news o the day

Despite its superpower status, the U.S. survival rate for newborn babies ranks near the bottom among 33 industrialized countries, better only than Latvia. The U.S. is tied with Hungary, Malta, Poland and Slovakia with a death rate of nearly five per 1,000 babies.

A Congressional study in 2004 discovered that the curricula used by 69 educational organizations in 25 states taught adolescents that a 43-day-old fetus is a "thinking person" and that the HIV virus can be spread by sweat or tears... At least two-thirds of American teenage females have had sex by the time they reach the age of 18, according to the Center for Disease Control. In any given year, nine in ten teenagers who have heterosexual sex without contraceptives become pregnant... while one in four sexually active teens acquires a sexually transmitted disease. Federal funding for contraception has declined by 59 percent (in constant dollars) since 1980.

The American College of Obstetricians and Gynecologists kicked off a campaign this week to prevent unwanted pregnancies by encouraging women to get prescriptions for emergency contraception... The "Ask me" educational campaign is the response of the American College of Obstetricians and Gynecologists to the FDA's refusal to make the drug available over the counter... Women need to consider getting an advance prescription, physicians say, because some have difficulty obtaining the drug within the 72-hour efficacy period. They sometimes can't reach their physicians or can't find a pharmacy to fill the order.

[The Senate is considering] legislation that would let businesses band together on a national or regional basis to buy health insurance for their workers. Senate Democrats are threatening a filibuster because they say the bill would pave the way for health insurance for millions to be scaled back... The legislation would also pre-empt state requirements for certain coverage, such as mammograms or diabetes supplies... [and] would leave out many important protections, such as the coverage of chemotherapy, or treatment for osteoporosis... President Bush supports the bill, the White House Office of Management and Budget said.

so today i was compelled under holy obedience, or rather by the social mores of the medical consultation, to stand quietly in one spot in a hot room for 40 minutes.

a woman with a bimp on her thyroid ("bimp" being a technical term invented by an otolaryngologist who was fond of hercule poirot) had come to visit the research endocrinologist for advice on its management, along with her husband, and the three of them took all the chairs in the room. i guess there WAS an exam table, but it would have been poor form to recline, under the circs.

due to my peculiar health status - no adrenal glands to speak of, inadequate prednisone coverage - this was a horrible ordeal. after about 10 minutes, the cold sweat began. i started holding my clipboard in front of me when i could feel it running down my belly and soaking into my blouse; i kept surreptitiously scratching my head and coming away with a handful of water. i was dizzy; my legs turned to pins and needles while my shoes constricted; a bit of nausea set in while my hearing dimmed; my nose ran.

internally, i shrieked very loudly when the worried patient became reluctant to end the conversation and started seeking exact statistical data on her risk of cancer - entirely understandable (she didn't know her risk is only about 2%, and that even if she did have that 1-in-50 thyroid cancer, it's really not a bad cancer at all, relatively speaking, with about a 98% rate of total cure) - and the research endocrinologist was only too happy to oblige - which is good of him, obviously. but i was afraid i'd conk out, and nervous whether it would be possible that i'd even have a seizure or something, and what would happen after that? it was one of those surreal episodes where you ask yourself with every breath, 'NOW is it time to run from the room? NOW? how about NOW?'

at last the appointment was over, and i got to flop down in a chair and try to dry my hair with paper towels and tell the the research endocrinologist, "i really was afraid i wouldn't make it there for a minute." he chuckled, "well of course the greater-than-physiologic levels of exogenous steroid you're taking potentiate your catecholamine response to orthostatic stressors," and added, "don't forget about that, when you have to run a code: your acute-coronary-syndrome patient with secondary adrenal failure will need a whacking great dose of steroid before that epinephrine will do anything." a clinical pearl indeed, but the take-home message was actually, "of COURSE you feel like shit!"

i'm just saying.

later, during the Nurses Day luncheon, the nurses were saying they don't know how to describe me now. i'm not a medical student anymore, and i'm not yet a resident. i replied, "well, dr. research endocrinologist calls me 'Our Young Doctor,' and since i'm 45, i find that very pleasant," and they said, "but if you're 45, you're several years older than him," and i answered, "that's what makes it FUNNY."

now i've gotten to spend the last half-hour at the back of the hospital library with my feet up, reading an article from 1997 showing that using a "sliding-scale" insulin protocol produces rotten blood sugars in hospitalized diabetic patients, for whom it is still, in 2006, routinely prescribed. i asked the research endocrinologist why this regimen is still in place - not only in place, but enshrined, with pre-printed instructions in every chart for its use - and he said, "because people are IDIOTS," which is the only succinct thing i've heard him say in the past three weeks.

The United States lags "at least a dozen years" behind other industrialized countries in adopting electronic medical records, according to a study published yesterday in the journal Health Affairs... The United States spent $5,635 per person on health care, two and a half times the average for industrialized countries... The article also estimated health technology spending per capita in several developed countries, and found that the United States - at 43 cents per capita - is spending less than a 10th of the second-lowest country, Australia. Canada is spending $31.85 per person and Germany $21.20, the authors report.

[Illinois] Governor Rod R. Blagojevich today announced that just three months after going on sale, the state's first lottery ticket to benefit Illinois veterans and their families has generated more than $1 million for veterans... [Blagojevich] also recently won legislative approval for a landmark veterans' health insurance initiative, Veterans Care... Approximately 9,000 veterans who don't have health insurance will have access to... comprehensive healthcare at affordable rates, with average monthly premiums of $40... There are 70,000 uninsured veterans in Illinois.

About one in 15 Americans has eyesight so poor they couldn't pass a driver's license vision test but most of them go without correcting the problem, a study released on Tuesday said. The situation is most severe among blacks, Hispanics, the poor and those without insurance.

The Hershey Company announced the preliminary results of a Yale University study confirming the cardiovascular health benefits of hot cocoa consumption. Conducted by the Yale Prevention Research Center, the study showed that drinking either sweetened or sugar-free hot cocoa made with Hershey's Natural Cocoa powder can result in measurable improvements in arterial function... The study was a continuation of ongoing research into the health benefits of dark chocolate consumption.


you know you make me want to shout

today an endocrinologist impressed the patient and the nurses in the room by telling them that i would only be his medical student for another 72 hours.

after that, i'll be a doctor.


the med school files

what're the med school files? i have transferred the notes i made during medical school to this archive, is all (not that i'm done with medical school, except in spirit).

we begin our story several years ago, as our heroine just begins to confront what it all really means...

story time

i can't stop talking. when i stop, i will have to get up and leave. when i get up and leave, i will have to go home to bed. i will toss. and turn. i have no idea how to calculate the odds ratio for mortality from lung cancer due to cigarette smoking. i do understand how spindle poisons work - i learned that at my mother's knee - but volume of distribution? renal clearance? organophosphates and how and why you need to tell them to feck off? i am burnt out like a dang swisher sweet on bourbon street.

so i will tell you a little story. once upon a time, a girl was forsaken by her kindred and captured by a villain, who kept her in an old motel room. she had to do all the work and nobody loved her; her only wages were cuffs and kicks. in the evening she would don her pitiful finery and hang out in the parking lot, where friendly dwarves and talking dogs sold quaaludes and amphetamines. and things went on like that for a time without changing.

"what have i done wrong," the girl would whisper to herself while the villain snored in the other room. "will no one ever help me?" but there was never any reply.

then one day, she took her basket and went to the grocery store as usual, provisioning her larder with macaroni and cheese and chicken noodle soup. as she stepped through the checkout line, she thought she heard a familiar voice, calling and calling her name. she turned and looked, and a bright light shone down from heaven and the sound of music filled the air. there stood her sister, whom she had thought had lost and forgotten her! racing to meet one another, they clasped hands and made a solemn vow, there amongst the shopping carts. "never forsake me," they repeated, "and i will never forsake you."

after that, they crept back to the motel room, where they pushed the villain's tatters and shreds through the door, locking it and all the windows. that night, in comfort and safety at long, long last, they grooved on mescaline while they listened to the villain rattling the locks and shaking the window frames, bellowing in wrath and begging to be let in.

they got jobs at jack-in-the-box and lived happily ever after.

once upon a time, the world was full of demons and vampires and predatory beasts, and nobody lived anywhere else. children ransacked their parents' drawers, and other people's, for protective amulets; they said their few charms over and over while they trembled in the shadows, they lit out for the territories as many times as they could. the world was different then, the dark was unfriendly, the walls had eyes, and there were nests under bridges and on rooftops, but even there, even there...

this is how i learned to pray. they say the point of scary stories, of cautionary tales, is to show that the world of clarity and rationality and lines and borders is solid and reliable, that things as they are on the local t.v. news are real and getting realer by the minute.

take your mother to the cancer ward and sit there and wait. carry your child into the emergency room. swallow something it turns out you didn't ask enough questions about, and wait while your spine grinds itself into that special fishook shape... find out the awful truth and try to keep taking breaths. i'm going to stand there, at the border of lucidity and shock. i'm going to hold your hand and tell you, hello, my name is leigh, i'm your doctor, we're going to take good care of you.

kill your television, personal complaints, and a lovely jane austin close:

five hours of sleep. that ain't right. now, in the med student 'puter lab at the hospital - where, by the way, the coffeemaker is apparently kept under lock and key on saturday - some fool has turned on the television. we are being treated to msnbc news at a robust volume. i suppose it is the liberal alternative to Fox. give me patience.

