Visage

Most of my academic half days are spent doing laundry, cleaning up the yard and house and on occasion, actually working on my research.

Last Friday I decided to try something new.

“Care for a beauty break?” She was friendly and inviting, and I had time to kill before my second yoga class of the year. I was not completely oblivious to her thick mascara and not so lightly glossed scarlet lips. But I yielded nonetheless. Who could resist a free makeover? And my attempt at finding shoes worthy of a future infectious disease consultant was in vain. (Looks like a pump, but feels like a sneaker...)



She glanced at the lime North Face fleece Jacket and gray cargo pants I sported and asked if I wanted to keep my “natural” look. I mumbled yes incoherently but it didn’t matter. “What gorgeous skin! And nice thick eyebrows!” (Little did she know, as someone with origins from the Hair Belt, extending from the Mediterranean Sea to the Bay of Bengal, my unruly eyebrows are the bane of my existence.) She proceeded to cover my “flawless skin” (not without an allergic salute, a subterranean comedone and a few straggling thick eyebrow hairs) with several layers of “face primer,” foundation, rouge (“Dallas: An Outdoor Glow for an Indoor Gal”), mascara, eyeliner, two types of eyeshadow, eye concealer, and for the finishing touch: “Flirt Alert” lip gloss. “This will cover the dark circles under your eyes,” she cooed, referring to my insistent allergic shiners. It has been a rough Spring.



I stared at the new face in the mirror for a few seconds and then awkwardly left the counter, thanking her. I was acutely self-conscious, convinced that my fellow commuters were staring at me on the long BART ride home, with my new saucy version of the Jane Goodall look I typically aim for during periods of leisure. I felt like a child who had snuck into her mother’s vanity drawers. As I embarrassedly glanced around, I also became aware that most women wear make-up, some with more subtlety than others.



My yoga class made me less aware of my face, and more aware of my inability to lengthen (or is it strengthen?) my core, which I am loathe to even locate in its formless, buttery state of being. The room was packed with yoginis chubby and thin, male and female and led by a peripubescent teen who had the cadence down, complete with crescendo and the decrescendo, voice riiiising with every inhale, and releeeeasing with every exhale. But her timing was a bit off...and a bit hurried for my liking. Never would I have imagined that I would have a yoga teacher who was literally half my age at this stage in my life. I spent the better part of the last 20 minutes staring at the fiberglass ceiling waiting to enter shavasana. The corpse pose.

I ambled home with a slight limp, picking up some dinner on the way. I had forgotten all about my beauty break. D walked in, took one look at my face and exclaimed, in as much horror as amusement: “What happened to your FACE?!”

And that is exactly why I married him.

****

Though we had met face to face only twice before, we had many long conversations over the phone, mostly about her regimen for constipation, on occasion about the bigger picture: how was she going to continue to live by herself?

“Oh you look so pretty!” she marveled. I am by no means under the delusion that “prettiness” is an attribute I own. But youthfulness I have, despite the several gray hairs that find their way through my short black pixie cut. And it was this, my young, open, unadorned but unwrinkled face, that was in stark contrast to Mildred Silverman’s own textured skin, her slate colored eyes only accentuated by a light blue eyeshadow. I thought to myself that she too was once pretty, but failed to be able to envision any other form of the face in front of me, a sweet earnest face with many reliefs and topographic edges.

She naturally proceeded to talk about her constipation. I politely interrupted her to first ask whether she had seen any of the assisted living apartments we had discussed previously and second to probe more about her 8lb weight loss in the last 6 months. At a mere height of 4’8”, the 117lbs she carried mostly consisted of a comforting adiposity that supported her hips and girdle and likely protected her from osteoporosis. But she was about 125lbs the last time we had met; concerning for a woman of 84 who was not in a position to try to lose weight.

“I guess I just haven’t been eating. Who wants to cook for yourself?”

She grew up in an orthodox multigenerational Jewish family, and raised her kids in the same tradition, only to find that they chose to chart out their own paths, a path that involved marrying goyim and not keeping kosher. I felt my own face grow warm when she spoke of her Indian son-in-law and wondered aloud why she had always been anemic and her son-in-law, who is vegetarian, seemed so robust.

