Transcription:
“Dear Dad,
Top 5 reasons why your’re the best.
1. You help me with my home work.
2. You play with me.
3. You drive me around.
4. You teach me things
5. Help me with social studies
love,
Mirai”
I sometimes search in my dog's eyes for an inkling of confirmation that there is any degree of thought going on behind there. Same goes for babies and kids-- while I think it's much more widely agreed upon that these tiny humans are indeed thinking, it's kinda cool to wonder about what. That's why I found this little craft so interesting. It's kind of a sneak peak into what this little kid was thinking, and what they valued.
It's kinda cool when that little kid was you! I remember this day actually– I was in second grade, and Father’s Day was coming up, so we were making Father’s Day gifts in class. I remember being confused: a fatherless child who was too shy to tell her second grade teacher her circumstance. This was my best guess at what an awesome dad would be like.
Somehow the thoughts back then evolved into the ones you have now, and boy can they really evolve. I like thinking of them as the beginnings of thought in someone’s life. It seems like I, personally, really really did not like social studies.
Name: Mirai Mikhail
I.
Medicine is having nightmares about your patients. It’s the understanding that what you do matters so much, and that you are ultimately responsible not just for the outcome of your patient, but also for your sanity. To keep your own conscience at bay. Practicing medicine is to relinquish control to the universe only after chasing every missing piece, researching, sermonizing, and lobbing order after order into the abyss. Only after checking, rechecking, and triple-checking what you’ve done can you enjoy your stale turkey sandwich in the hospital cafeteria in peace.
II.
Medicine is dark humor. Seeing an old lady with a mummified finger, and laughing when the surgeon says she’ll wake up one morning with the finger rolling around in bed with her. It is to be doing CPR in the bed next to a blind man’s, while he is yelling for his morning Jell-O. It is asking a patient about their bowel movement at seven in the morning. To have your eighty-year old patient ask you, “Is it still beating?” when you listen to his heart. To reply “Still going!” and have him say out loud, “God damn it”. Medicine is to be at peace with the idea of misery. To understand that the chaos of the universe yields tragedy haphazardly, and that there is little we as human beings can do about it. To realize your ability to despair is matched by your insane, and completely natural, ability to find joy even when you don’t mean to.
III.
Medicine is being knocked on your ass. It’s going into a patient’s room with the desire to set them straight, only to see their child with them. To be brought down a peg by a three-year-old with an iPad, demanding his mother’s attention. Practicing medicine is to be gracelessly humbled. To hold onto a concept of right and wrong, of black and white, is to do so at your own peril. Medicine will humiliate you, and singlehandedly annihilate your ego, in the oddest, most unique ways via the most unexpected things. Practicing medicine is to realize at once how highhanded you can be, how cavalier you are with people’s livelihoods. To be shocked by your patients, by the knowledge you do not have, by the human body, and the human stories that surround us, all in the moment you thought you knew it all.
IV.
Medicine is remembering even when you don’t want to. It is the ability to picture your first patient in horrifying detail, but not really remember him at all. It is the ability to recall the particular roundness, and shape, of a mole on his left cheek and forget what he was there for in the first place. To remember his pride about his daughter being a lawyer, but nothing else about him. To spend thirty minutes in medicine is to tell one patient she can’t have children, and then prescribe an antacid to another. To sit with the weight of the conversation you had earlier and hope it washes away with time. Medicine is sitting at a nursing station and hearing loud pop music over the radio, while your colleague tears up on the phone next to you. To suddenly realize where you are, and the gravity of what you’re doing, while singing along to club tunes. It is to come face to face with the fact that the world continues no matter how much grief looms large in front of you. To be out somewhere and suddenly be hit with the idea that someone you met once might be suffering. It’s the desire to simultaneously want to remember, and also forget. To dip a toe in the sea of lives lived every day and walk away both deeply affected and unscathed.
Name: Priya Bhave (she/her)
Cohort: 2022
Hometown: East Brunswick, NJ
It started on a muggy August morning, my first day on the oncology wards and my second month of intern year. My latest overnight admission was a 36-year-old male, no past medical history, with 3 weeks of fatigue, found to have 250,000 white blood cells, 25 times the upper limit of normal. He was status post bone marrow biopsy in the ER, results pending.
I walked into the small room and found it filled with people. My patient was a tall, good-looking guy with a generous helping of thick, mousy brown hair, sitting atop his medium frame. He was wearing a “Keep Calm and Chive On” t-shirt, sitting in bed, with his 3 and 5 year old kids hanging off of each arm. His lovely wife, petite and blonde, was sitting in the chair next to him, with the look of a woman who has more questions than answers, and realizes how much her life is about to change.
