Sunday, February 08, 2004

A Fusty Valise

The title of the piece piqued my attention instantly: Why I didn't become a doctor. Ambivalence about practicing medicine is one of my favorite topics, and stories about people who, as Philip Larkin puts it, "...chucked up everything/ and just cleared off" ignite in me a heady mixture of fascination, envy and anxiety. Julie Leung writes of her horror at the apparant hard heartedness of the emergency room staff after a homeless man is brought in, moribund, and dies. A sophomore in an eight year medicine/humanities program, she sees him

...stripped of his clothes, nearly naked, legs together but arms outstretched, looking like some kind of strange Christ...

and is astonished by the lack of emotion shown by the ER doctors and nurses. And although other personal considerations fueled her eventual decision to leave the program, this powerful image of abandoned suffering represented what was emotionally intolerable to her about that ER experience, and medicine: the sometimes icy distance between patient and provider.

I imagine that if she had remained in medicine she would have found a way to preserve her compassion and empathy, and also learned that empathy can (and sometimes must) operate behind a countenance of reserve.

In 1977 I was an intern in a community hospital, headed for a psychiatry residency. I was doing an ER rotation with a fellow pre-psych intern, and, although I forget the details of the case, I remember that an infant had just died. Right there in the ER. There's nothing quite as awful. The nurses were traumatized, distraught. My fellow intern, noting this, noting how "business as usual" has shuddered to a halt, made a loud and disparaging comment that included the phrase

"...decompensation over the issue of a dead baby..."

I'll just say he's lucky to have made it out of the ER that day without being torn limb from limb. I suspect that his breathtakingly insensitive comment was a defense against his own overwhelming feelings. One would hate to imagine a psychiatrist so unwilling to acknowledge and resonate with distress, so eager to pigeonhole it as "decompensation" over an "issue."

Julie links to a piece on Hermes - A Resident's Life , second year medical resident Victor Van Hee's extremely well-written weblog. He's a wonderful writer, darkly witty and observant, and sounds like an insightful and compassionate doctor. His post also caught my eye. It's called "A Great Case," and is about a case review of a young person dying of meningococcemia, a swift and devastating bloodstream infection. The title gave me a jolt.

Any doctor who has had or seen or even heard tell of a patient with meningococcemia never forgets it.

I had such a patient during my residency in the late 1970's. He was a middle eastern jeweler, a young man. I remember the detail of his packet of jewels residing safe in the hospital vault as the jeweler unraveled swiftly in the ICU.

I remember doing a skin scraping and slide of the ugly, almost visibly advancing purple skin lesions -- called for good reason purpura fulminans -- and how a shudder of horror passed through me when I saw the oddly beautiful double bean shaped pink coccobacilli through the microscope lens.

I also remember the next day's morning report , the meeting where residents gather and present the previous night's admissions. Our chief was a pipe-smoking, tweedy, bow-tie sporting thyroidologist, a pleasant, somewhat dusty, smart and enthusiastic man, whose favorite phrase was

A Great Case

He used it so often that year that I came to imagine him carrying a large, dusty valise. The jeweler with meningococcemia was, of course, a great case. And, as the sleepy resident who presented it at report, it became my great case. Even years later Dr. R. would remind me of it, my great case, the jeweler who died (after many days of terrible suffering) of meningococcal sepsis.

For me, "great case" is a portmanteau phrase that carries within it that dusty thyroidologist whose pipe fumes I can conjure to this day. Also, in its fusty depths, is the jeweler, dying, fulminant purple, and his packet of jewels, occulted in the hospital administrator's vault. And myself, the resident, peering through the microscope at the oddly beautiful coccus, horror struck by what it signified.

Years later, hearing of a similar patient (a girl, 16) who had come through our hospital's ER overnight (word of such great cases spreads like wildfire) I remembered the jeweler, and Dr R. with his large valise. I thought about the second limb of my residency that I'd undertaken at the doddering age of 40 after the world's longest maternity leave. How staining slides in the empty micro lab in the wee hours had seemed a blissful refuge from the demands of the wards.

And I shoved it all into the fusty valise of this poem.

Gram Stain

for I. R.

Purpura fulminans. She scrapes a bit
of flesh from one dark lesion’s leading edge,
and spreads it on a thin oblong of glass.
The lab, at 3 am, is empty, still,
except for the dull throb, the metered hiss,
the intermittant click of instruments.
The redolence of agar, warmed microbes
spreading over plates and clouding flasks,
milkens the basement air, reminding her
and her breasts of the infant sleeping, home.

