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The Storyteller and the Stethoscope

Across each time zone, hidden from the light of day, hundreds, perhaps thousands, of people lie awake, unable to fall asleep. Some suffer from insomnia. Others are light sleepers and have their sleep interrupted by the loud TV or stereo downstairs. Some made the mistake of drinking an extra-large latté after dinner. A handful might even be on the run, whether from the police, a rival gang, or assassins sent by a mysterious power broker. And then there’s me, lying in bed with a throbbing, swollen thumb, cursing my own tired stupidity.

Just a few hours earlier as I was getting settled to sleep, I quickly reemerged from my comfortable bed and the warmth of my girlfriend’s company to close more doors in my suite and muffle the loud, rumbling bass of my neighbor’s music. As I slammed the door with disapproval, contempt, and weariness, I didn’t notice that I had placed my thumb between the door and the frame. It’s often said that paper cuts, however small, are so much more painful than large gashes and scrapes on much less sensitive parts of the body, like one’s shins or arms. If paper cuts expose the nerve endings in the fingers to the harsh air, imagine what it is like to have those nerves crushed and dozens more compressed by rapid, internal hemorrhaging.

Despite the pain, I decided not to go to the off-hours, college Urgent Care facility. The last time I went there, I had been punched in the face during an intramural soccer match, leaving a wide enough gash on my eyebrow to require stitches. However, I had to wait four hours before I received any care, even though I was one of two patients in the facility. I was not pleased. I ended up disinfecting the wound myself in the men’s room and using paper towels to stanch the bleeding while the nurses chatted the hours away. This time, I decided that it would be better to wait for the normal outpatient service to return in the morning.

Yet, here I was, lying on my back, restless, frustrated, and angry at just about everything that popped into my head. Angry that the urgent care facility was a joke (e.g. I wouldn’t be surprised if the first question they asked was, “Were you drinking?”, closely followed by “Are you pregnant?”). Angry that it was too ridiculously cold outside to venture out in the middle of the night to seek substandard care. Angry that despite my excruciating pain in my hand that felt like it was throbbing as loudly as the bass next door, my girlfriend was sound asleep beside me, oblivious to my state of misery. I started feeling sweaty and feverish and had difficulty deciding whether to keep the covers on to stave off winter’s bite or shrug them off to cool the delirium.

By the next morning, my nail bed of my thumb was, in full, the darkest shade of violet. My anger had subsided, but my feeling of stupidity was reinforced by my girlfriend’s concern and question, “Sweetie, why didn’t you wake me?” Somehow, biting my tongue about a jammed thumb didn’t seem so manly as it might have at 3 in the morning. We immediately went to the student health center as soon as the evening shift was over, and I was promptly seen by a doctor who came up with a quick solution: a cauterizer. He explained that the trauma to my thumb broke blood vessels that were pouring their contents under my nail. He was going to relieve the pressure on the nerves in my thumb by burning a small hole into the nail to drain the blood. If there was no damage to the nail matrix, it would simply grow out and my thumb would be back to normal in a couple of months. My girlfriend, in a more keen and cheerful mental state than myself, asked the doctor, “What is the Matrix?” I smiled in appreciation of the joke, but sadly the doctor didn’t recognize it and instead answered with a quick medical explanation. Well, at least I was in a stable enough mental state to appreciate jokes now. The procedure went without a hitch, and the pain was relieved instantly. For the next several weeks, I occasionally stared at the hole in my nail with the comforting observation that it was progressing forward to the edge and would soon be gone. And also, I would think to myself, “Well, that was easier than expected.”

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She means business. As soon as the young man in the white coat calls her name (”Stacy R.?”), she jumps out of her seat and instinctively leads the way back to the clinic. She suddenly realizes that she’s walking ahead and turns back to make sure she’s walking in the right direction. “This way, right?” “Yes, Ma’am!”

The young man introduces himself and a young woman in a white coat as medical students: he explains their roles, and assures her that the attending physician will be arriving soon. As soon as the first student pulls out his pen, Stacy launches into a rapid-fire recall of her chief complaints and history: she’s a young, recovering heroin addict with an annoyingly itchy (fungal) infection on both feet, among a laundry list other complaints. She’s a mother of one but divorced. She’s also a war veteran: honorably discharged for medical reasons. As the first student is frantically jotting down the details, she continues on with the real kicker: an accident during the war left her unconscious, and when she woke up, she was amnesiac and couldn’t recognize her own family. Her husband promptly divorced her and took their five-year-old daughter with him, and when she finally regained her memory some time later, she plunged from her straight-shooter life into despair and drugs. Now, a year later, she’s trying to get back on her feet again, with a promise from the courts that if she cleans up her act, she can have her daughter back.