It was 6:30 in the morning, and the sun was just rising over I-95, the main attraction visible from our eighth floor vantage point. Tiny cars sped down the highway, people outside this place eager to start their days, too. I introduced myself to the room.
“Hi, I’m Dr. Tripp. I’m going to be one of the doctors taking care of you here. But you can all call me Tovah.”
I got a quick history. My patient and his wife had been on their tenth anniversary vacation. He had felt a bit fatigued, but that’s to be expected with two little kids, right? He went to his primary care doctor, and on some routine labs was found to have a severely elevated white blood count and was sent in to the hospital. The diagnosis was likely acute leukemia, but most tests were pending.
“How do you feel?”
“Fine. Weird, because I don’t know what’s going on, but fine!”
What ensued was a slew of questions that I was not at all adept to answering. Questions about diagnosis, treatment, the “plan.”
I smiled, and handed them a notepad and one of my spare pens.
“Unfortunately I do not have all the answers right now. But I will get you more information. Write down all your questions, we’ll make sure to answer them all.”
I did a quick exam, the watchful eyes of his family gazing on my inexperienced hands as I palpated his spleen and liver, listened for his regular heart and lung sounds. I reassured them I would be back soon with the rest of the team.
Seeing the stress and anticipation in his family’s eyes, I uttered words which I myself was told during my own family’s health crisis. “Guys, this is the worst part, the not knowing. Once we have a handle on what this is, we can go into attack mode and fight this thing.”
What ensued was a busy few days with CT scans, blood tests, lumbar punctures, and initial chemotherapy to lower his white count until we knew exactly what was causing his leukemia. For days we pumped him full of IV fluid, to flush out toxins released from dying cancer cells. “I’ve never had to pee so much in my life!” he laughed.
Every morning at 6:30, I’d walk into his room, the glare of the sun through the window blinding me. With eyes as bright as the sun, my patient would declare, “I feel great, Tovah!” After which, his dad, a spitting image of my patient who often spent nights in his room, would cheerfully ask “Where are we today?” referencing his son’s white blood cells, which eventually lowered to a much safer level.
I started to spend free time with his family, visiting them before leaving for the day. I’d show them pictures of our dog, our house we were trying to buy, and how I met my husband. My patient and his wife went to high school together, but weren’t dating until college. Their oldest was about to start Kindergarten in the fall.
When we finally had the diagnosis, the plan was for high intensity chemotherapy to wash out his bone marrow. The eventual goal was bone marrow transplant for cure. The day before his induction, his sister came to trim his hair, in anticipation of the inevitable. “What a shame,” she said. “Most men would kill for this hair.”
Hyper CVAD, a vicious course of chemotherapeutics ravaged my patient. He was already over a week into his hospital stay, and was stir crazy. I’d walk into his room in the morning, bags under his eyes, and he’d tell me how he hadn’t slept all night. When his white count reached 0, and he had no infection fighting ability, he felt worse. His hair was gone and had no appetite for the food that filled his room from well meaning friends and family.
I would round on him progressively later each morning, hoping to give him a few more minutes of rest before I’d poke and prod at him, asking him my usual morning questions. Stripped of his jovial demeanor when it was just us, he’d express his frustration. Before leaving his room I’d sit on the edge of the bed and reassure him that when his neutrophil count got higher, he’d start to feel better.
Later in the mornings as I frantically wrote notes and orders for the day, his dad would poke his head through the door to our workroom, which, despite being around the corner from my patient’s room, also carried the same view of the highway. Despondent, he’d ask, “Hey, Tovah. Sorry to bother you. How is it today?” in reference to the chase against his white blood cells. I would go home hoping for neutrophils, for normal and healthy white blood cells to come from his bone marrow, giving my patient physical and emotional strength to move forward.
And just when I had given up hope on his marrow, it started climbing. Day by day, higher and higher, as his white count rose, so did my patient. He had new energy, and we all had new morale. His dad and I shared a high-five, and he gave me a pat on the back, as if I had some role in re-stimulating his bone marrow. The possibility that he might make it home to see his eldest son go to his first day of kindergarten finally seemed real.
My last Saturday on service was a picturesque, quintessential New England summer day. The sun sat happily in a cloudless baby blue sky, its rays beaming down, warming my skin and drying my hair I had haphazardly thrown up into a ponytail after showering. There was not an ounce of humidity, and the air smelled fresh and slightly salty, something I did not appreciate as I was scurrying from my car through the large hospital campus. I ran past trees and flowers in the small courtyard behind the hospital, swaying in the gentle breeze. I had always felt annoyed by this long 15-minute walk, vengeful, perhaps, and today was no different. I was running late.
My patient approached me in the hall as I was taking care of some last minute things before leaving for the day.