--what, you ask, is the news, which many excited caucasians have been presenting us, these past 5 minutes?

it's all about the publication of a special new bible just for teenaged girls. apparently this interpretation contains verses like, 'The Lord comes down with a Cleansing Fire that Tightens the Pores and Minimizes Blemishes.' ...experts are concerned that this edition trivializes the soul-saving message of the bible. i am not making this up.

i can't believe this story is getting so much airtime.

oh - now it seems that teenaged boys are demanding equal time [via 'popular demand']. the publishers expect that the boys' edition will be similar to what may be seen in maxim magazine. perhaps the gentlemen in the neighborhood can explain the significance of this. i would have expected something more like sports illustrated, or possibly soldier of fortune.

commercial time: an SUV ad featuring heavily-laden soldiers forging forward through smoke and shadow. help help! i'm scared!

do you think that if i slept now and woke up at, say, 11 pm, and started reading up on autoimmune disorders and indirect-adjusted mortality rates and protease inhibitors - would i become smart enough? i don't think i can get smart at this time, no matter how hard i work. - but will my family let me sleep? stay tuned.

what i really need is some dang chow, but now that i have descended into trivial minutiae, i will simply close and say,

with my hand on my heart,



yesterday's scholastic debacle has been redeemed. do you remember albert einstein saying - and MEANING - "do not be troubled by your problems with mathematics; i assure you, mine are greater"? our dear, kind,ancient pharmacology teacher said something very similar. he said he always, always flunked pharmacology exams. the only way he could ever get through them was to take amphetamines. 'everybody did.' the good old days. he added that there was no discernible decrement in amphetamine-mediated learning. he was very casual and offhand about the consequences of failure - for, after all, they are not great.

no matter how many years i go, no matter how massive a superstructure i build around myself, i always stay at the center a captive, a fugitive, a lunatic, and the compleat high school dropout. --but even at that i am not the only one: one of my schoolmates is a former dropout, addict, and street hustler to boot, and he is very brave indeed. don't it make you shiver, don't it make you feel like going home?

i finally realized that the reason medical school is sometimes so hard... is that it's... well, it's supposed to be hard. it just is. that way. but i still wish i were apprenticing instead. the practice is so much closer to hand, so much more in-tuited, than the theory.

the second blessing came as i went to put away my coffee cup and found our big, goggle-eyed, rough-skinned pathology professor on the couch, visibly gathering his wits in both hands. i asked him whether he was the next performer, and apologized that i am probably too sleepy to give his [Two. Hour.] lecture the attention it deserves - and he cocked his big head, smiled very sweetly, and said in a mellifluous indian accent, "You probably don't need this lecture anyhow. You could go home and go to bed."

have you ever heard anything as filled with loving-kindness as those words? "You could go home and go to bed."

my house is empty and quiet right now. sun is slipping through the lace where cats dream on my bed. it is the picture of repose, completely untroubled...


an actual comment by a medical student.

"my life is one big chemical gradient like an amoeba! go away from the salt, go away from the salt..." [does imaginary breast stroke]

what the professor said

"As long as you pick a response that the population will respond to, the response will always go to one hundred percent. You always choose a positive or negative response. So as long as you pick a plus-or-minus response, they will always respond. Unless it's not a normal response, which you would not normally see."

the funny thing is, i kind of know what he means.

notes from pharmacology:
sarpagandha. rauwolfia serpentina.
for thousands of years it has been used
to clear memories. it acts
by obliterating sympathetic activity.
the heart slows.
it is slow to respond.
the eyes undilate.
desires fade, because they are few.
the primary side effect is death by drowning.

what the pathologist said

"Now, be very careful: macrocytic does not necessarily imply megaloblastic. Because when you say magaloblastic, you are necessarily implying nucleocytoplasmic asynchrony, yet you must always keep the nonmegaloblastic macrocytic anemias, which may be normochromic, at the back of your mind."

he also said this:

"This days everything is micro and nano! That's why all the radiologists are always fighting with the pathologists."

imagine this with a strong backbeat:

"you see blasts, uh-oh, it's a no-no,
somethin mus'be goin'on in the mar-row!"

"look at the cellularity, look at the nucleoli,
they're twisted, they're ropy,
they keep their own company..."

i mean, really. am i tripping, or is he?

he also said, kind of apologetically, "you can't tell at all what's going on; i know it seems like taking the easy way out, but these days, everything is flow."

...he was talking about labs that do cell sorting by flow cytometry, but it didn't sound like it, did it? you automatically understood that he was talking to you directly - yes, i mean you! you sitting there right now! admit it: these days, everything is flow.

great emphasis on early defibrillation

i'm at the hospital. every so often they call a code over the p.a. system. you want to cross yourself, or cross your fingers, or something.

kado chigai shite kudasaru na fuku no kami

don't go in
the wrong gate, please
god of luck.

(issa, 1824)

i know a lot of folk think i am a big flake. a lot of folk think i suffer from pernicious softheartedness and/or softheadedness. i've been hearing it all my life. i've had to listen to folk speculate on how my refugee mentality and my fear and loathing of conflict have turned me into a big doormat. i am naive, have no balls, and so on. and there's always, always, always SOMEBODY around whom folk think i should shove out the house and lock the door behind.

my primary identity is as a mother. i am congenitally lonely. it's important to me that you know you are free.

stephen gaskin told this story once and it has influenced my ways tremendously. he said, suppose you had a swimming pool, and everybody was swimming in it and playing in it and having a great time. but there were some folk around who were really thirsty, and getting dehydrated, and just not doing well at all for lack of water.

so you put a fence around the swimming pool because you recognize that there isn't enough room for everyone to get in the pool & still have the good time you have been enjoying. he said, there are always going to be some folks who will hurl themselves over the fence; they will throw themselves into the pool, and then they will start drowning because they don't know how to swim.

so what should you do? he said, "you have to pull them out, you have to pump them out." and he went on to say that his hope was that people who had had a difficult life would be able to enter the community he was addressing - his hippie congregation, basically - and they would eventually be healed by the contacts they had with the members of the community.

when i first read this, i was sitting on a beach in florida as the sun was coming up. it had been a late and dangerous night; my boyfriend had slapped me down, hard, and said a lot of really shaming, hate-filled things to me, and told me to get the fuck out. since we were staying in a houseboat, this was problematic, but i gathered up my waitress uniform and my makeup and got in the dinghy and rowed to shore. and sat there crying and waiting for morning and reading the book i'd stolen from the wisconsin group home i'd run away from. i was sixteen years old. kindness, even the kindness of stephen gaskin in print, saved my life, and i mean that literally. saved me from being lost and stupid and mean and worthless.

i really, really, really, really, really, really believe in kindness. i never, never, never, never, never, never forget the baby that was you.

be afraid!

in medical school today, we are studying antidepressants. one of the students asked if it was really right - he sort of meant, morally right - to give antidepressants for bulimia.

"At what point do you just have to say, Eat the sandwich already?" ...to clarify, he added that a lot of mental patients honestly "just need a kick in the ass."

he knows this because he worked in a mental hospital for years.

our pals 'n' their neuroscience jokes

my pharmacology teacher can't pronounce the word "dysarthria."


the new pathology teacher is teaching us about about the liver.he started by saying it's his favorite organ because it detoxifies his primary nutrient, which is alcohol.

...he also said there are neuroendocrine cells in the liver, which are hard to find but they're there. i am an expert on neuroendocrine cells and their wicked ways, because my mother has neuroendocrine cancer. he mentioned that these neuroendocrine cells in the little gullies and hollers of the liver can turn into cancer, and then he started to move on but i stopped him and asked what their normal function is - since none of my mother's doctors have answered that question to my satisfaction.

he said he did not know. but he said that's actually what his research lab is working on right now; he said that the neuroimmune system is pretty much unexplored so far, mainly because "there are no knockout animals yet" (a mundane descriptor to biochemists, but very peculiar-sounding indeed to everyone else).

then he said, "maybe neuroendocrine cells have some kind of behavioral effect... like if you're drinking carbon tetrachloride... did you ever have one of those times when you're doing something, and you Just Know You Shouldn't, and you really need to stop?"

there are so many layers of whimsy to that explanation, i don't know where the charm even begins.


formerly, for a given condition, pharmacologists would watch out for side effects & secondary actions of a drug, hoping to find the most effective use for it. thus e.g. thalidomide turned out to be worthless as an anti-nausea medicine but strangely effective against cancer. then the pharmacologists would tweak subtle aspects of the drug's structure, and test the resulting huge series of compounds on an endless stream of lab animals, trying to arrive at the drug that would have strongest and safest effect on the condition they'd stumbled across by accident. this is called the "brute-force approach" to drug design.

this approach delivered theories about normal human physiology, but only in retrospect. for example, we figured out that the thalidomide birth defects arose because the drug limited development of new blood vessels, so now we know that new blood vessels are crucial to the progression of cancer.

but what we really need is a way to start out from well-understood physiological mechanisms and then create drugs that correspond to them. and now that we can manipulate DNA, we can reproduce functional and dysfunctional biological processes in the lab. from there, we can predict what drugs would be like that would participate in those processes, but would act longer or faster or more specifically than the naturally-occurring chemical players do. so this is called the "rational design" approach.

the whole enterprise is founded on the concept of 'fit.' the basic model is teleological: the lock-and-key model. a molecule has a certain shape that makes it bind to a certain cell, and change how that cell behaves. one lock, many keys, some natural and some synthetic. and some keys are master keys that fit many locks, all leading to vastly different mansions. the purpose of a key is to fit into the lock. the lock is nothing without its key. you can make a perfect key if you perfectly understand the lock.

it's not the only metaphor, but it's the popular one.

my point is that i am interested in rational relationship design, instead of brute-force relationship design. but i wish i knew whether this approach works as well in other metaphors as it does in the one we use now.

pathology teacher = king

he said the thyroid gland is extra-interesting because - he actually said these words - "it has the best of cancers; it has the worst of cancers."

the best of cancers is papillary carcinoma, which he described as displaying a "branching-arborizing-treelike" pattern of cell growth. keeping with the triple-adjectival motif, he went on to say that the tumor cell nuclei are called "vesicular/ground-glass-appearing/little-orphan-annie nuclei."

when he got to the worst of cancers, anaplastic carcinoma, he simply stated that it "literally goes through and through the head and neck until it chokes the life out of you and then it's good-bye." --spoken in a melodic hindi accent, against a backdrop slide of a very sad-looking old man with an enormous brioche of a tumor growing out of the top of his head.

