In Candlelight

Beirut, March 2012

In candlelight the glass doth glow

One look at it and you will know

That when a day just took its toll

The wine is here to launder all

In candlelight the glass runs low

These sips of wine will just not throw

All of your troubles, here to stay

So please my friend just drive home safe

Nothing like sleep, ever will fare

In wiping off that nightly glare

It all starts with a nodule...

We are taught by life to greet people with courtesy; always smile and say something nice, always ask how people are doing. You enter a sick patient's room on the morning rounds and say something like: "Hello sir, how are we doing today?", and hope for some optimism and a smile in return. Try doing that on the oncology wards. On a few of my first patient visits on the oncology floor, I was caught off guard by a 38 year old patient with a body torn up, on the inside, by a uterine cancer. Now in the terminal stages of her disease, N. answered my question in a way I was never ready to handle.
- Me, entering the room for the first time, smiling: "How are you today Mrs. [...] ?"
- Her, stating the obvious, pointing at her distended, asymmetric, diseased abdomen: "Well, how do you think I'm doing?"
Realizing the retrospective absurdity of my question to a woman with a mass the size of a basketball inside her, and many other little ones scattered around her frail and broken body, I froze for a second, and nodded, with my stupid, embarrased smile still stuck to my face, and proceeded to interview and examine her, gathering a few pieces of information to write my stupid little note in her chart.
How? How can you be pleasant to a dying person? I'm still learning here... perhaps learning that oncology is the single most impossible specialty for me to work in. Oncology, cancer, that indiscriminate, slow killer that catches persons and tosses their bodies around for seeming ages.
Cancer means you see your patient on Friday and think he's doing a bit better:
- Mr. H, a nice and unfortunate old man: "Thank you doctor for coming to see me, it makes me stronger"
and then you go away for the weekend and on Monday you hear the news that Mr. H passed away on Saturday, his son's wedding day. They tell you that Mr. H's son had been pushing since thursday for a discharge so that his father can die in his hometown, and to kindle a glimmer of hope that his father would get a chance to see his son get married, even if he has to feel this fatherly pride in a wheelchair. No such luck.

It's too much for me to handle. Too much to see this losing battle day in day out, too much to see so much suffering. Too much to see so much harm coming from what started as a small nodule, a small blip on a chest radiograph... Not for me.

The ER Delivers...

Bring it ER, Bring it Med IV... That was the closing sentence in my Beginning of the End post. Excitement and ambition.

I have to say that today, the ER delivered. Today, I couldn't help but think that what was happening was some kind of response to what I wrote and felt a few days ago when I was just starting out...
The ER never faltered, even in the med III ER rotation, in showing us how little we knew, and how completely unprepared we can be for handling situations and patients beyond our qualifications.

Cruel Discussion and Modern Medicine

Overheard at the OPD Pediatrics Clinic between physician and a patient's mother.

Mother: What can we do Dr. N?

Dr. N: There is a new and effective drug for what your son has. But it's too expensive. Neither you nor I can afford it.

Mother: So what's the solution?

Dr. N: ..........................................

P.S. I will elaborate on the case soon.

Drafts from the Past

For a few days now, I'd been wondering how to get back on the blogging track. For me it's one of those times when you have a lot to write, but not enough time. So much to write you can't just cram it into one post and expect it to make sense... So I thought why not see what I had been up to before my unjustified hiatus...

Here's to fishing a few drafts from the past, a few posts that were never posted. Figured we'd go from there!

August 22, 2009 - A Med Student's First Patient Crush

"Well here it is. It finally happened... It had to, I guess it was only a matter of time. I guess it's always only a matter of time before any med student gets infatuated with one of his patients. I had to check on a total of 6 patients yesterday, and these include two patients from my previous post.

So after a long on-call day at the hospital, I get beeped for my last admission of the day. I thought to myself, "here we go. One more intestinal obstruction or jaundiced patient and I'll be on my way..." And so I got to 7 South. I saw Dr. K (one of our residents) and R. (a visiting student from Syria) at the end of the long hallway leading to the desk. As I got closer, I started hearing tidbits of what they were saying, and the little that I could put together was "She's status post whipple procedure in 2007".

When I heard this, I tought "ok, here comes another 90 year-old... [end of draft]"

September 26, 2009 - Enraged Med Student Slays Many in Elevator Frenzy.

"What is wrong with people? What is wrong with Lebanese literacy? what is wrong with normal psychomotor and cognitive development?

You're probably wondering why I'm asking these questions... Well let's see. In order of appearance and respectively, here's what they... [end of draft]"

November 6, 2009 - Some Will Never Learn...