Having told her story and seemingly inspired some empathy and eagerness to help, she’s happy enough to put up with the students’ double-examination. “Do her radial pulses feel weak to you?” the male student asks. “Heh, they’re fine,” his more experienced partner replies. “The four heart sounds sound good, but what’s the one that sounds like ‘Kentucky’ again? S3, right? I thought I heard one.” “Nope, her heart sounds good to me,” she says.

Eventually, the students finish their examination and present the case to the attending physician. “Do you believe this story? What sort of husband leaves his wife like that? Don’t get me wrong, she might be telling the truth. Maybe I’ve just been in this business too long,” she says. The first student replies, “Eh. I haven’t been in this business long enough.” They go in to see Stacy again, and the attending interviews her: her story checks out exactly as the students described it. The physician counsels her to address the issues one at a time: she’s still early in the detoxification and rehabilitation process, and there will be plenty of time to address the less immediate issues during subsequent appointments. Stacy is eager to have everything sorted out at once: she doesn’t want to waste time getting her life back on track. Nonetheless, she defers to the doctor’s recommendations and goes home with topical cream for the fungal infection. On the bus ride, she repeatedly thinks to herself to keep her eyes on her goal: I want my baby back.

I want to say a million things. I want to shake your hand again, redo our brief conversation, asking all the right questions and saying all the right words of encouragement. Hearing my friend choked up on the phone brought me back to that day, only a handful of months ago, when I ran into you at a coffee shop I frequent.

In the same way that all everyday tragedies begin, I have to admit that I didn’t know you well: maybe it’s an attempt to relieve myself of the responsibility of feeling overwhelming grief, or maybe it’s an acknowledgment that whatever I feel is felt a thousand times worse by someone else, someone closer to you. Nonetheless, with my backpack slung over my shoulders, full of medical school books demanding my time and attention, I walked into that coffee shop, shook your hand, and made small talk, happy to see a familiar face. As I always do, I asked “How are things going?”, and yet this open-ended question didn’t elicit the response that I, standing as a shadowy intruder in the memory of that day, so desparately long for. Or perhaps, as I dissect away the fragments of that memory, my preoccupied self, listening to your response, didn’t listen closely to the hesitation in your voice, the clues in your statements. Perhaps your humor and gregariousness masked your pain.

How could I have known that your father committed suicide half a year ago? Perhaps that was the reason why you were taking time off, and in my long absence from the world I once felt I reigned over like a prince, responsibility-free but respected and adored, I did not receive the news. Instead of staying to chat, I adhered to convention: a few friendly statements, getting the general public-safe idea of where we are in our lives, and then parting ways to return to our preset schedules. I probably went to the other side of the coffee shop to study Anatomy, or perhaps I was leaving the coffee shop when I spotted you or you spotted me. Would my time have been better spent if I sat down with you, asked you more about your life, and heard your story? My retelling here is lacking in detail, because I’m lacking the paint with which to paint your portrait.

Each day I get closer to becoming a doctor, I wonder what the effect of each death will have on me: will I become desensitized over time? There’s a certain sadness to diseases of the body, but these deaths carry a mixture of random chance, personal choice, and sometimes a blow to one’s professional self-concept. However, diseases of the mind, particularly in the mind of a friend, can make one feel at a loss as a person: it feels like a personal failure, not a professional one. People die all the time, and sometimes we feel more strongly about some than others. I’m not an explicitly religious person, but I do believe in a god, heaven, and hell. I believe that heaven is in the memories of those we have loved, those who have loved us, and every person we have touched in some way: they remember us, and we live on through them. Hell is being forgotten or being remembered in a bad light. If this is the way it is, I know where you’re headed, with your humor, your good nature, your creativity, and your warm, generous welcome. It is the deaths of good people that hit us the hardest, that hurt us the most.