in other medical school news... you know how there's always somebody who compulsively jiggles their leg up and down at a rapid rate? and how most of us who are not jigglers regard it as a sign of a nervous disposition? well, yesterday i counted five med students displaying this behavior in class, out of N=17. that's a rate of about 30%. doesn't that seem high? another 11.8% had laid their heads down and gone to sleep. after another few minutes, this figure rose to 17.6% when i joined them...

so a mere 53% of the class were awake and calm during our discussion of tropical sprue. i won't mention the 6 students who didn't come to class at all, since the probability that i could have been one of them runs at about 40%.

the way pathologists wave their hands

you know how ordinary people say, "oh, i don't know, whatever"?
pathologists say, "oh, infection, infarction, necrosis, whatever."


and another thing!

for the kitchen witches in the audience - it turns out paregoric is not at all the same as laudanum. althought they're both poppy tinctures, paregoric has camphor in it & laudanum is ten times stronger. ten times. did you get them mixed up? quick, take some atropine - why yes it does come from that lovely nightshade plant at the back door.

symptoms of too much atropine: red as a beet, dry as a bone, mad as a hatter. you're welcome.

today in pathology it was all about the female urogenital tract; all the ways one's pap smear can go wrong due to the human papilloma virus, which is aquired by women from men. i sat uncomfortably squirming 'til i finally couldn't resist saying, "question! what if a woman is sexually active and not with a man? and what about the risk to men who have sex with men?" and i really wanted to ask, "how come every single powerpoint penis we have been shown in medical school is both caucasian and circumcised"... but already enough people were turning around to stare at me.

medical school. the take-home message: cigarettes will kill you. everything else they tell you is only a partial truth.

la mia vita pazzesca

wednesday night i was with the youth of america at the corner tavern & we were chattering like happy monkeys as usual re: gender trouble, japanese electoral politics, and the victoria's secret television show. a good time was had by all, including healthful grapefruit-and-vodka drinks.

but when i took a moment alone in the clean, quiet restroom, i started feeling alienated. i thought of the sad-eyed geeks at the medical school and wondered if they ever, ever relax, then wondered if i'm turning into one of them. i try to avoid their company as much as possible, because they react to everything i say as if it were either criminally flaky or a laff riot, plus everything they say to me is unbearably mundane.

then i thought to myself, "and not one person here has any idea what i've spent the last four weeks doing," and i felt so separate. then i realized that that is, in fact, the point of medical school. not just to teach medical work - that could be taught outside of a school, e.g. as an apprenticeship - but to force you to Become A Doctor.

i can feel myself being socialized. the process is radically disagreeable. i'm complicit in it, because i assume that my daily life is too boring and weird for anyone to understand - except for other medical students, and eventually, other doctors, who supposedly will comprise my future social circle and my future social class.

i have entered the silence. doctors do not talk about what they do, even to each other, really; they speak in gruff shorthand to each other, displaying their in-crowd savvy by not elaborating anything beyond the technical vocabulary.

for the last four weeks (and the time before that is just a blur), every day i have sat in a darkened classroom looking at microscope slides projected on a screen. on a very basic level, all these slides look the same. there are a lot of little pink circles, sometimes in rows, sometimes in rings. they are peppered with deep purple dots. they're cells. they are presented by the lecturer as though they have distinctive appearances, and the students glance at one another with bewildered eyes and press their lips tight shut.

there is a normal size for a cell to be, but given the varying degrees of magnification, we don't know what it is. we are told that, on some of the slides, the little circles are much too big. there's a normal amount of distance that's supposed to lie between rings of cells - rings of cells usually indicate some sort of glandular, secretory activity going on, sort of like the stone edge of an old-fashioned water well - but we were only shown a few slides of normal glandular tissue last year in histology class, so we just try to impress the general appearance of each individual pathology slide on our memories, hoping eventually it will take on some sort of familiarity. at least that's what i do.

cells are supposed to have "nice" nuclei. we have been told this over and over again. they are not supposed to have bad, angry nuclei, the lecturer will say, indicating a new slide. however, the new slide seems to be stained differently - the tissue samples are stained different colors, because otherwise they'd be see-through - so the thing that makes these new cells look angry is that the whole slide has been dipped in a wash of red ink. like the way a photograph of some cows in a field could be made to look menacing through a red filter.

all the nuclei look different to me - big, small, round, rectangular, ghostly, chiaroscuro - in one corner, they are spindles; in another, they are specks, and all can be called "nice" or "nasty" or both, as far as i'm concerned. if only some were in the shape of letters ("h-e-l-p-"!), or if only some were double (there is, actually, a [normal] kind of bone-marrow cell that has a nucleus that looks like a crysanthemum).

okay, you are saying to yourself, so the material is difficult to start with, and then is badly presented, so what?

my point concerns the cumulative effect of spending the same two hours engaging in this same activity, monday through friday, for four weeks (and the time before that just a blur). i leave the table at the bar and go to the restroom, and as soon as i'm by myself i feel disoriented and immediately start to worry about the implications of the fact that the slides and slides and slides of little pink circles and purple dots are so meaningless to me at the moment, yet so urgent to me a few hours before. the slides and slides of circles and dots are estranging me from the cool kids. i'm already developing the supercilious martyr complex of the american physician.

maybe it's time for nursing school. i don't even like doctors. i am disloyal to the caste. they will find me out and expel me - or i will crack under the dissonance, and become one of them.

i kind of want to flunk my exams, i kind of want to fail these classes. you know why? because then they will make me (let me) take the exams over, and i may finally obtain enough time and space to learn the damn material. it's not right to move along through medical school never understanding the essential utility or the deeper meaning of the little circles and dots. after all - these are cancer cells. these are blood cells with no hemoglobin. these are immune cells possessed by demonic viruses that make them act vicious. they are going to make you feel terrible. in real life, that's what they really are.

maybe the problem is just that i am so impatient with reductionism's constant quest for complete control. i must must MUST identify the angry nuclei that will allow me to identify one of the 11 kinds of ovarian cancer, so i can finally look in my magic recipe book and find out whether we will poison this woman, burn, or cut her, or all three. i'm not wholly opposed to reductionism as a method, i guess... i used to love working in the organic-synthesis and biochemistry labs... but they did not pretend to look deep into the core of a living creature and divine what makes that creature really tick, and deem that creature's status, treatment, and fate. they just wanted to make stuff. like mixing paint. like building with legos. like using an easy-bake oven (motto: "you always been able to see what's going on inside!").

so anyway. slides and slides and slides and slides and slides. on exams we are given faded, shrunken, black-and-white photocopy renditions of the slides. we guess at answers and never, never, never complain. this is medical school. we are your future doctors.

introduction to clinical medicine

...and i am to be "physically examined" for the first time BY ANOTHER MEDICAL STUDENT. IN FRONT OF OTHERS. yes, of course all students have to go through this, but the point is that I have to go through it. guess i should have been more congenial. not calling them "sad-eyed geeks" and stuff. it's payback time.

so i will be clad in a SPORTS BRA, which is not my usual attire. maybe i would not hate it as much if it was not named SPORTS. or BRA. i also will wear BIKE SHORTS. oh boy.

the room where the playing doctor will take place has unflattering light and is freezing. therefore i have arrived equipped with my silken robe and slippers.
here is how i imagine i will look:

but here is how i will really look:

disregard the weird curvy thing in the sand. it must be the met-life-actuarial version of me or something.

so, how 'bout that socialization process anyway? don't it beat all? if only i'd gone to dentist school instead - i could be getting my teeth cleaned by my classmates. or to massage school - i take it lying down.


How To Be A Doctor
Lesson 1

If someone starts crying, do not get up and leave the room.

Lesson 2
what you say vs what they say:

barber's itch = tinea barbae
burping = eructation
drawing spell = convulsion
haircut = penile chancre
midriff = region of diaphragm
misery = pain
stomach growling = borborygmus
swamp favor = malaria
upchuck = emesis

...so do not say, i got a misery in mah midriff; mah stummick's grellin' so's i don't know whether tu burp 'r upchuck!

instead, say borborygmus and pain in the region of my diaphragm seem to indicate that some sort of eructation or emesis is imminent.

exciting abbreviations:
c/o = complains of (remarks upon)
NG = nasogastric (tube)
PX = physical exam
h/o = history of
S/NT s OM/PM = Soft, nontender, without organomegaly or palpable masses
AXRp = abdominal x-ray, portable
HOB30deg = head of bed elevated to thirty degrees
EGP = epigastric pain
htn = high blood pressure (hypertension)
stat = at once

thus pt w/ h/o htn, c/o EGP, PX abd S/NT s OM/PM, but HOB30deg, NG, AXRp stat!