"Ever wonder why you seem to keep making the same mistakes... [end of draft]"

December 24, 2009 - Wandering Attention, You're Welcome

It's 2 am and I'm awake, wondering what it is that drives the seemingly coincidental encounters, the apparently arbitrary events, large and small, that seem to just explode in apparent randomness until they inevitably crash back together and make up that mess that we call life... [end of draft]

I had been thinking about a few of these posts, the few worth posting, that is, and wishing I had posted them when I remembered more of what made them worth writing. But I have to say that while a bunch of fine-script details are lost to hazy recall, some memories are tenacious and come out vividly as soon as they are elicited.

Like L., my 26 year-old patient with not only the most intriguing and sorrow-inspiring medical history and problems, but also with the most unforgettable face and big blue eyes and out of this world sweetness one could imagine. One of the many patients I will never forget.

Or that insane feeling I get everytime I get in the elevator at AUH and people start pushing and shoving to get in before anyone has a chance to get out. When they look in at some of us 'elevator insiders' and ask: "Going up?" with that bewildered look on their faces! And finally, when stuck in a packed elevator for 10 floors with a stop at each and every single floor with agonizing slowness and the same sketch of pushing, shoving, and moronic questions, the nice feel of less-than perfect hygiene: the 9 out of 10 people with breath odors prompting the eloquent question: "WTF???" and let's not forget the 8 out of 10 people with body odors worthy of wildebeest! I used to think about that frenzy every day! "LOOK OUTSIDE YOU MORON! THERE'S A LARGE ARROW POINTING EITHER UP OR DOWN! AND GUESS WHERE THAT !@@#$% ELEVATOR'S GOING!! AND TAKE A GOD!@#$ SHOWER AND BRUSH YOUR GOD AWFUL TEETH!" Oh that felt good!

As for the last two drafts, I can't seem to remember what I was on about. I'm sure it would have been interesting though!

Ok so there was my flashback. My way of dotting the i's and crossing the t's paving the way for a few more memories fished from the past as I catch up.

No Comment...

No comment, because I can't say how it feels to connect with someone like you do when that someone is your patient. And even less when you spend hours in that room talking and talking and end up wondering if you'd ever meet someone as interesting, as insightful as them, and with a story as captivating as theirs...

There's no describing it. Much like there's no describing what it felt like when I got this note after saying goodbye to Mel, who was leaving the country for good. It felt like saying goodbye to an old friend.

Goodbye Mel, All the best.

Dear Sarah...

I came in and you were there. I sat at the table and you were around.

With your fresh looks, you stood out from the crowd. With your enticing smile, you caught my eye. There is something about you that played with my mind all night. Is it that smile? is it your hair? Or is it just as simple as your being at such odds with all of our dearly held ideals, self-ordained stereotypes and mundane ideas and clichés of the laws of attraction, that I just couldn't let it go?

So I told you. And from that moment, you knew my secret. You blushed and smiled. I did the same.

I was struck, and I knew so little. At an unfair disadvantage. But I will brave it.

I told you, and it wasn't that simple. He has your heart.

It's not to be. Not for now, maybe not ever. Or maybe...

Thank you for a pleasant night.

Yesterday, the day it all went wrong...

Have you ever felt like a stone surrounded by glass? Like you couldn't make a move without something or everything shattering and crumbling down in a deafening rumble and screaming racket? Minutes or seconds later, you look back: nothing more than a hole in the ground, where once all the great plans you had just built up seconds -or years- ago stood tall. Nothing left... Be it an hour, a day, or an entire lifetime, actions and their consequences are the same. Well at least they act the same. With a little hindsight on things that have happened in my life as far back as 15 years ago, or as recently as yesterday, I realize how strong and steady of a truth it is that when you make decisions, life starts moving so fast that it's not like you're moving through it anymore. It just starts happening to you.
It's strange to realize that this holds true at all scales... Whether it's your career choice, or that crush you decide to finaly do something about after so much hesitation. You just make the slightest move and it puts in motion some restless unstoppable mechanism, like thousands of cogwheels all spinning, each at its own speed, but all equally inexorable in their relentless thundering stride toward that common end point, like an army marching to the Valkyrie.

Here we go. I didn't know I was on one of my late night ramblings again... I didn't get the memo! I'm rambling again. It must be the melancholy found in the resignation to a few concequences of a choice made in the past, no matter how distant, with a certain goal in the future, no matter how remote.

Our Humble Beginnings... Who Are We?