“Hey, Tovah. My neutrophils are as high as they’ve been yet. Do you think I could go outside?”
I realized that throughout our month together, he had not been outside once. His whole world had been reduced to one room on one floor in a hospital, with the sounds of beeping monitors and a cacophony of numbers and values and vital signs. I instantly felt guilty for hating that 15-minute walk to and from my car. While I was allowed the therapeutic benefit of breathing in the outdoors and feeling the sun on my skin and a fresh perspective after a bad day, my patient was limited to one view of the highway, with only the warmth of fluorescent hospital lights on his skin. I checked with my attending.
“Sure! I don’t see why not.”
He smiled.
As I made my way off the floor, so did my patient and his wife. He was disconnected from his IV pole, his PICC line bandaged up, hat on to cover his bald head, zip up sweatshirt and flip flops. They waved to me on their way out, holding hands.
As I meandered towards the parking lot at the end of my shift, I saw them sitting together on a bench, in the sun, arms around each other laughing. I imagine it was a scene not unlike many of their times together before chemotherapy and neutrophil counts.
I approached them with tears in my eyes.
“Can I join?”
They parted their arms, and invited me to sit in between them, the three of us embracing, laughing, and looking up towards the cloudless blue sky.
Name: Dr. Tovah Tripp
Brief description/explanation of the work: This piece is dedicated to Brian, who passed away a few years ago from complications from leukemia. Thank you to him and his family for allowing me to care for and learn from all of them, and may his memory be a blessing.
Part I
I don’t know why they never had children. I can piece together their story in my mind, from the bits she has told me, from the pulmonary fellow who took care of them for two months, and much from what I imagine.
She was tough, a straight shooter. Tough as nails to make it in an all-male world of medicine I really can only imagine. Maybe they met at a conference. Or maybe one of her fellow Vienesemen introduced them. A famous anesthesiologist from Hungary. That I learned from the nursing home face sheet that gave his vital information. A nephew in Maryland. A wife, Dr. Greta; although there she is identified as a Mrs. A phone number, a contact person, and an address. And here she is now, a hundred and fifty blocks north of that address, their apartment, and the other ICU he left only a week ago.
It’s hard not to think of how many A-lines he must have put in over the years, as we stick and stick his pulses, futily trying to thread a catheter over a wire. At the end of his day, he would change out of his scrubs – which were always spotless, even after the messiest case. He would leave the main entrance of the hospital dressed in his jacket and tie, hat tipped slightly to the left, and smile and greet passing colleagues and the man he bought the paper from every morning, as he headed back toward their apartment.
She spent the day seeing the daughters and sons of their friends and neighbors, prescribing glasses, drops. Always giving her opinion of a boyfriend or a school, or a blouse. There is a wonderful program on tonight at the symphony. A prodigy; in from Italy. She tells her assistant as she puts on her coat. They must have made quite a couple at the Opera or Philharmonic. He never could stand the Ballet.
When their nephew came in from Maryland, they would see the latest show or concert, go to a fine restaurant, and dine with colleagues and friends. In his own, second generational way, he too is proper, just so, and just as successful. She will tell you of his high university post, of his responsibilities, his honors.
But he isn’t their child. He is in Maryland. He wants a chest tube. He is not here. She is here. And yet, she should be with her husband, the Famous Anesthesiologist. At the opera, out to dinner, dancing. Anywhere but the ICU. Anesthesiologists know critical care well, but ophthalmologists rarely visit the ICU.
It is hard to debate with her. It is hard to end a conversation and it is hard not to listen to her stories. Maybe it was because of their professional drives, their focus and their love of the life they led together; maybe that is why they didn’t have any children.
She must have been tough as nails to make it in medicine when she did. He must have been tough as nails to make it to 90 years with her. But she nourished him, and he nourished her. She is the one keeping him alive now. I can understand how she can’t see surviving him. Two elegant, proper, tough cookies. How could they be apart.
Part II
It was easy to write about their life. It made me smile to myself. The day after I admitted him, I was so disturbed and upset, I had this horrible feeling inside my stomach. I came home and sat down and wrote about their life. But after she made him DNR, and after he died, I didn’t have that twisted, bound up feeling inside my stomach like I had had 11 days earlier.
I had tried and tried to make her think about their wonderful life together, instead of the wasted, bruised man barely alive inside my ICU. But even though I knew the stories she had told me, and the stories I had imagined, I needed to write about what had happened in the ICU.
I admitted him 11 days ago. That was 7 days after he was discharged from another hospital, to the nursing home that put him in the territory of our ICU. The call from the ER made us all roll out eyes. Nursing home resident. Vent dependant. Respiratory distress. Ugh. Does he need to come to the ICU? He looks like death.