"The goal is not for the student to prove the patient is not real. Rather, it is to assist students to achieve their educational goals."

a surprising amount of adult coughs are actually pertussis, a.k.a. whooping cough. some folks call it the "hundred-day cough." this fact was used as a kind of flourish in lecture, to underscore the folly of anyone ever not immunizing their children - rather than as an illustration of the imperfect "herd immunity" bestowed by the pertussis vaccine in particular.

half the med students think folks don't immunize their kids because they are brainwashed by anti-vaccination websites; the other half thinks it's because they're lazy and don't care. one gal thinks it's because of the fierce mother instinct to protect a child from danger in the form of a painful needle stick. "they'll do anything," she said, "to protect that baby."

half think the reason there is a shortage of vaccines is because the drug market should be run on a supply-and-demand basis, thereby giving more incentive for multinational drug corporations to make more vaccines; the other half thinks it's just a fact of life in a capitalist system and nothing can be done about it. one guy thinks more people should be allowed to die of childhood illnesses, to boost demand for vaccinations. "that's probably the only way you could do it," he said.

everybody in the class believes that they are much smarter and more capable of making reasoned individual and social health decisions than anyone else is - except me.

everybody in the class believes that they are far more rational than everybody else in the class - especially me.


medical students are sitting around talking about a mother who is reluctant to allow anyone to perform surgery on her small daughter. they recommend "surgical removal of the mother." they actually used that phrase.

surgical removal of your mother is the only solution

surgical removal of your mother is easy with femgard tissue shield
surgical removal of your mother is offered at the vein center
surgical removal of your mother is available online
surgical removal of your mother is necessary to preserve your privacy and protect your health

surgical removal of your mother is safe and beneficial
surgical removal of your mother is fast and easy
surgical removal of your mother is affordable
surgical removal of your mother is a snap

surgical removal of your mother is relief to prevent persecution
surgical removal of your mother is the newest treatment option
surgical removal of your mother is recognition of and incentive for positive internal change over a significant period

surgical removal of your mother is a mystery that has puzzled mankind
surgical removal of your mother is that kind of a scare
surgical removal of your mother is merely a ruse

surgical removal of your mother is a unique blend of art and science
surgical removal of your mother is the first medical breakthrough in over 100 years
surgical removal of your mother is notoriously difficult using either active or passive treatment
surgical removal of your mother is never done

shuffling off the mortal coil

shuffling off the mortal coil is deadly
shuffling off the mortal coil is needlessly difficult

shuffling off the mortal coil is the most embarrassing
thing that can ever happen to you

shuffling off the mortal coil is only the beginning

shuffling off the mortal coil is an honor
shuffling off the mortal coil is an art
shuffling off the mortal coil is worth doing with style
shuffling off the mortal coil is the only way to live
shuffling off the mortal coil is sexy but why do i have to prove it?

shuffling off the mortal coil is morally and theologically impermissible
shuffling off the mortal coil is like being arrested
shuffling off the mortal coil is poorly planned
and frequently ignores the preferences of the family

shuffling off the mortal coil is written in very simple language
that would be accessible to a teenage reader
shuffling off the mortal coil is spreading
shuffling off the mortal coil is disturbing

shuffling off the mortal coil is about the ways in which people
insist on declaring the value of their lives
when those lives count for nothing

shuffling off the mortal coil is intended for those
who want to bring a spiritual yet personal presence
into the shuffling off the mortal coil experience

shuffling off the mortal coil is somehow sanitized by the white walls
shuffling off the mortal coil is a birth inwards
shuffling off the mortal coil is not the end of life; it is its mate

shuffling off the mortal coil is far from the worst thing that ever happens to us
shuffling off the mortal coil is trying is flying is trying is flying is trying is flying is trying is flying is trying is flying
shuffling off the mortal coil is a sense of belonging
shuffling off the mortal coil is a philosophy

You first, poetry second, the good the beautiful, the true come last. As the lad said: We must love one another or die.
-karl shapiro "lower the standards"

the happy anorexics. please don't read if ana testimonials are a trigger.

age: 17 in 3 days
height: 5'5
current weight: 126
lowest weight: 113
highest weight: 152
1st goal: 113
ultimate goal: 105
what kind of ED do you have? ana
why did you become anorexic/bulimic? I wanted to be pretty
how long have you had it? 6 months
what is the most amount of weight you have lost in a short period of time? 4 pounds in 2 days
how did you do it? no food, no water
anything else you want to tell us? being fat is horrible

omg my diet is so not working. even though i am at my lowest weight. i still don't feel thin. hopefully i can fast for a couple of days and lose some lbs. anyone wanna join me? it starts today.only water, diet coke, tea, and some gum(i know i am a cheater) someone please call me fat. thats what thinspires me most. luv ya all and keep up the good work.

goal weight for fast:90
unlimate goal weight:85
remember:remeasure, reweigh, try harder

age: 18
height: 5'2
current weight: 139
lowest weight: 98
highest weight: 140
1st goal: 115
ultimate goal: 105
what kind of ED do you have? anorexia
why did you become anorexic/bulimic? I couldn't look at myself anymore.
how long have you had it? For three years
what is the most amount of weight you have lost in a short period of time? 6 pounds in 3 days
how did you do it? momentum, lots of water, running and weights and eating lettuce
anything else you want to tell us? I'm coming off a round of heavy involuntary treatment (read: force feeding and medicating). Good thing I turned 18 and they can't touch me anymore. It was terrifying and I can't stand it anymore. I missed ana, but now I'm back. Let's play in the snow.

age: 14 (ill be 15 in 3 months)
height: 5'1 1/2
current weight: 75 lbs
lowest weight: 74 lbs
highest weight: 120.5 lbs
1st goal: 69 lbs
ultimate goal: 55 lbs
what kind of ED do you have? anorexia
why did you become anorexic/bulimic? im not really sure
how long have you had it? about 2 1/2 - 3 years
what is the most amount of weight you have lost in a short period of time? 10 lbs in 5 days
how did you do it? not eating anything and moving alot
anything else you want to tell us? nope
but i was wondering if anyone had any good suggestions about how i can reach my ultimate goal or at least my 1st one fast?

current weight:95
lowest weight:95
highest weight:125
1st goal:85
ultimate goal:75 or 65
what kind of ED do you have?ana and mia
why did you become anorexic/bulimic? i used to be fat. plus i like to punish myself
how long have you had it? 2 years mia 1 year ana
what is the most amount of weight you have lost in a short period of time? 10lbs in 5 days
how did you do it? i didn't eat for 5 days
anything else you want to tell us?
i want to be 85 by christmas anyone eles have the same goals or goals for the holidays maybe we can be buddies. if there is anyone thinner than me out there please e-mail me with your stats. i need to feel fat.

age: 17
height: 5'5"
current weight: 133
lowest weight: 125
highest weight: 160
1st goal: 125
ultimate goal: 100
what kind of ED do you have? bulemia
why did you become anorexic/bulimic? i wish i remembered
how long have you had it? 4 years
what is the most amount of weight you have lost in a short period of time? 20 lbs in 2 weeks
how did you do it? it was in the summer, i was sad, so i just stayed in my room for 2 weeks.
anything else you want to tell us? i hate having nothing to show for my disease.

age: 15, 16 on the 12th though!
height: 5'5''
current weight: 118
lowest weight: 110
highest weight:127
1st goal: 110 by christmas
ultimate goal: 90 by Febuary 14th
what kind of ED do you have? ana
why did you become anorexic/bulimic? i didnt become it, it became me. it wasnt a choice
how long have you had it? 1-2 years? seems my whole life though
what is the most amount of weight you have lost in a short period of time? 7 pounds in 3 days
how did you do it? lots of exericise, fasting, and laxatives
anything else you want to tell us? Umm i'm also a cutter if anyone can relate

Guess who's about to get her claws on some phentermine :)
I told my parents this morning about my plans to quit smoking for New Years. They were thrilled. I also mentioned that really the only reason why I haven't stopped yet was because of that whole "bothersome" weight gain thing. You want to know what my mom suggested???? She said, "well honey, why don't you just lose ten pounds now and then you'll be in the safe when it comes time to quit?"

Lolol...my Dad fucking freaked out. "She can't stand to lose ten pounds as it is! She needs to gain a good twenty - don't go telling her to lose weight!" It took everything I had to stop myself from laughing at the two of them. I love them both, but do they really think they have the slightest bit of control on whether or not I decide to lose weight? News flash, people.

So, now that my mom suggested I lose ten pounds, I'm going to hunt down her perscription for phentermine when she gets it. I was going to buy the stuff over the web anyways, but the whole delivering-it-to-the-house thing presented a significant problem. Now - AS RECOMMENDED - I'll be losing weight with the help of my mom, whether she realizes it or not. She obviously things I could stand to lighten up a bit...hey, at least there's one thing we can agree on together, right?

Oh, and by the way...I'm back.


1. here is our forecast for today:
"Snow then freezing rain mixed with snow and sleet in the afternoon. Snow accumulation of 4 to 5 inches. Ice accumulation up to 1/4 inch. Highs in the lower 30s. East winds 10 to 15 mph. Chance of precipitation 100 percent."

2. today is st. agatha's day. here is what one is supposed to say to her:
"Saint Agatha, you suffered sexual assault and indignity because of your faith. Help heal all those who are survivors of sexual assault and protect those women who are in danger. Amen"

3. and here is what i say:
"Saint Agatha, you suffered because of your faith. Help minimize the snow and freezing rain mixed with snow and sleet, heal all those who are survivors, defend us from the snow accumulation of 4 to 5 inches, protect those women who are in danger, and save us from ice accumulation up to 1/4 inch. Chance of glorifying your name 100 percent. Amen"

4. "Ascites connotes an abnormal accumulation of fluid within the peritoneal cavity. The word derives from the Greek askos, which means bag or sack."

yesterday i saw a nice old man get 7 liters of yellow fluid drained out of his belly. he was a little disappointed because 3 weeks ago they got 10 liters. 7 liters weighs just about 15 pounds (10 weighs 21).

the doctors standing around commented that it sure is nice to have vacuum bottles, not like back in india when they were in training. they said that without vacuum bottles, they had to kind of milk the fluid through the tubes, and that it was much more painful for the patient and took a long time. they had to do this taking blood samples, too, and they all started laughing about what a hassle it was to keep re-sterilizing everything - tubes, needles, bottles - and re-sharpening the needles with diamond sandpaper.

i felt relieved to know that these procedures can still be done with minimal accoutrements.

by the way, this procedure was wholeheartedly welcomed by the nice old man, who was literally bursting with fluid. his belly-button had turned into a belly-damson, and he had a scary-looking purplish throbbing bulge over his solar plexus, where his abdominal wall was just kind of coming apart, like that certain scene from 'alien,' only in verrry slow motion. his only wish was that it would be finished by suppertime, because he was "Starvin', Marvin!"

5. here is a cute kitten to relieve your minds from ice storms, sexual assault, and ascites:

6. and here is a glorious portrait of ME:


buddha says, put your hands on your hips! put your hands on your head!

This being, that is; from the arising of this, that arises.

