clinic to see an unfamiliar provider and convince them you're not just scamming for drugs. Imagine, then, being the person hooked on oxys or vikes or percs, sick, having to scam for drugs. That can't be a picnic.

Take it beyond the clinic. We were just warming up, doing the Hanon exercises. Imagine being the father who killed his children and buried them along a forgotten highway then killed himself in his jail cell. Imagine that. You can take this exercise as far as you like.

I think the practice of compassion enables right speech.

I used to have what I'd jokingly call Dr X's two rules. Not unSpanky-like. The first rule was "no family in the exam room." It wasn't a rigid rule, but it was there. Dr X herself, being the loner that she is, would never think of bringing her mother or husband into the exam room with her for, say, a visit to the doctor for a cough or cold. Or ear wax.

I came to realize what an completely awful "rule" this was; that a patient's need for moral support superceded my own need not to have a relative chiming in from the exam room corner or otherwise scrutinizing my care of their loved one. Or my own prejudice that people should undergo a medical encounter stoically and alone like I do. So I abolished rule number one. Ashamed that I'd ever suggested it.

Rule number two -- no crying -- was never really enforceable. Or meant to be enforced. It simply was my way of expressing, with some black humor, my own discomfort with people's tears. I tell myself, self, if a patient can't cry at the doctor's, where can they cry ? It's true. Of course they can cry. My discomfort remains. I'm working on it. It's a problem. My problem. The imperative is not to make it the patient's problem.

This week, speaking of crying, I found myself in tears while reading the New England Journal's CPC. Every week the NEJM prints a "clinical pathological conference" in which someone presents the details of a difficult medical case, and an expert discusses the case and the differential diagnosis. It's an institution. They are often fascinating, and instructive, but this one was unexpectedly moving.

It wasn't so much the usual "come up with the diagnosis" exercise, for the diagnosis was clear: it was a woman with terrible burns. The presenter described the ER care and then the subsequent lengthy ICU care of a case of critical lung and dermal injury from fire. There were pictures of the acute burns, which went so deeply they charred her skull, and also of the areas when they'd healed; they included a picture of her, smiling frankly at the camera, wearing a beautiful wig. One eyebrow is pulled upward by scar tissue, but it's subtle. And, at the end of the conference, she comes out and addresses the doctors herself. She'd been in the Rhode Island night club fire, whose one year anniversary was this week, in which 100 people died and many sustained horrible, mutilating injury.

What moved me, I think, was how she, and patients, all of them, are our teachers. And how gracious and lovely this is. "Doctor" comes from the Latin root docere meaning to teach. But our patients are teachers, too. Not just during our training. Every encounter is instructive. Especially the ones that push our buttons. Listen to the patient. Listen to ourselves. Listen ! Audite ! The first word of St. Benedict's Rule.

Yes, I know that there's little spare time for the luxury of investigating interpersonal dynamics in an understaffed, busy ER. And, yes, I know that ERs are there for saving patients like the critical burn victim I described above, not for delivering routine, primary care. And, furthermore, I know that nursing is physically taxing and often dangerous -- I do some occ med for our hospital and see many nurses with back and neck injuries. Usually not from caring for particularly large patients, either.

Maybe Nurse Spanky is simply venting, and he's really a fine, empathic fellow. Maybe he keeps his distress inside: keeps it as his problem, and doesn't make it his patients'. But I could not let the curious venom in his ER vignettes go unanswered.

Amilcare Carruga realized that perhaps the thrill of his new glasses had been the last of his life, and now it was over

-- Italo Calvino, "The Adventure Of A Nearsighted Man."

I love wearing glasses. I really do harbor an inner Elton John. I've worn them since seventh grade, for nearsightedness and slight astigmatism.Glasses and I had a brief falling out after the need for bifocals kicked in, but we have reconciled.

My first optometrist was a pleasant, ungainly man who talked very fast and mumbled so he was hard to understand. A friend of my parents, he had a narrow storefront dispensary in Lawrence, Massachusetts. I loved everything about going to his shop except his breath up close as he looked at my retina through the ophthalmoscope.

I especially liked trying on frames. Even then I loved glasses. Oddly enough, I've had plenty of pairs that I have not liked. In fact, I have yet to find the perfect pair. My first frames were a blue cats-eye number, ugly and wrong by any account. My second pair, for some reason, was a gray copy of the awful first. Then came some oval plastic horn rims, and a succession of coated wire-rimmed variants in tortoise shell, red and black. There was a gold rimmed pair, maybe even two, and a couple of ill-considered and owlishly huge plastic frames, one beige and the other a strange green-black.

I have my father, the dear Raul Stanati's, army issue world war two eyeglasses. They are delicate gold rims with cable ear pieces. Very, very beautiful. They are the UR-glasses in my optometric life. Iconic. A precious artifact. As are the horn rims Raul wore in the 50s and 60s along with his age-of-anxiety crewcut.

There is a distinct oedipal aspect to my eyeglass life. My mother had a pair of glamorous, pale horn rims that she kept in her drawer with her handkerchiefs and costume jewelry. They smelled like her: tobacco, perfume, ballpoint pens. She'd worn them in college, she explained. For typing. I never actually saw her wear those beautiful glasses. I want to wear glasses I thought, seeing them.

Wearing glasses was glamorously intellectual. One could cultivate so many sophisticated gestures with them, like sucking pensively on an earpiece, or pushing them up on top of one's head, or even pushing them absently up the bridge of one's nose. I simply had to have glasses. Nature cooperated: the blackboard blurred, and I was taken to the eye doctor.

My most nearly perfect glasses have been recent. I was heartbroken when an optometrist refused to replace the lenses in my ten year old round, reddish, light-brown horn rims with a new prescription, afraid that the plastic had become brittle and might break. He didn't want to be liable for that, he said. Luckily, I found a pair of coppery/bronze roundish wire rims that I like, and that have held up beautifully. I have a second pair of glasses -- plastic rims, a dark uniform ruddy brown, round but strangely flat on top, that are strangely severe. I feel like Cynthia Ozick in them. I wish I could say they make me think and write like her. Alas, they do not.

Nowadays, glasses have all become narrow, slit-like little jobs. I hate them. Narrow glasses look wrong on my big, squarish face. Plus, wearing them is like peering through keyholes.

I resent the little narrow glasses with an unreasonable resentment. They make people look like stock brokers. In MY day, we all wanted glasses that that made us look like Trotsky or John Lennon. Round glasses. I rest my case.

I tried to buy sunglasses last year with a Christmas gift certificate from the ever-thoughtful DK. I went to the local McEyeglass joint and, cheapskate that I am, bought a pair of little narrow sunglasses. Ugh ugh ugh. What a mistake. I hated them instantly. They made me feel ugly and dorky. I felt like small children were running from me in fear when I wore them.

Last September, on the day of my infamous auto wreck, I had been planning to bring the beautiful but brittle round hornrims to the glasses joint to get the lenses tinted. I'd set them aside on my desk for that purpose. I would do it later that day, after bringing the cat to the vet. Well, I certainly got sidetracked. Somehow, the accident seems linked to that plan to tint the beautiful old glasses.

The other day I realized that one can probably buy glasses on the internet. So I googled eyeglasses. And soon I was in glasses paradise. I found these and these and these and these and these -- the glasses of my dreams, lovely round frames in a world of sneeringly narrow ones. A small ember of glasseslust burns in my breast, kept in check for now by my inner skinflint. Who knows what will happen after my next eye exam, which I can schedule as early as next month according to the measured generosity of my HMO.

Until then, I am comforted to know that there are enclaves of round glasses in this narrow-eyed world.