Then I met his wife. Her thick Austrian accent, her pocketbook, her Bergdorf Goodman shopping bag. A small lady, but a lady not to be ignored. She told us about his pleural effusions, his infections, his tracheostomy. Suddenly she clenched her fists, squeezed her eyes shut, and stopped talking. Are you alright? I have supra-verntricular-tachy-cardia, pronouncing each syllable. We felt her pulse. Do you want to be seen by a doctor? She continued to bear down. We felt her pulse again; she had valsalva’d herself out of it.
A few hours later, I reached the pulmonary fellow who had taken care of him for two and a half months. She filled in the details of his metastatic cancer, his infections, hemorrhage, respiratory failure. His wife had fought the discharge to the end, she questioned every medicine and treatment, swallowing up hours of the team’s time. But please remind her to go to that doctor I gave her the name of. And please give her a hug for me.
I don’t know who the 10 days he spent in our ICU tortured the most. He got arterial lines, venous lines, foleys, blood draws, pleural taps. His lungs were drained of their fluid, and filled up with fluid again. He barely had any oxygen in his blood, even on 100% oxygen, and his heart just kept on beating.
The team discussed it every day on rounds. There is no point. We aren’t doing anything. I hate going in there.
We followed numbers in circles. If one was low, we raised it. If one was high, we lowered it; if we could, which most of the time we couldn’t. Thankfully, discussion on the chest tube faded after the first few days. We’ll just continue chasing numbers, doing nothing, but doing too much, until his wife finally lets go.
And his wife. With her never ending questions. Everyone had an opinion on how to end a conversation with her. She’s the type of person where you just have to say, I have to go now. Just tell her you can only talk to her for five minutes. Tell her you have 10 other patients you need to see. Those people have obviously never spoken with her.
In her thick accent. But what about the pulse. What is his oxygen saturation now? At the other hospital his blood pressure was always 100. Shouldn’t he get a little digoxin, he was on digoxin at home? I tried every tactic, every answer. But her questions really had no answers, certainly none that I could think of. And so, I spent hours on the phone with her, trying to explain the gravity of her husband’s condition.
And so she came in, and she called on the phone. She traveled from their apartment on the other side of the city, and she stroked his head, and gave him kisses, and called him her dear. And she asked and asked, what will I do without him. What will I do. And so we kept on poking and testing, and infusing and treating. Until there was nothing left to treat, and the machine was breathing for him, and he no longer moved, and drugs maintained his blood pressure, and his kidneys were failing, and his liver was failing. And still, what will I do without him.
And finally their niece came in from Maryland. And she cried with his wife, and she saw that he was gone, but was still here in our ICU. And the attending who so dutifully had cared for the patient and his wife spoke with them both, and told them this was the end. The medicines aren’t working. But still, what will she do without him.
And I talked with them both. And the niece cried, and the wife stroked his head. And the machine breathed for him. And the blood pressure medicine was raised and raised, but his blood pressure continued to fall, and so we stopped raising the medicine. And he didn’t move, and his lips were dry and cracked. And I told her to think about her husband, about how he had cared for his patients, how they had lived their life together. How this was not her husband. And she told me how he was a sculptor and violinist, how their apartment was filled with his works. How he loved classical music. He was the first anesthesiologist to put his patients to sleep with music.
So I took the clock radio from the clerk’s desk and put it in a bag to protect it from his multiply resistant infections, and I went into his room and plugged it in, and put it on the floor, and turned it on. And the Bach or Brahms or whatever it was played in his room. And she stroked and stroked his head and gave him a kiss and left the room.
This is the end? Yes, this is the end. It is over? Yes. And she signed the DNR, and she gave me a kiss. And I said goodbye to his wife and his niece, and they left the ICU.
And I sat there with my medical student, and an hour later we stood up and went into his room, and we watched his pulse on the monitor. 60. 40. A few beats, then none. And we stood there. That’s it? That’s it. The famous anesthesiologist from Hungary, husband of the famous ophthalmologist from Vienna.
Name: Dr. Miriam Hoffman
Brief description/explanation of the work: I was part of the first group of residents to have narrative medicine formally incorporated into our residency training. This was when I was a Family Medicine resident at Columbia, and was funded by a grant the faculty received to build what was then an emerging field. It was a very powerful experience - for example, narrative medicine rounds were a regular part of our inpatient service.
After a particularly intense experience as a resident in the ICU, I came home, sat down, and wrote this piece. I wrote the first part early in the patient's admission, and the second part after he passed away.
Both the experience in the care of the patient and his family, and the process of writing about it and having that writing as a way to hold onto its impact, are things I have carried with me for many years (as that happened a long time ago!).