With an understandable degree of ignorance as condition,
study and review activities come to be;
With study and review activities as a condition,
partial understanding comes to be;
With partial understanding as a condition,
drawing-of-erroneous-conclusions comes to be;
With drawing-of-erroneous-conclusions as a condition,
an insufficient set of parameters comes to be;
With an insufficient set of parameters as condition,
a bogus means of assessment comes to be;
With a bogus means of assessment as condition,
spurious diagnosis comes to be;
With spurious diagnosis as condition,
compliant somatization comes to be;
With compliant somatization as condition,
predictable social stigma comes to be;
With predictable social stigma as condition,
realignment of affiliation comes to be;
With realignment of affiliation as condition,
lowered expectations, additional forms of failure, self-punishment, and a generalized decline of the psychosocial and aesthetic niceities which make life worth living come to be;


things i learned in clinical microbiology class

remember the professor i had who, when asked why cigarette smoking is one of the risks for human papillomavirus ('venereal warts'), replied that cigarette smokers don't know how to take care of themselves, and when asked whether chancres (painless sores of syphilis) could appear on men in places other than the glans penis, replied, "i don't know, and i don't want to know"? remember?

well, today she wanted us to know that in 2003, Canada had 103 cases of SARS, and the US had 193, and when asked why the Canadian outbreak got so much more coverage in the US press, replied, "their cases were sicker because of their healthcare system," and went on to emphasize that the single mad cow discovered in the US actually came from Canada.

now, those assertions did not surprise me all that much, because that's the kind of thing you read in USA Today, and such 'current events' can still be regarded as political and subject to interpretation to some degree, and not all the facts have come out, &c.

but i was irritated when she went on to give the glorious history of smallpox vaccination as beginning with jennner in 1796 (not in china in the 1500s or turkey in the 1600s) and displayed an eighteenth-century political cartoon of people with cows' hooves and horns and tails growing out of various parts of their anatomy (asserting that being innoculated with cowpox would have this effect) and went on to say that the parents who today hesitate to have their children vaccinated "because they think they'll get autism" are "just the same."

plus, she referred to "cows" as "he."

finally, in discussing the origins of the ebola virus, she explained that "African people who see a dead animal in the jungle think it's a gift from the gods, so they just eat it."

silly africans!

what do you imagine this woman looks like?

...nope! in fact, she is a petite, perky, soft-voiced, stylishly-coiffed young blonde in nicely tailored semi-hip professional clothes.


tales from med school

what can one say about mrs. code? when she came in, it seemed like she had a "line sepsis," meaning that the semipermanent IV port under her collarbone had made an infection that entered her blood. in the beginner's mind, the obvious thing would be to remove that line. this wasn't done for several days.

she was put on IV antibiotics and her white cell count did not respond after 48 hours. in the beginner's mind, the obvious thing would be to try a different antibiotic. this was never done at all.

when you are sick and lying in bed for a long time, the blood pools in your legs and can shoot a massive blood clot up into your heart and lungs (deep vein thrombosis and embolism), so you are given special leggings to wear that massage your legs to keep things flowing. mrs. code kept yanking hers off. in the beginner's mind, the obvious thing would be to give her a blood thinner (heparin) instead. this was not done.

she developed dangerously high levels of calcium in her blood, because the dialysis lab was giving her doses of calcium that she didn't need. in the beginner's mind, the obvious thing would be to write down anything you give her, or at least mention it to somebody. this did not occur.

she finally developed chest pain and an abnormal EKG, on top of all her other problems, and in the beginner's mind, the obvious thing would be to have cardiologists take care of her in the intensive care unit; she never went there. the way she died was this: her heart beat slower and slower and slower and slower and slower and slower and then it stopped.

now everyone is either blaming everyone else or not talking about it at all.

please don't tell anyone i said any of this.

learning to pronounce

1. there was an old man who had a heart attack and went to the hospital. after the heart attack, his heart muscle was very weak and he was having a very bad time and we didn't know if he was going to be able to get better. his wife came to the hospital and sat by his bed all day. then she went home, and as soon as she got there she had a massive stroke. she immediately went into a coma, and her breathing was going bad, so the ambulance brought her back to the hospital, and they brought her to her husband's room. their kids, who were grown up, went in the room and pushed the beds together, so the old man could hold her hand. and her kids brought roses, and put them on her pillow all around her head, and in the morning she died, still holding her husband's hand.

my senior resident was asked to go in and pronounce her officially dead. when he came back out, he told me that the old couple were lying so quietly together, holding hands, that at first he didn't know which one he was supposed to pronounce. right about then the hallway filled up with crying relatives and the nurses didn't know what to do with all of them. finally one suggested, "call down to dietary for a Bereavement Tray," and they all went, "what a great idea!" i asked, "what on earth is a bereavement tray?" and she said, "it has muffins and stuff. it's real nice."

at last they wheeled the old lady out of the room on a gurney. she was covered up with a green patchwork quilt. they drew it up over her face, and tucked her in under her shoulders, and away down the hall they all went. the old man had to stay in his room. he's still there now.

2. last night i was in the back room at the emergency department and we were filling out papers to admit a lady who could not stop vomiting. we were kind of in a lull in the action, when my intern said, "there's a code going on at the end of the hall, why don't you go watch it, so you know what one is like." a code is when you try to revive someone who has no heartbeat. i went down the hall, to where the last exam room was packed full of medical people and cops, and i heard a nurse say real quietly, "he's just a teenager." everyone was talking very softly and moving around slowly and carefully. on the table was a boy the exact same size and shape as my son, and for a second i saw stars, and my mouth filled up with spit, in horror.

then i realized that this boy was wearing big muddy work boots like none my son has.

i could not see the boy's face because it was covered with a mask for air. then i saw that the doctor on the far side of the table was pushing the rib-spreader, a kind of large steel bracket-looking thing, into the side of the boy's chest, and turning the screw lever thing, and bending low to look inside, and pushing his hand deeply into the boy's chest. i had a very strong impulse to start screaming, like you would if you saw someone about to be hit by a car. i looked instead at the heart monitor, which slowed a series of long smooth hills and valleys, produced i suppose by the jostling the boy's chest was getting. i looked again at the boy's body, carefully, to make double-sure it wasn't anyone i knew. his jeans had been scissored open by the paramedics and he had that newly-adult kind of leg hair that looks so surprising when you see it on your own child. his shirt was open and he was a skinny kid, just starting to have some actual arm muscles, and his skin was a disturbing yellow-gray color, with just a few little smears of blood.

my eyes got blurry and i realized i was going to start crying right then, so i left the room. out in the hallway there was a tv monitor that shows each e.r. room on a closed circuit, and a small crowd of nurses was gathered around it with their hands over their mouths, watching the code. on the screen, you could see all the medical folks taking off their gloves. they looked ashamed. i went back to the back room where the heart monitor, which had been tuned to that room specifically, was knee-deep in scrolls of tracing paper with an endless flat line. no more hills and valleys. i called home to see what my kids were doing.

this afternoon, i bought my youngest child a bike - she really needed one, and it was cheap, plus it's pretty cool-looking - and as i watched her riding away through the parking lot on it, i thought about that kid last night. he had been driving a tractor down the road and got rear-ended by a car, and basically the tractor rolled over on him. the other car was totalled, and it took awhile for someone driving along to find them. the teenaged driver of the car is now in critical condition in the same hospital. we don't know if he'll make it. and i thought, i bet those children's parents really wish they had bought their kids that one thing, the thing he'd been pestering them for, which they thought they couldn't afford, or which they didn't want to spoil him with. so i was glad i bought my kid a bike.

3. i went back to the hospital this morning really, really early. i left the house at 5:15; it's a ten minute walk, and it was still dark out, and the crickets were singing, and the sky was totally clear, so you could see the moon low in the eastern sky, a thin, fine crescent, so thin that there was a shimmer of light around the whole circle. it looked like a silver ring, with venus riding next to it, big and piercingly bright. i was walking up to the hospital when i saw someone else outside, walking around the breezeway where the cars can pull in next to the entrance. he was pushing an IV pump along with him; i could see the little blue screen shining in the darkness. when i got closer i saw it was a patient i've been taking care of during the past week, a fellow a few years older than me, who has AIDS and has been very sick with relapsing fevers and shaking chills. it was nice to see that he was feeling so much better. he was in a cheerful mood and said he'd been bored after his fever broke, so he was walking all around the hospital. i asked him if he'd seen the moon, and he hadn't, so we went out into the parking lot, with the IV pump, to look at it. he told me that even though he still has fevers, he just wants to go home; he can take tylenol there just as easily as he takes it here.

he was diagnosed with AIDS last month in florida, where he was living; he had no idea he was even seropositive when he got sick. he got pneumocystis carinii pneumonia and a candida infection of his upper GI tract, which basically is a message from your body that you have no immune system. his t-cell count was 38. so after he got the pneumonia under control, he came home to his parent's farm. he said his parents have a big hammock under a buckeye tree, and he just wants to get his pillows and blankets and lie out there and sleep. then he took a deep breath and said, "i left illinois 22 years ago, and i never came back even once until now. so when i came out here today - you can smell the corn, and the grass, and the dampness in the air - that smell! i feel like i'm a little kid again."

after a while we went on inside, and on the way back up the sixth floor, he told me he always gets up this early, so he has plenty of time to do his devotions. he joined a tiny church a couple of years ago and he just loves it, but now he can only communicate with his church friends over the internet. he's looking for a new church, but he wants it to be really special, because he was never really religious til lately.

so here's what i was thinking when i came back home. i was thinking about him and his buckeye tree, and about the kid on the table in his muddy boots, and about the old lady with the roses on her pillow, and the hospital beds pushed together. so often i look around at everybody and i just see former babies, and i think about the way babies exist in a state of grace; and i know we've all fallen from that grace, but maybe that fall is only temporary. and i'm so filled right now with a kind of frightened angry tenderness. so i was searching my heart to see what it was i so desperately wanted to have happen. finally i guessed that my prayer for today would say, "look after all the innocents, and keep them safe, and first please don't forget that all of us are innocents."


this is the mess the lord hath made

the guy with AIDS is back in the hospital, and he's sicker.