It is a the end of this one-month vacation that I realize that we are at a new checkpoint. For those of you who remember, I was rambling about time and how we seem to be pissing it away by the years and decades without even wondering where it went. But today, I stand before you a changed man *grin*. Changed by the beneficial effects of that exquisitely inculpating farniente month that just seemed to rain down from the heavens. And is difference a beauty or what?

Here, we're contemplating the onset of a new, 2-year era, a new setting and a new context in our lives, as we peer through that door, ajar, on the threshold between books + exams on the one hand, and the patients + associated responsibilities + real medical practice on the other. On Monday, tomorrow, we begin our 2 clinical years, as well as the beginning of the second half -and end- of our medical training.

It is at this opportune time that I started thinking back 2 years ago. When Le and La Colleague were nothing but strangers to one another, and I thought I'd catch us up on how it started... For simplicity, I will be Le Colleague, and La colleague will be the "She".

Some time around the end of August, 2007, the first day of med school for 83 students from AUB, adding 2 from universities abroad. She was one of these two. The first time I laid eyes on her, I knew that our love story had begun. REALLY??? Wait it's that glass of whiskey talking. Let me rephrase. Hmm... let's see. She was hanging out with the wrong crowd -as wrong as it gets if you ask me-, she dressed funny but I've never told her, hair looked funny but I've never told her... -need I say more?- we were casually introduced, and I looked away and made no note of it, just another med student in the sea...

The next few days didn't get any better, as we had our first meaningful encounter at the Saab Medical Library. If memory serves right, someone was on the phone *cough* and another someone was all pissy and "please can you keep it down?" with a serious frown and "woe is me" (La Colleague 2007). It was all downhill until we had one crucial conversation at main gate during that skipped class (what was it again?); that conversation was to prove a landmark, a milestone without which no further contact would have been made. That made me realize back then: hmmm... we may be on to something there...

Here's to you...

Keeping the story short, we sure have come a long way since then, La Colleague became La Friend, and perhaps La Baby Sister (although there's nothing baby about her, so don't get me wrong on this) and now as we look ahead for even better times, I can't imagine how everything would have turned out if she hadn't been so interesting to talk to on that fateful day at the gate. Ups, downs, crazy days, relaxed times, easy sailing and rough seas, we've seen it all, and I don't see why anything would change.

I don't know about you, but it's just sinking in right now; the day before the beginning, before we start getting the feel of real medicine, and I couldn't be more excited if I tried. So here's to another 2-year batch of heaven and hell, and many many more to come.

"Quelque chose de pas très propre" . . .

"Quelque chose de pas très propre" -translation: "something that's not so clean"- said A. with a trembling, worried voice over the phone. It took me a few seconds to realize what on earth she was talking about. And I still had to ask her, I wanted to hear it.  "You know what I'm talking about", she uttered in a shy, now reserved voice. 

So that's what they're calling it now? She caught me off guard, I have to admit. I had heard all kinds of nicknames, from the shiest "haideke" (the other one) to the boldest "el marad" (the disease), but never had I heard about cancer being called "something not so clean". It came as a shock; I have known A. all my life. In fact I grew up under her watchful eyes, ate her wonderful cooking, and she tucked me in countless times, I watched her get sicker and sicker over the last 15 years of my life. Fighting asthma, diabetes, repeated hernias, age that's getting older and older, A. looks weary, as she barely stands, 70 years old, and a mere few steps away from giving up on living in a body so spent. We talked many times of her diseases, and I reassured her as much as I could, listened to her complaints and resignation to a disease-laden life, but I had never heard her talk about that 'unclean bastard' before in my life. An awakening? Fine, call it that. It hit me like a truck, that's all I know. 

Lately A. has been calling me regularly to report what her doctors have been  telling her. She has more faith in her grandson and future doctor, I guess. All the tests she'd been getting done, the results and what they meant. Her recent worry has been a chronic anemia, her hematocrit having dropped to the low 20's. She and her doctors have not been able to treat it effectively despite supplements and diet considerations. This means that there has to be a loss of blood somewhere. Gastro intestinal tract bleeding is a prime suspect in these cases, and the doctors ordered an endoscopy.

-A: "I am scared, R., really scared of the results"

-R. "What results ya A.? what are you talking about? You haven't done anything yet!" 

-A: "That there may be something not so clean in there my boy"

-[...]

-A: "You know what I'm talking about"

A. is on more medications than I could count on 2 hands and 2 feet, I don't even know what conditions they're supposed to treat and control. The first time she talked to me about her intractable anemia, I thought "bleeding ulcer"; all these meds can't be doing her stomache or intestines any good. I have to say I never even thought about cancer. Denial? I don't think so. But may be... No, surely not... 