Sitting quietly while the nurse inflates the blood pressure cuff on his arm, he keeps a straight face and listens to the music. He hates this tune: it’s agitating, like the loud rap that young kids blare from their rolled down car windows. Beside him, his wife reads a magazine, turned away as one would be to give someone privacy as he changes his clothes. They are a quiet couple and a satisfied one, having spent thirty-eight years of their lives together and having brought to life three beautiful children. It’ll be another seven months before the family reunites for Christmas, but by then, his first grandchild will be born. He secretly hopes it will be a boy.

The tune picks up again, and he shifts in his seat as the nurse makes her exit, promising that the cardiologist will be in to see him soon. He’s not too worried about anything he’ll say: he’s fit, well-built, and feeling as good as he could expect for his age. He’s never felt the panic and anxiety preceding a heart attack. And yet, there is a heaviness in his chest as he waits. Tight-lipped, he pulls in a thin stream of air, and blows out as though whistling, half-expecting some relief. A few minutes later, the cardiologist arrives, followed by another white coat. The cardiologist introduces the medical student, who greets him with a smile and shakes his hand. He doesn’t smile, but gives a polite nod of acknowledgment.

The cardiologist reviews his records: everything looks good. His LDL and triglycerides are down, his HDL is low but improving. The doctor then moves on to the question he was anticipating: “Are you still smoking?” “Yes.” The doctor says, “Hmm,” evaluating this disturbing detail. The man’s face remains expressionless. The cardiologist takes out his stethoscope, unbuttons the man’s top shirt button, and places his stethoscope over four points on his heart. He then listens to the carotid arteries in the man’s neck. “I’m going to listen to your lungs.” The doctor places the stethoscope on his back, and he breathes in deeply. “Ah, come here and listen to this,” the doctor says to the medical student.

The medical student fumbles with the stethoscope for a moment. As soon as he breathes in again, the student says quite suddenly, “Wow. I’ve always wondered why rhonchi are described as musical.” The cardiologist asks the man, “Do you want to listen?”, offering him the stethoscope. The man immediately says, a little darkly, “No, I can hear it already.” The cardiologist and the medical student sit down, and the doctor says, “Your heart’s fine. The problem is with your lungs. They’re going to quit on you, unless you quit. You really need to stop smoking.”

“I know,” the man says, noting his wife looking intently at him from the corner of his eye. The doctor asks if he’s tried using a patch or another smoking cessation treatment. “No, that’s not for me. If I’m going to stop, it’s going to be with the power of my own will.” He’s worked hard all of his life and never asked for sympathy, favoritism or crutches; he’s made a life for himself with his own hands. He’s not about to start now. The doctor says, with a note of skepticism in his voice, “It’s your choice on how you do it. But you need to stop smoking. Let’s set this as the goal for the next visit in six months.”

As the doctor and the medical student make their departure, the man and his wife stand up to leave. He knows what’s coming, and the tune rising from his chest is only the first sign of things to come. As he takes his wife by the hand, he feels her squeeze it a little more tightly than usual, and he feels a little more resolved. He’s no quitter: he’s not giving up this fight yet, his eyes tell her. But the music keeps playing, the same tune over and over again, like the song of the sirens drawing him closer, and closer, and closer.

Medicine, at its core, is a profession of storytelling: receiving, retelling, and acting. In light of suffering and disease, there is a powerful impulse toward telling others of our plight. As physicians, an important aspect of our role is to receive these stories: this early step in healing not only informs our later interventions, but it also serves as a method of healing itself. Though we seek to provide our patients with as much autonomy as they need and desire, there is considerable relief provided when you know that you won’t have to endure this suffering and fight this disease alone – there is an angel by your side. Physicians don’t act in isolation: we retell the stories of our patients, whether as medical students and residents reporting to attending physicians, practicing physicians consulting our colleagues, or even as writers of case reports in medical journals or presenters in M&M (Morbidity and Mortality) sessions. This is all part of the process of delivering medical care, evaluating mistakes or unforeseen outcomes, and improving the practice of medicine. Storytelling, furthermore, is the platform on which we build our humanity and our connections to others. Lastly, with the stories of our patients in our minds, we must decide how to act.

There is powerful symbolism in the one instrument that all physicians carry with them: the stethoscope. It emphasizes that in order to heal, we must listen: to the stories of our patients, from their minds and from their bodies.