when you are in the hospital, if you are very sick, they are likely to do a few tests to see if you have bacteria in your bloodstream. finding out if you have viruses in your blood (or in your spinal fluid or whatever) takes a lot longer, and finding out about mycobacteria (that cause tuberculosis) and fungal infections takes longer and longer still. so this guy had already gone home, last time, when his various test results came back.

he has cytomegalovirus in his blood, and MAC, which is mycobacterium avium complex, a cousin of TB, as well as HIV and the yeast infections. at least his viral load is dropping, now that he's a month on anti-retrovirals.

he came back to the hospital because he hasn't been eating anything - anything at all - and got very malnourished and dehydrated. even though his HIV is actually getting better, he feels really, really crappy. he is spiking fevers with sweats every night and has alternating chills and hot flashes all day. no appetite. no energy. no joy. no will to live.

what he has been saying, to me and to the nurses, every day, is "i've lost the will to live." "i just want to go home and die." "i'm thinking of stopping taking my medicines so i can just die." "just shoot me; i want to die."

the chaplain - a cute girl with a little gold cross - came to visit him, and he told her that he just wants to die so he can go back to god. when he was diagnosed with HIV in july, he came back to this state to live with his parents - he hadn't been back for 22 years. the chaplain asked him if he kept in touch with his friends in california, and he said no, because he had given up his gay lifestyle for god, and after that, they didn't want to talk to him anymore.

he says he knows that homosexuality is a sin.

and he says he just wants to die.

this is the mess the lord hath made, rejoice and be glad in it.

it is hard to frame the encouraging news ("your medicines are actually killing the virus that's in your blood, and the fact that you're having fevers might mean your poor battered immune system is starting to fight back") in a way that he can hear. especially since while all this reasoning is going on, he is shivering and sweating and moaning with every breath. he won't eat. he doesn't get out of bed anymore. his doctor is incensed - "he ought to be overjoyed that he's responding to the medicine!" - and is no help.

he got on some antidepressants, but they take a while to work. one of the anti-retroviral drugs has listed in the side effects, "severe depression, suicidal thoughts, abnormal dreams." unfortunately, just switching from one med to another is not as simple as one would hope. i honestly believe this man will get better - and i would feel differently about the whole situation if he really was at death's door - but just yet, he doesn't believe it, and he doesn't want to talk about it. he has sinned, he is paying, and if he suffers, god might take him back.

it's one thing to agitiate, politically, against such attitudes, regarding them as abstract - and another to try to figure out some way they can be recruited toward healing and hope, when they are materially real and god's own truth to a person, with devastating implications. can a person make themselves just lay down and die? "i've lost the will to live," he tells me - he's exactly my age - is the will to live an approximately physical entity? can you lose it, like losing your memory? can we supplement it, like with vitamins, or restore it to normal function, like with contact lenses, or build up its strength? should we chart its progress daily in his chart, just like IV-fluid-input minus urine-output equals net-fluid-balance?

we only look at what we can count.

the mess the lord hath made, part two.

cute young newlywed girl comes into the emergency room, she has swallowed nine grams of acetominophen.

i remember when tylenol first came on the market. it was an exciting new alternative to aspirin, which was your father's pain reliever; it was easy on the stomach, and soon after was found to not cause reye's syndrome in babies with chickenpox, unlike aspirin. so tylenol was the safe and easy pain-and-fever killer. now i'm surprised it can be sold without a prescription, because it's so poisonous.

the girl has horrible menstrual periods. they started when she was ten. ordinarily, she calls in sick and spends the week crying and thrashing around and bleeding. it sounds to me like she has endometriosis - uterine tissue growing outside the uterus, then leaking blood into the belly at period-time - and i ask if she's ever been diagnosed with this. she said the one gynecologist she's seen told her that women under age thirty don't get endometriosis. sometimes birth control pills make this kind of problem better - you basically suppress menstruation - but that's against her religion, which is catholic.

the problem here is that she had out-of-town visitors - her new in-laws - staying with her and she didn't want them to hear her crying. so she took two tylenol. they didn't touch the pain. an hour later, she took four more tylenol. then an hour later, two more. they still weren't working. three hours later, in the middle of the night, desparate to get some sleep, she took six more. three hours later, in the morning, four more to get her through church.

a few hours later, the vomiting starts. it goes on for six hours.

"The normal pathways of metabolism become saturated. Excess acetominophen is then metabolized in the liver via the mixed function oxidase P450 system to a toxic metabolite, N-acetyl-p-benzoquinone-imine (NAPQI). NAPQI has an extremely short half-life and is rapidly conjugated with glutathione, a sulfhydryl donor, and removed from the system. Under conditions of excessive NAPQI formation or reduced glutathione stores, NAPQI is free to covalently bind to vital proteins and the lipid bilayer of hepatocytes; this results in hepatocellular death and subsequent centrilobular liver necrosis."

right now it's the next day, she feels fine, and that's just what you expect. because the liver doesn't start dying til a few days later.

every four hours we make her drink an antidote that smells like rotten fish - "Muco-myst," what a name! - which will hopefully build up the abovementioned glutathione stores. glutathione is a liver chemical that binds to toxins and makes them water-soluble, so they go out in your pee. with no glutathione, your liver can't detoxify stuff, and in this case, a tylenol-derived toxin actually binds to your liver cells and kills them irreversibly dead.

it takes a while. you have a few days to get onto the organ-donation registry. hope you find a liver that matches. otherwise, you're going to die. to keep from dying, you lie around praying that someone else will die, someone with a good liver. after the transplant, you will spend the rest of your life on immunosuppressant drugs so your immune system doesn't kill the donated liver. all because your menstrual cramps were real bad and the tylenol just didn't touch the pain.

now, hold on, i'm not going to leave you hanging there. this girl is not going to die. the clincher is, she doesn't drink. she's not, in fact, old enough to buy alcohol (and neither is her husband). and that's a very good thing, because if you drink alcohol, then your liver can be killed by only two grams of acetominophen. that's only four extra-strength tylenols, people. a bottle of champagne and four extra-strength tylenol tonight, and you might be getting an organ transplant next week.

get that shit out of your medicine cabinet right now! throw it away! buy some dang aspirin! i am not kidding. no ifs, ands, or buts. do it NOW.


hospital stories.

today i got commended by a doctor. "i commend you," he said.

i met a man with carbon monoxide poisoning. he's my age. he remembers stepping into the car... next, he was in an ambulance. he hadn't left a note, but he had left an empty six-pack and 2/3 of a bottle of vodka. and, of course, the car, out of gas, with the hose taped to the window. when i met him, he was wearing a 100% oxygen, non-rebreather mask. he had spiked red hair and freckles. his blood carbon monoxide saturation was 35%; normally, of course, it is zero.

his friend was hanging around the room. she said his mother had filed a missing-persons report on him three weeks ago. it was really by chance that the police happened on him this morning. he's not from around here. he used to be a salesman. he used to be married. we asked him why he came down here, and he said, "because this is where i went to school," and started to cry.

the thing about carbon monoxide is that your red blood cells like it better than oxygen, but if you breathe enough oxygen, you can make your blood let go of it. however, it also binds to bits and pieces inside your cells - deep inside, for example, your brain - it hits the "electron transport chain" and poisons it, too, and that ventilator mask won't stop this from happening. so even though you feel better - our guy, for example, felt okay, except for the hangover - and even though the levels in your blood have gone down - in his case, to 8% - it still may happen that weeks, or months, later you begin to have problems. not able to walk anymore. not able to talk right. not able to think right.

we spent a long time calling different hospitals trying to find a hyperbaric (high-pressure) oxygen chamber for him, to prevent this from happening. i guess if you are in a pure oxygen environment, under enough pressure, you can force the carbon monoxide even out of the insides of your cells. finally, we found one that was neither full, nor broken, and only a 35-minute helicopter flight away. so we strapped him into a special gurney and went up to the roof of the hospital, out into the bright sunshine and wind - and away he went. he told me thanks. i told him good luck.

a lady with dengue fever is here. she went to visit family members in central america, and they all had cool drinks out on the patio, and now they are in the hospital down there, and she is in the hospital up here.

she'll probably live. but seeing her is like a glimpse into the old school of infectious disease, burning up with a high fever, gasping and hitching her breath because of pain, covered with fine spots - her white blood cells are almost all eaten away, now her platelets are going too, and her blood is getting more and more concentrated as plasma leaks out of her failing blood vessels, into her lungs, into her belly. everything burning up and crumbling. we're putting her in a positive-pressure room, one that blows all the room air out into the hallway, so she doesn't catch some horrible hospital bug and die of that. she's not contagious; we are.

if she can ride it out for a few days, and if the constant shift changes and new nurses and residents and interns don't let her fall through the cracks, and with enough i.v. fluids and extra platelets and so on, she'll get better - one article estimated a month of exhaustion and melancholia, after the fever part is over. they used to call it "bonebreak fever," because it is so painful that you feel as if your bones are breaking. you catch it from a mosquito. the only cure is your own immune system. this woman is eleven years younger than me, and she has six children. she looks like your average cute midwestern teenager - a teenager breathless and stunned and pressed flat by pain. you can feel the heat from a couple inches over her covers. bonebreak fever.

this morning at 5:30, an old man i've been taking care of said, "thanks, mom," after i tucked him in and fixed his pillow and turned off his light. i patted his shoulder and as i was leaving he said, "mom?" i said, "shhhhhhhhhhh," and he smiled gently and settled back down to sleep. he was brought here from the nursing home because he had "altered mental status" and "combative behavior," and had fallen down several times. we gave him the deluxe workup, with brain scans and a neurosurgery consultation and everything. when all was said and done, nothing had acutely injured his brain - his troubles had started years before, with a two-sided stroke, which ended up with him in the nursing home. his daughter is in charge of his medical decisions, because he's pretty out of it. he isn't where he thinks he is, we are not who he thinks we are, and he isn't doing what he thinks he's doing... but he's cheerful and friendly, just the same.