Another Sunday Night, Monday Morning?

Yes... here we go again. And no, I'm not whining this time. Wow! Is it numbness to stress? Learned helplessness to the runaway clock? No, not really. Just feeling indifferent and disinterested this time around I guess. When I stay up late in my room, I feel like I'm getting hints of what's going on outside during the late hours of the night. These samples come in the form of distracting but interesting noises ranging from the rumble of an 18-wheeler driving by Southbound, to the engine screams and tire shrieks courtesy of that maniacal neighbor in his "watwat (Arabic for 'bat')" Beemer (Lebanese Jargon for the late 80's model BMW 3 Series Coupé) driving donuts round the conveniently empty intersection a couple hundred meters from my home, to the essentially worrisome, reassuringly distant, but worryingly nomadic sound of machine gun fire disturbing the peaceful moonlit night (YES, true story!). Did I mention it was past 3:00 am? Quite interesting, really! Most days of the week I'm fast asleep, clenched fists, and completely oblivious to everything that might be going on outside! I should do this more often!
For the curious among you, here's what my desk looks like tonight. Quite the way to spend the better part of the night, huh? I want to be about 20 Km away, drink in hand.

Ok enough with the night-time daydreaming. The noise has subsided. Screw this week's exam I'm going to bed!

Now Two Different Persons...

I remember the hype right before the Christmas break last December. I remember how I felt, on our last day of classes before our 14-day (or so) break. (Needless to say that a 14-day break in Med School is nothing short of a trip to heaven).
I felt light. Relieved. Granted, It was not my first time looking forward to a long awaited, much needed break, and yet, the feeling was unique in a way that I cannot put to words. December 24, 2008, we went out for lunch, a bunch of close friends/select classmates, meeting with expatriated childhood friends who had just flown in from respective countries, and the atmosphere was just fantastic. I felt light. relieved. I felt different, and silently baffled at how good it felt to feel different, and how long it had been since my last similar moment. A glass of wine helped. Later on it took a bunch of my friends, who noticed the difference, a few minutes to describe to me how they saw me from the outside. They said I was a different person when I was taken out of the academic atmosphere. The atmosphere of constant stress, constant information binging, and constant evaluation and scrutiny. Apparently there are more smiles, pleasantness, jokes, and less worrying. That made me a different person. So what's unique about that? Everyone is different under stress right? The problem is, this was the perception that I had of my personality, and it was supposed to be the case no matter what the context. My affect in this atmosphere was supposed to be unchanged no matter what. I made sure of it, and was complimented on it by many friends. I am now different. Apparently I cannot maintain my laid back character anymore. Things get to me more easily now.
When did I change? How and when did I change so much? And could I have changed so much without even noticing? Not the slightest clue! I don't know... It's hard to sum up, and hard to pinpoint exactly when or how this change occurred. That's Med School for you. I guess the last 2 years of my life have gone by in a flash. And a flash may even be too long... that's how fast, yes. I can't help but carry this thought further back into the dark alleyways of my memory and try to remember the last 'checkpoint' in my life that feels genuinely distant in time. I can't find one. I could wind up all of the 26, soon to be 27 years of my life in a heartbeat, and It's a frightening feeling.
So here I am, on another one of my late-night musings, typing away with a Gastro-Enterology book obstructing my reach, thinking that oddly enough, it is now Monday morning, rather than Sunday night, rather than Saturday afternoon... Where did my weekend go? Might as well have been last Monday, the one before that or the one before... Same difference... Yes, here I am, Monday, March 23, 2009, at 1:35 AM, with a lost track of time, anticipating (for a change) the change that I'm about to exhibit "tomorrow": Friends have flown in, exams will have let off for a little while (Upcoming exam in exactly 6 hours and 25 minutes).
I wonder what's in store this time...

The 3:00 A.M. Outlook

It's 3:00 A.M. and I find myself thrashing in my Renal Pathology slides trying to make things stick, and what better, more potent distraction than the seemingly grim outlook on life, career, and future as looked at through the pessimistically polarized prism of present dissatisfaction and knowingly unjustified fears of complete, utter, and miserable failure? I've told people repeatedly, and I've been told repeatedly, that life just has a way of working out in the end, but somehow, for some reason I just can't see it right now. Sometimes, instead of fears of complete, utter, and miserable failure, you get scared of a life that ends up being sub par, somewhere below self-set standards and ambitions and it's just as scary when so much time and effort has been put on the line. The obstacles are just too many and the premonitions too ominous for even an optimist such as yours truly to overlook... well they are, at least during a 3:00 A.M. last minute cramming session... I need my sleep.