Madonna

Like many, she was born to a family that had lost everything in the second World War. As if poverty in a land with little social welfare wasn’t a hard enough challenge to live with, she had an even more difficult obstacle in front of her: she was a girl. Once her brother was born a year later, any dreams and aspirations she may someday develop were dead on arrival. Despite the scarcity of food, her brother was fed well enough; she was left with scraps and bones. Once as a small child, she broke her arm while walking home from school; her mother didn’t noticed until the next day. She did grow up and made it through high school, where she found her religious faith and secretly harbored hopes of becoming a nun. However, the nuns who taught her, recognizing her intelligence, her creativity, and her quality as a great listener, as well as her compassion, encouraged her to try to go to college and pursue an interest that would fully express all of her qualities. Despite the odds, she made it to college and met the man she would someday marry. They fell in love, and as they were looking toward the future, she decided to pursue a dream that had been developing for some time: she decided that she wanted to become a doctor. She had the heart, the mind, and the soul for this pursuit, and it seemed to be a natural fit.

However, her mother forbade it: how could she be so selfish, putting her own interests and dreams before the welfare of her family, especially when her brother could pursue the same career and make more money to support all of them? As her boyfriend trained in his own career in the U.S., she boarded a plane to this foreign place, leaving behind the few comforts of her home and her family in order to work in the U.S. and send money home. And that, she did: working in sweatshops, first in San Francisco, and then in New York City, obediently sending home the wages she made. Angered that she was being forced to slave away to fund her brother’s medical education, her boyfriend flew up to New York and married her on the spot, severing ties of dependence from her family.

For many years, they lived together happily, raising two sons. However, she never had the chance or the money to go back to medical school: instead, she did what she could, first working as a nursing assistant in a hospital and then as a tech in her husband’s research lab. If she couldn’t pursue her own dreams directly, perhaps she could still contribute to the welfare of others through teaching. And that, she did: she was sent to train in some of the top research facilities around the country so that she could return and teach researchers, medical students, and fellows.

The pair moved many times, finding better paying jobs and rapidly pulling themselves out of the poverty of their youth. However, she started developing abdominal pains, unexplained and sudden. Having dealt with pain and considerable suffering before, she didn’t think to complain or to see a doctor. Months passed, and the pain kept getting worse, sometimes making her cry out at night. Her husband didn’t know what to do: he was so frightened, and furthermore worried that the neighbors would think that he was abusing her. On the other side of the wall, her children lay awake in their beds, paralyzed and confused. She lost her appetite almost completely, and was only able to eat mint candies. He ceased his usual complaints about her “junk food” eating habits that he attributed to the days before they married. Eventually, they went to see the doctor: she had a rare and lethal form of ovarian cancer (sarcoma). The oncologist recommended surgery, which proceeded without complication. However, she wasn’t expected to live long. Her strength and appetite recovered, however, and her pain subsided. She went back to work, her children continued to grow, and life went on.

Soon, a new milestone in their live together arrived: her eldest son was accepted to an Ivy League college! She was very proud and happy, though this new development proved a challenge as her eldest son found college to be very disheartening and difficult. She and her husband did what they could to support him through the experience, despite her quiet knowledge of her cancer’s return. Surprisingly, during this time, she returned to visit her mother who was lying on her death bed. Her brother, however, now a well-respected doctor, refused to prescribe stronger pain killers for her than what could be found over the counter, further fueling the anger of her husband at the insensitivity of her family. Finally, when the spring semester grades arrived with her elder son excelling in his courses, she breathed a sigh of relief. Two weeks later, she was brought to the hospital, the pain of the cancer having reached a new peak.

She spent two weeks in the hospital with palliative care to minimize the pain. Her two sons and her husband stayed with her each day, talking to her, reading her poems, and trying their best to express everything they wanted to say. At one point, her temperature dropped rapidly, and when no nurses could be found, the three piled clean towels on her until she recovered to her normal body temperature. Excited by any sign of improvement, her youngest son went outside to greet the rounding doctor, wondering out loud when his mother would be able to return home. The doctor stared at him blankly, and saying nothing, went inside to check on her patient. In that moment, her youngest son finally received her pronouncement of death, without a sad smile, a hand on the shoulder, or a word from the physician. Saying their last goodbyes, the two sons were sent home, and her husband remained with her until her heart stopped beating, just shy of midnight before Bastille Day. Perhaps now, she was finally free of the pain and suffering. However, in life, though she couldn’t help but show the pain, she never showed herself to suffer. She was 49 years old.

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