(Iron supplementation was never an option for her because of her chronic constipation. She has had colonoscopy after colonoscopy which has only revealed outpouchings of the colonic wall known as diverticula- which can be a source of bleeding and more commonly is caused by low fiber diets and poor bowel habits. It is a vicious cycle, one that a typical Kosher diet probably does not help.)

She grew tearful as she thought of her aunt reprimanding her when she threw away her kosher meat as a young woman. “There was just so much fat, I couldn’t eat it!” She confided to me that she sometimes saw them, her whole family, in her room at night. “And when I open my eyes, they are gone. It is only me who is left.” She missed them. Every day.

Her daughter and son live nearby, busy with their own careers and growing families. “My grandchildren are all I live for,” she sighs wearily. We go over the options again and again. The lack of kosher dining options in the assisted living residences which are closer to her family. The presence of kosher dining options in the residences which are further away from her family. The expensive ones. The less expensive ones.


I tell her I am worried. She is not eating. Her place is quite cluttered and she could break her hip. (I know this because I have had what we call a home safety evaluation done. She is a hoarder and has kept clothes in her closet that have been with her since the age of 16.)

In the end I could only get her to agree to at least pay for in-home support services. What she really wanted was for someone to stay with her at night. She is fraught with panic attacks.

I think about my own parents 20 years from now. Mildred’s story is not an uncommon one. It is an archetypal American story. A 21st century story. Grandmothers who began their lives in a culture in which the family was central and everyone’s business was your own. Grandmothers who now face the end of their lives in a culture where individuality triumphs, families are fractured and no-one’s business is anyone else’s unless you are on Facebook. It is funny how internet social networking is seen as a treatment for depression and social isolation when in reality it only mirrors, and at times enhances, our own alienation. We live in a time when you can’t walk down the street without talking into a cell phone, you can’t drink coffee at a café without text messaging your friends, you can’t have a day off without updating your status. We are desperate to feel connected, and have effectively disconnected ourselves from our experiences and our lives.

Perhaps I should encourage Mildred to keep in touch with her grandchildren on Facebook. It may be her saving grace, for the few years that she has left.

Cutting Loose.

"I'll give you 20 dollars if you cut me loose!" At 75, she was petite and spry, her legs dangling across the bed railing, her arms gesticulating wildly. Unrestrained, sassy and delirious. Just after extubation in the windowless confines of an ICU room.

She cut herself loose not long after, and died a peaceful death after she was transitioned to "comfort care."

By month 2 of your intern year you learn how to make this transition quite deftly. You explain, tactfully, but not excluding some of the vivid details, of the process of resuscitating what is, for all intents and purposes, a dead body. You explain, sagely, that it may cause more suffering and sometimes cause irreversible injuries to the brain. You give families a choice that they rarely ever want to make. Some patients and families are ready. Others aren't.

You realize that paternalism is not always a bad thing, and "autonomy" is not always a good thing, especially when you ask families to speak "autonomously" on behalf of the patient. And you are constantly striving to redefine those words and negotiate your place between them.

Since month 2, you have had strong opinions about this matter. The answer is easy when your patient already suffers from severe dementia, has widespread metastatic lung cancer and is 95 years old. Medical futility.

Primum non nocere. First do no harm.

For the first time in a while, I found it difficult to cut a patient loose, in spite of his persistence. He was in his mid 70s, a jovial Creole gentleman with a really bad heart. His heart failure specialist had determined that he was not a candidate for advanced therapies and thus he was on my service. My goal was to send him home with palliative therapies. And so we tried to "optimize" his heart failure regimen, with diuretics and medications to help his heart pump, but each change seemed to make him feel worse. And I could not let go of the fact that we were doing more harm than good, and all I wanted to do was change things back to "the way they were." Before he started to feel worse. Before we threw on the lasix drip and the dobutamine drip and the milrinone drip and everything.

We spent two weeks chasing numbers. Creatinine to measure his kidney function. Jugular venous pressure to measure his intravascular volume. "Ins and Outs"- how much fluids he took in, how much was he urinating out.