Gram stain (c. 1860, Christian Gram)
is a task that any intern knows by heart.
Which really means, she thinks, by hand and brain.
She leans to stainless steel, adjusts the stream
of water (gentle, cold). Uncaps the lamp
whose woven wick leads spirits into flame
atop a thick glass bulb, a zungensprach
whose bluish heat will fix the stolen flesh
to glass, Pompei without its coat of soot.

First comes crystal violet. She decants.
The livid fluid drowns, obliterates.
She counts -- one onethousand, two onethousand --
recalling lightning, and how she’d time the gap
between it and thunder, terror-struck, to tell
how close the storm was. Mother ? Fast asleep.
Fulminans, it split the purple sky,
photographic negative of how
the purple lesions split her patient’s flesh
white from white, so swiftly she could see
the fingers gloving purple, the slender flank,
barely sixteen, now wise beyond its years,
putting on the horrid, tattered lace
of a certain betrothal. Time to rinse.

Next, is Gram’s iodine, brown but kin
to violet. It blackens starch and stings,
astringent, medicinal. She counts again.
Recalls ParĂ©’s humeur fuligineux ,
the sooty, brackish humour that meant death,
modernizes it to DIC,
disseminated intravascular
coagulation, when the whole works
clots and bleeds at once, the clotting cascade
become Niagara, and then recalls
how every cliff and cataract reminds
a mother of her infant’s perilous
sojourn upon the earth. She shivers, yawns.
Thinks of the silent woman by the bed
behind the weft of tubing in which her child
sleeps, and in which both seem caught. Now rinse.

This is the tricky step. Decolorize.
Too long and the caught flesh will wane to ghost,
too short and it’s an inkblot, both everything
and nothing. It takes intuition, eye.
The rods and cocci come out pink or blue
according to their kind, gram-negative
or positive. Like us, they’re named for stain.
Rinse. A name’s a stain, a drain. The brain’s
so easily misled by likeness, rhyme.
A bruise is not a flower, and breath’s not time.

Last comes the counterstain, the safranin.
She counts again. The embalmed cells enrouge.
I undertake, she thinks. It undertows.
Her fingers, carelessly ungloved, are red
on splattered purple, on raw pinkish beige.
She counts. Her shoulders bend beneath the weight
of hospital. She likes it underground,
amidst the caged, proliferating germs,
things with no business but their own to mind
busily, mindlessly, endlessly, thousand.
She counts and breathes regret. The final rinse.

Then blots between the leaves of bibulous
paper, red and wrinkled as if by fall,
and looks, holding the slide up to the light --
a pinkish whorl caught on transparency,
the fingerprint that solves the heinous crime
but cannot ever resurrect the corpse.
She knows what’s there, what fateful, slashing sword
undoes the body’s weave so thoroughly,
terribly, swiftly, fulminans, more
fulminans than a Papal fulminare ,
not war or condemnation or a flower
blooming on a girl, but just a Gram-
negative diplococcus, bean-shaped,
able to undo the body utterly,
within hours, within a breath. The mother sits,
she thinks, and listens to the bloody falls
just a bit downstream from where her child
hangs caught midchannel in frail branch and vine.
Penicillen, pencil, little brush
seem useless against this inexorable
flow and gravity. And microscope.

Three fifteen, she thinks, is the worst time.
Immersion oil bathes eye and lens and slide
in highest power. She twists the focus, fine,
and is ashamed to find them beautiful --
hard, fuschia, twinned, stippling a field
of pink and blue nucleated honeycomb:
Neisseria meningitidis, akin
to N. gonorrhea, named for Neisser
who was a German syphilologist,
as syphilis was named for the hero
of “Syphilis Sive Morbus Gallicus,”
the sorely afflicted shepherd, Syphilus.
Named by Girolamo Fracastoro,
a doctor-poet of Verona,
circa 1530, who was in turn
named by his mother, for something round
or spinning, for mud or olives, a fracas-
maker, bull, brother of beavers, Pollux,
swordsman, Hieronymous, holy name --
who knows ? How did his name stain him ? A name,
a dusty cabinet, piled bibelots.
Her baby, she thinks, she hopes, must be asleep.
After names there comes the bedside watch.
She tries to count the hours left till home,
loses count, and tosses out the slide.
Glass clinks on glass. She’ll take the stairs. L’chaim.


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