finally his daughter decided, correctly, that more brain surgery would be too much for him. but she also wanted a psychiatric consultation. it turned out that there's a woman he's hooked up with in the nursing home, and they have been up to quite a bit of hanky-panky, the nature of which was not revealed to me, but which was very, very upsetting to the old man's daughter. one way or another, this led to combative behavior... now i'm wishing that nursing homes, structurally, made some allowance for sleeping two to a bed, making out on the couch, taking showers together, just like the rest of adult life does... a worthy project for our greying and affluent baby-boomer kindred.



lump is found
lump is found and does not disappear
lump is specktackular

lump is discovered
lump is frightening to most women
lump is present and the physician suspects it
lump is evaluated by a doctor in a number of ways

lump is on one or other side
lump is a localized swelling
lump is not deformable
lump is a normal color or pink
lump is small and easy to retrieve
lump is fluid
lump is mobile

lump is described in relation to the clock face
lump is marked on the sheet
lump is the size of a walnut
lump is bothersome
lump is to cut the lump out or piece of the lump out and have it examined under a microscope

lump is new? created
lump is the evidence of god's healing
lump is the human form completely redesigned by an engineer and an ad agency
lump is absolutely efficient and marketably cute
lump is comprised of normal looking cells
lump is made of meat from the hind leg
lump is hard lump is soft lump is soft and compressible

lump is a very good lump

lump is painless and does not interfere
lump is of no consequence and disappears
lump is gone


mr. olsen told me about this place.

mr olsen makes "church glass and art glass," and he says the kokomo plant is the best in the world. "it's because of the sand." he is 84.

his medications? one aspirin, one vitamin pill a day.
ever had surgery? just a double cataract surgery a few years ago, which fixed his vision
so he doesn't need glasses anymore.
ever been in the hospital? he got some stitches in his face three years ago
when he fell down drunk.
other health problems? none, ever. he is completely intact from tip to toe.

he has a tattoo on his arm, that he got in 1941 for $5. it looks like a big black blur to me, but he can still trace the outlines of the eagle and the flag and his name on a banner. i told him how much tattoos cost now, and he laughed in astonishment.

will he live to be a hundred? i do believe so.


for posterity. the way things are right now. the even strain.

i am protecting this entry from my mom, because she just has plenty already on her mind.

she's spending the weekend videotaping herself reading her poetry because she expects to lose the use of her vocal cords. I myself am more concerned about paralysis of her diaphragm - through i suppose if your everyday work consists of cruising through chest cavities with sharp-edged instruments, you get pretty used to teasing those nerves out of the way.

they look like dental floss.
lymph nodes look like shredded boiled chicken.
so if you can scrape the shredded boiled chicken away from the dental floss with your sharp knife good enough... then you're cooking with gas... or something...

because i know plenty of psychology, i have the superpower of sublimating all my anxieties into your traumatic breakup, your online test-taking disaster, your hurt foot, and your falling-down ceiling (there's always a falling-down ceiling), as well as the problem of not being able to get in touch with anybody at the medical school for permission to just split to attend my mother's thoracotomy. so far, i have sent emails to ten individuals. apparently nobody involved with university administration or medical care reads email.

so anyway.

one does not know how to act in such circumstances. one sees how it's done in movies and books, thank goodness, and one hopes one can pull it off as successfully as the circumstances deserve.

i love my mother with a late-nineteenth-century kind of love, like houdini had for his mother, the idolatrous kind. i honor her heroism and the depth of her character. i love her for the trials she has passed, and she loves me that i do pity them (that's a paraphrase). i strive to emulate her goodwill and compassion, as well as her fondness for whimsical and sarcastic turns of phrase. i bow to the quick, graceful, willowy girl in the daffodil-yellow dress she feels herself at the core, as well as the heavy, graceful she-bear she appears to the world.

it's hard to envision cancer. i used to imagine my own (cervical) as a dark, softened, collapsed spot, like a bruise on the flesh of a nectarine. i have imagined hers (metastatic) as a bit of hot stuff, like a blister from a burn, self-contained and senseless, to be persuaded - by me, with a rosary, on my knees, in darkened churches - persuaded into coolness and stasis: cool down, cool down, be slow, be slow, go to sleep, go to sleep, go to sleep. now that blister has become a bit of shredded chicken with taut strands of dental floss running through it - nerves to the diaphragm, the vocal cords, the ribs, the heart. scrape careful, mister surgeon, scrape well.

i see the heroine waiting expectantly in the crowded waiting room. i know how burdened the doctor is by bad news, how he depends on bare facts to make it indisputable; he carries them in his mind down the hall as he pans toward the heroine. that's the fear. that one movie. the nurses pulling out the IV lines and wiping away the streak of blood, somewhat annoyed, resigned. and whatever happens after that - stunned and sickening farewell in the unused hospital room? unctuous mortician? blue ripstop body bag? lawyer on the phone, hushed, cautious? ashes in a thousand-dollar box? who knows? the camera always cuts to the aftermath: Moving On. i'm not ready.

so i won't rehearse. again.

i see a woman as big as a house, i see her figure arcing up over the city, over the valley, over the edge of the hemisphere, and with my heart i cry out to her, let me never be separated from thee. never was it said that any who fled to your protection, sought your intercession, or implored your help was left unaided. inspired by this confidence i fly unto thee.

and why shouldn't i?

My Day, by Mrs. Henry.

my mother got through her surgery okay, and now she trudges the long road of postthoracotomy pain - no small affair. last night i stayed up late worrying. but then this a.m. i got up and drove one hour to the veterans hospital for my first day of surgery.

there i did a couple of histories and physicals. but before i could type them into the computer, i was summoned to the operating room. so i put on my little blue hat and my little blue footies and a little blue mask with a nifty built-in clear plastic eyescreen. i washed my hands for a long long time, then went backwards, dripping, through the door into the operating room, where a nice nurse dressed me in a long blue gown and yellow latex gloves. i know it's the VA, but i disapprove of latex gloves. just sayin'.

in the o.r. was a kindly old surgeon who handed me a man's leg to pinion in my arms while he jammed a large steel spike into the kneecap, then started squirting water in into it. then he jammed a second spike and the water squirted out that side. i started sweating. then he threaded a fiberoptic camera in through the second spike and we all turned to watch it on t.v....

and just as i watched the shreds of pale pink cartilage floating across the screen, and the kindly old surgeon started explaining in latin what we were seeing, i lost my hearing, and big black splashes appeared before my eyes.

the nice nurse grabbed me by the back of my gown and dragged me to the corner and told me to SIT DOWN NOW.

out in the hall, i was asked, "are you okay now? do you feel better?" by each of the 20 surgical staff. i was, actually, okay now. i did, in fact, feel better.

i sat down and typed my H&Ps into the computer and snacked on some cheese crackers.

then i was summoned to the operating room again. hat, footies, mask; wash wash wash; be gowned, be gloved. this time the issue was a man who had a number of Boils. these are what Job had, you know. so i stood around gripping bits of skin with sharp-toothed tweezers while another friendly surgeon cut them open with teensy knives (they don't call them 'scalpels' anymore, they call them 'knives'), burning the little vessels off while i sucked up the smoke with a little suction-wand. for the last one, the friendly surgeon handed me the syringe, then the knife.

it's a lot like cutting through wet canvas. crunch, crunch. lots of digging around. lots of bleeding. lots of burnt-up-blood smoke. and not a twinge, on my part - not a bead of sweat, not the smallest palpitation. maybe it's easier when you have to concentrate and be really, really careful, as opposed to clutching a leg, watching it get scraped and chopped underwater on tv.

i sewed up the skin. it's a lot like when i used to embroider my jeans while wearing them (child of the 70s) - awkward, requiring some force and plenty of control for a pretty, orderly, decorative result. then the whole thing was all wrapped up under a see-through dressing, and i felt like whistling a tune.

so that's my day.


shoulder surgery. i was starting to see sparks and break into a cold sweat because i'd been pulling steady on a retractor in one hand and the patient's arm in the other hand for the previous twenty minutes, while the surgeon went at the joint with a mallet and chisel. then i felt a hot gush of blood in my underwear. i was afraid that if i passed out on the floor, the man would be seriously hurt by the savage physician...

but everyone got through it somehow. a few minutes ago, the patient began to emerge from anesthesia and started getting upset, in ultra-slow anesthetized motion, trying to climb off the operating table, and telling me in a high shaky voice to get him his sniper rifle, where is it, he needs his sniper rifle, he knows it's here somewhere.

sometimes i despair of finding the buddha-nature in folks.


are you dealing with pain? are you afraid your pain will deform your relationships to others in your world? epistle to you.

this was originally a letter to my mom, who is having painful radiation treatments,
but i have been telling abbreviated versions of this to various "patient" types,
and now i'm telling you.

there's pain, then there's the pain of pain. the instinctive feeling of
being punished, and the distance one feels from the rest of the world on account
of it, like being pushed out on an iceberg and floating away.

there's also a kind of physical numbness that sets in, that keeps you from the worst of it. which gives you the cold comfort of, "you don't even know how bad this really hurts." but that's illusory. how much you FEEL it is how much it hurts - that's the only measure.

one thing that might be important is for you to take pain medication well before
each treatment. WELL BEFORE. to pre-empt those pain pathways, to minimize the fallout in your mind.

it's the fallout in your mind that is salient, because the pain doesn't occur in
your body, but in your mind. electrical charges go off in your body - the meaning of the message obtains in your mind. scramble the signal with the drug of your choice, to reduce the amount of suffering your mind has to confront.

after that, there is the suffering of the suffering. it is a very tough discipline, to make your consciousness grasp that the point of this suffering is to be well and whole and restored and strong and free. it is very tough. it is a lot like labor. i mean the labor of birth.

in natural birth, Fear is actually the weakest link.
any extent to which you can disable Fear brings the pain
more under your control.

that's why self-help books and support groups are effective: Fear can't flourish
except in secrecy. by "flourish" i mean flourish. cancer and radiation
and pain are all scary, but being scared is not the same as freaking out.
when we are freaking out, it is in secret and we do not confess it.
but when we encounter other people's fearfulness, in a self-help
book or a support group, e.g., we recognize it as rational and not untoward,
even manageable. "now i see as in a glass, darkly, but then face to face."

well, that's pretty flowery, but my point is this.

a.) you can and should use drugs.

b.) you can and should minimize your level of Fear. there are narratives,
there are therapists, there is yoga, there is the Bene Gesserit way
("I will not fear. Fear is the mind-killer," etc.), there is, oh, I don't know,
distraction, marijuana, the first 3 seasons of West Wing on DVD...

pick a few strategies, WRITE THEM DOWN, and pursue them.
take it on as a project. e.g.:

1. i will take 600 mg naproxen 2 hrs before every treatment.

