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.