But he had his own ideas. His idea of "the way things were" were vastly different from my own. In my version, he was the jolly old man in a chair, watching Haiti on CNN and comfortably eating his cardiac/renal diet of bland eggs without seasoning and home fries. In his version, he was home, walking around, running his errands with a little bit of shortness of breath now and then. And when we made it clear that he was not going to be able to be that person again, he wanted out.

He kept telling me that he was feeling weaker and weaker. And all I could think about was the fact that we were doing something to him. Like most patients with severe heart failure, it is impossible to find that balance between getting fluid off with diuretics to improve the dynamics of the heart's "pump" and making him pee so much that he becomes dehydrated. If you don't find that balance, the kidneys will fail. Assessing a patient's "volume status" by virtue of the clinical exam can be even more challenging in someone whose has pulmonary artery hypertension from other causes- in his case scleroderma.

In the last 48 hours, I became fixated on the idea that he had digoxin toxicity from his now worsening kidney failure. This can cause obscure neurologic symptoms, GI disturbances, heart arrhythmias and malaise.

But so can heart failure.

He finally said to me, "Doc, I am ready." And I finally listened. He told me that I "had done a good job." And, for the first time in a long time, I wept. Right there in front of my team, in the hospital.

Cutting loose.

"I am glad in the end we could be friends." This was the last thing he said to me today. Whether I will see him tomorrow remains uncertain.

Most of the time, transitioning someone to a more comfortable death can be one of the most powerful and gratifying experiences a physician can have. Those were some of the most profound experiences I had as an intern.

I am at a loss to explain why this was so hard for me now, 6 months shy of the end of residency.

****************

She was 81, chattering away at the nurses' station in Cantonese, looking splendid in her leopard print pajamas and Adidas running shoes. She refused to go back to her room because she did not like her male "sitter." The alternative euphemism, coined at the county hospital, for these individuals who watch over our cognitively impaired patients is "coach."

At the VA, the double doors to the lowest acuity floor have the following sign: "Wandering Patients: Please leave doors closed."

I hope that one day, when I am a little old gray haired lady with dementia that I too will have the wherewithal to sport leopard print pajamas, and more importantly, running shoes. Lest I ever feel the urge to cut loose.

the freedom fighter

“Obama!” my grandfather’s younger brother declared, “Obama… celebrated Deepavali last week! Eh?” He was making sure I was listening. I was sitting on the veranda on a leather recliner between the two of them, staring at a thin layer if skin that had formed on the surface of my lukewarm tea. It was my 3rd cup of the morning, having visited 2 other houses already as part of my grandfather’s full agenda for me. To refuse the tea would have been rude. As it was, my American-ness, my limited ability to speak the mother tongue and consequently smile rather dimwittedly, was all too palpable. And unpalatable.

The leather recliner should have seemed oddly misplaced in this garden straight out of a Kipling novella. But it wasn’t.

A mongoose ran across the path through the garden.

“Obama! Is a disciple of Gandhi! He said this last week!”

“Hmm? Hmm.” My grandfather nodded sagely. “Anyway it is good that America finally has a negro president.”

I cringed, and contemplated bringing up the political uncorrectedness of that statement to my 87 year-old grandfather, a former “freedom fighter” and chemical engineer. I decided against it. I mean really, what right do I have to correct the man who was imprisoned at the age of 24, for his “passive resistance” against the British in the Quit India movement so many years ago? What have I done with my life other than get flustered by the circular discourse of the theorists and the academics in the post-colonial period and my overwhelming inability to speak a cohesive sentence?
************************************
Jet lag, I soon found out, is not the same thing as taking call. Every morning, no matter how little sleep I had gotten the night before, I would get up between the hours of 1 and 3 am. I would stay awake until I saw Achappan’s light turn on and heard him slowly shuffle into the bathroom. Just as I would drift off to sleep, the radio would turn on, first the soft humming of a mridangam which would progressively get louder, followed by a charged but harmonized Vande Matharam. "I Bow to the Mother," the call to rise and revolutionize, first sung by the Indian National Congress is 1896.

A dramatic opening of the wooden doors would let the light into to my room and I would hear a soft chuckle.

My body would be stiff from the hard mattress, my legs hyperextended and locked and my elbows taut and slightly rotated outwards, causing me to wake up with a tingling sensation radiating to my 4th and 5th digits. Bilateral ulnar radiculopathy- I had managed to hit both my funny bones simultaneously each morning. I would slowly rise, pat down my hair, and greet him with a weak smile.

“At a certain point, the parents have to obey their children,” Unni Achappan lamented. That children are an investment had never occurred to me until my aunt clucked her tongue at the fact that her aging aunt did not have any children of her own. You have children initially against your better judgment, in spite of the fact that you have limited resources, because you know that once you age, if you are so lucky (or unlucky) to age, you will have no-one to take care of you.

My mother's father, however, is a freedom fighter through and through. He refuses to obey his children and is determined to stay alone in his home of the last 30 years, what was previously a coconut shed, instead of living with any of his three children.

I watch him sit across from me. A gecko scrambles across the wall. His lips are moving, constantly reciting prayers under his breath. But his mind is far from still.

*******************************************
I am watching a sparrow hop and slide across the marble floor of the café in Bangalore’s swanky new airport. And I wonder, how much has India changed in my lifetime, let alone his?

I also wonder- if we are all to aspire towards a state of silence and mind unstirred then we are all a lost cause. Because the most venerable saintly man I know is never without worry, never for himself, always for his children.

And perhaps, abstractly, for Mother India.

lymelight

On why a patient had a bowel resection many years ago:
"I didn't even want it any more. It was full of shit!"

*****************

On why a patient once insisted that he could not take oral pain meds:
"Why can't you understand this. I am ON METHADONE. The methadone EATS the dilaudid. It ain't gonna work!"

************************

Pulmonary attending, on listening to a patient's lungs: "You sound really junky. Do you feel junky?"

Patient, forlornly: "Yeah. I am a junky."

My attempt to suppress a tear and stiffle a laugh when I watched this encounter manifest itself as an awkward post-call snort/sniffle. I watched this puffy, blue-hued man struggle to get a deep breath in.

And I sighed.

I don't know a single resident who does not agree: Chronic pain is painful...for everyone involved. But somehow most of us have more tolerance for the chronically inebriated and addicted than we do for the ones that perhaps look like us.

A junior resident wondered aloud if we could practice medicine anywhere outside of these United States, would we find as many people suffering from chronic pain?

Perhaps they have all been infected with Lyme disease.

I wish I could say that with more authority and less mockery. Checking for Lyme is not uncommonly part of the work-up for chronic pain. But those of us who have treated pain know that it is more often than not a somatic symptom. So we pull out the cymbalta and the imipramine, drugs that have historically part of the psychiatric pharmacopeia that are now in our armamentarium for chronic pain. We compulsively sign pain contracts to keep track of every opioid we dispense. We periodically send urine tox screens to make sure that the opioids are truly in our patients' bodies and not being sold to feed their meth habits.

We remind ourselves daily that we are treating an organic disease, that pain is mediated by a complex neurochemistry that many of us are loathe to understand.

Physicians find solace in the tangible and the sometimes grotesque: a laceration, an abscess, a fungating crusting skin lesion. And things that are less tangible are rendered so with the miracles of modern radiology that can detect tumors as big as your fingernail. I'd like to think that internists are the exception, that we dissect and pontificate and analyze. We are exacting, discerning, cerebral. But in the end we are truth seekers just like everyone else, and in the end that is often our demise. The truth is more often messy than not.

Since I began residency, I have suffered terrible migraines, chronic knee pain, overwhelming fatigue and now more recently neck pain. I can rationalize each of these symptoms- sleep deprivation, inappropriate footwear climbing up and down stairs when rounding, sleep deprivation, falling asleep on the couch in an awkward position, sleep deprivation, vitamin D deficiency. (I kid you not- my vitamin D levels were nearly undetectable.)

I was LIVID when my husband, also a physician, jokingly suggested to me that I have fibromyalgia. How dare that he imply that my symptoms were not rooted in the tangible?

The organic?

But the thought of starting an SSRI has not escaped me.

And with that, I leave you with this sobering statistic from the World Health Organization.

"Depression is the leading cause of disability as measured by YLDs (Years Lost to Disability) and the 4th leading contributor to the global burden of disease (Disability Adjusted Life Years) in 2000. By the year 2020, depression is projected to reach 2nd place of the ranking of DALYs calcuated for all ages, both sexes. Today, depression is already the 2nd cause of DALYs in the age category 15-44 years for both sexes combined."

moo

so what's up with all the cattle references in American politics?

The Best Medicine.

Seen and heard on the floors during my first two months in a long white coat:

Q: Have you ever used any substances such as intravenous drugs or cocaine?
A: "The only dope I've ever been addicted to is my husband!"


As several doctors and med students peer at his jugular vein to determine his central venous pressure, Mr. J remarks, dryly:
"You're so vain. You and Carly Simon."

Kindly admit to Med unit III

It has been about 6 weeks since our Air France flight landed in Bangalore. I remember peering out my window at 4 am IST, city lights aglow, making this city, this Country indistinguishable from any other. "It's deceiving," I told Dave, who was still half-asleep. "You think it's just like any other, but you don't know..."

I can safely say, that 6 weeks later, he now KNOWS. Like any other pardesi desi, he understands the congestion, the openness, the immensity, the smallness of it all. Madness.

We spent three weeks in Kerala, God's Own Country. And if you looked from above you would understand that it is true. First the hilly mountaintops lined with palm trees. Then miles and miles of flats, lined with palm trees. Then iridescent waters rushing the coastline, also lined with palm trees.

But the land and the people are changing. And with it my vision. We spent two weeks listening to the stories of sex workers in Kerala. Yes my friends, there are sex workers in Kerala and they come in all different sizes, shapes, colors, creeds. Fiscally liberal, socially conservative Kerala has a growing HIV infected population. And the women are mobilizing, forming unions, pukka communist Kerala style. They are determined. They will not become victims.

I am so proud.

It is hard not to be religious in God's Own Country. All the Hindu sex workers go to temple every morning, after "taking bath." When I see them, their wet black hair is neatly pinned back, one long braid falling straight along their spines. A red line of kum kum dons her forehead. She is a pukka Kerala beauty.

The Christian ammas don't look terribly different. In fact, most of the time I can't tell, unless they tell me their names. Perhaps they are without kum kum. Instead a beautiful 22kt gold cross falls elegantly around their necks.

The Muslim chechis wear hijab, only covering their heads, not faces. They wear saris or salwars.

It is hard not to be religious here, because there are temples, churches and mosques at every corner on every street.

But even God's Own Country is changing. Five years ago we would hear about the riots up North. But the violence is infiltrating our land and fundamentalism is making its way. Now the "Riots up North" doesn't refer to violence in Gujarat or Delhi. It refers to violence in Calicut and Kasargod.
~.~.~.~

"Bangalore has changed alot," she said as she watched her chubby 10 year-old girl unhappily complete another lap around the tennis court. "They used to call it 'The Garden City.' Pensionner's paradise.

I watched this perfectly coiffed, manicured Bangalorean mother in amazement. She had grown up here, spent her whole life in this city, watched it evolve into the congested smog-filled IT capital of the world it is today.

I saw her a couple of mornings later at the gym. I was sweating it out in my green Champion men's basketball shorts and blue High Sierra Cubs shirt which spent one too many washes in hard water. My legs had a not so flattering coating of coarse 3 week old hair.

And she was elegantly dressed in stretch pants, a tank top and coffee coloured lipstick. I was jealous because she could do a pull up, one more than my challaballa Ningileri arms could ever attempt.

I had this strange feeling that I wasn't in India anymore Toto. I think I somehow found myself over the rainbow and in Marin County, California.

Yikes.
~.~.~.~

Every admission note I see on the floors have the following (polite) instruction: "Kindly admit to med, unit III."
And in the days before match day, I find this hauntingly prophetic.