2. i will practice yoga breathing for 20 minutes 1 hr before every treatment and
for 20 minutes as soon as i arrive home from every treatment; only after that
will i continue with my day.

3. i will attend the radiation support group offered by the clinic twice each week.

4. i will write in my journal every morning, even if it's only one sentence.

MAKE A PLAN and you will have a grip on your world;
youwill be able to observe these events, and write about them,
and not be subjugated by them. that's my advice. that doomy feeling you
can't shake? that's the mind-killer. it will go away by itself.
please let me know if you need help.


Potatoes are My favorite food." -- God

one potato contains: almost HALF your daily needs of vitamin c, and one-quarter your daily need for potassium! 8% of the thiamine you need to keep from getting brain damage from all that binge drinking! almost as much protein as an egg! no cholesterol!

here is marilyn monroe in a potato sack:

"happy birthday, mr. potatohead..."

today i chatted with a very old little surgeon about potatoes. he grew up in india during world war two, when the british rationed potatoes, so potatoes became a luxury item. then he rhapsodized about all the indian food that uses potatoes, and said his daughter makes fun of him because of his inordinate love of potatoes. she does not realize they are the perfect food.

then he told me he knew ghandi. THE ghandi. he used to go to ghandi's prayer circles. they were held every day at 5 p.m. sharp, and he said it was a wonder ghandi wasn't assassinated sooner, because he was so very strictly regular about the same time and place every day. he also said ghandi went to international summit conferences wearing a loincloth no matter what the temperature, and this made winston churchill absolutely furious. "he was a good leader, churchill, but he had terrible ideas about the empire," said the little old surgeon, shaking his head sadly.

over his microwaved potatoes.


a psychiatric patient just told me he was admitted to the hospital for optic proctitis. he said it's when your optic nerves get crossed with your rectum, causing you to have a crappy outlook on life. i was going to say that such a thing could only be anatomically possible if you already had your head up your ass, but it would not have been an appropriate doctor-patient interaction, so i didn't.


what the neurologist said: Know what you do, do what you know, and don't lie a lot.


one life to live.

he said: you're not having any more bad thoughts? not thinking of killing yourself?

she said: i'm a lot better. i'm not really depressed at all. i've been making dinner at night. the only thing that disturbs me a little is: i keep shopping for a new husband.

he said: m?

she said: i keep thinking about what it would be like to have my next husband. a better husband. i mean, he's not a bad guy, i guess, but - i thought it was part of the depression. but the depression went away -

he said: how's the sex?

she said: awful.

he said: m?

she said: i don't care if i go for weeks - months - without sex. i don't care if i never have sex again. that would be fine.

he said: m?

she said: it's partly that he's not as skilled a lover... i've had boyfriends in the past and felt really eager at that time, and had others where it was good, not like every day, but three or four times a week, and that was fine. but with my husband...

he said: what part of that do you think is due to the medication?

she said: m?

he said: how much is the medication causing this.

she said: ?

he said: did the medication kill your sex life?

she said: well, no, because the medication came later. it was always pretty much like this. and it disturbs me because i don't know if i can stay in my marriage and still get better. i just don't know if i have the extra resources to deal with the differences between me and my husband, and still get better.

he said: m?

she said: like: i come home after working all day, and i'm tired, and i make dinner, and i can't even make what i want to eat, because he just wants to eat kraft dinner and mashed potatoes every night, and i want to have new things. he's not at all adventurous. but i am. and i want to start having the life i dreamed about when i was a little girl. this is just not the life i planned for.

he said: then what part of it is the medication causing?

she said: m?

he said: the medication isn't causing you any problems? except that you don't have the interest in sex? but when you're doing it, what happens? do the parts work?

she said: after a while, i feel okay, but it's not something i want to do, it's something i have to do. i can even have an orgasm with my husband, if i try hard enough, or with a private toy i don't have any problem having an orgasm. but it's something i have to do for him.

he said: the parts work.

she said: yes.

he said: m.

she said: and i know i'm not the biggest sexual - i mean, i didn't even have an orgasm until i was twenty-six.

he said: and if you were single, if you just went to work and came home, and you were taking the medicine, you would be fine with that?

she said: i would be fine with that. i would feel good.

he said: well, there aren't that many medicines we can give you for this.

she said: m?

he said: most medicines only work on the level of making the parts work, but sometimes they can help with the interest.

she said: m?

he said: have you ever tried buspirone? it's an antianxiety drug and it's very mild. it can help a lot with this in, say, fifty-sixty percent of cases.

she said: m.

he said: and i'll give you some samples of viagra. you know about viagra, right?

she said: m.

he said: so you start taking the buspirone, twice a day, cut the tablets in half, and the only thing you might notice is some upset stomach. and it can give you bad dreams at night. some people, it just makes them sick and they can't tolerate it at all, maybe one in a hundred people, it makes them feel really crappy. if that happens, just stop taking it, and switch to the viagra. with the viagra, take that when it seems like things might get a little romantic later - take it, say, twenty minutes beforehand. with the viagra, people sometimes get nauseated, and you can get reflux. acid reflux.

she said: m.

he said: maybe a headache. and sometimes, people actually lose their sensitivity to differences in colors. not a really big deal - it's not like you're colorblind - but if somebody all of a sudden turns on the lights, and everything's all gray, they can get really freaked out. but that only lasts as long as the drug is in your system, say about twenty-four hours.

she said: m.

he said: any more questions?

she said: ...




i DON'T want to be at work today. my stockings have a run. my professional-looking blazer has lost a button. my hair is falling down. my stomach hurts. because we have so many cars in my family, i had to move one car, and scrape another, to get here, and then all the good parking spaces were gone.

i don't want to know any more gory details about how all five siblings ended up in foster care or how that girl had three children by age fifteen or why so many kids in the family died of "sids" or why the mom and eldest brother are in prison. i don't want to decide whether someone should be tied down with leather straps or given a shot that will make them paralyzed and drooling.

i hate grownups and i don't want to be one. i hate doctors and i don't want to be one. i could have been an english teacher. i could be preparing a lecture on poetry right now. i have a biochemistry degree - i could be sitting on a twirly stool watching slime grow on agar plates. i could have called in sick. i could be lying in bed reading about rwanda and writer's block and the italian resistance right now.

i am going to get up out of this chair and walk out of the hospital and get in my car and go home and pick up the phone and call the medical school and tell them i am vomiting - which, considering this entry, is kind of true. then i am wiping off my lipstick, turning off my pager, and going back to bed.

...or not.


say it in broken english.

sitting in a sunny interview room with a korean psychiatrist. he makes big wide gestures:

there are only two mental illness.

schizophrenia - over here. it is black - dark, dark black. bipolar disorder - mania. it's over here. it is bright, bright white. blinding white. in between, is all grey. and here is the patient.

schizophrenia, the patient has flattened affect and thought disorder. it doesn't matter for hallucination, delusion - it is flattened affect and thought disorder. disorganized. they stay alone.

bipolar, the patient has affectivity - he wants to tell you all about all his feeling. he might have flight of ideas, tangentiality, circumstantial speech, but not the same as schizophrenia. he go wild. he never come to see you til it's over. unless police bring him.

bipolar disorder - mania - is historically underdiagnosed. schizophrenia, historically overdiagnosed. schizophrenia historically becomes a wastebasket: you don't know what's going on, you throw patients in. mania is very ancient. very ancient, and underdiagnosed.

in mania, the patient wants to tell his story! he has too much story! in schizophrenia, not enough story! he can not speak!

anxiety disorder, major depression - i don't know. patient's mother dies, he is sad, he is hopeless. why does he want to get rid of those feelings? he can still function. people have terrible stress in life. they have bad dream. they are scared. is not severe mental illness. should they be given SSRI? they still function. it depends. i don't want to give drugs to great artist so he cannot make art.

you judge whether patient has mental illness by your own standard. you tell if he is too anxious by your own standard. to be psychiatrist, you have to have healthy mind, because you are the bearer - you make standard. some people become psychiatrist with ulterior motive - hidden agenda. they want to resolve conflict. maybe that makes rapport. maybe they are more empathetic with patient. but maybe they give too many drugs. i am not a drug dealer.

the reason we are here is to make the patient feel better - if we can. but to make the patient do well - that is what we have to do. if we can make them feel good too, we will. but we want them to have a good life. not the same thing.

so why become psychiatrist? you become anesthesiologist, how much you talk to patient? you become radiologist, all you look are film. you become psychiatrist, you see whole life. every patient different. every patient interesting. and nobody die from schizophrenia. they might kill themselves. but you do not see on death certificate, "cause of death, schizophrenia." patient come to your office and you help them have better life.

patient's life is my patient. patient's quality of life is my patient.


so this morning i have an oral examination in psychiatry. this is like the Board Exam kind of deal: watch a video of an intake interview, gather your thoughts, then present a psychiatric evaluation and discuss w/the examiner. most of medical training is off-the-cuff and on-the-fly this way.anyway, last week there was a practice exam, and the interview was so badly done that there was actually no psychiatric data to report. it turned out it was kind of a trick - figuring out how to report on what was NOT elicited. live and learn.

so yesterday i studied hard all day, then watched a documentary about prehistoric beasts and a video by betty degeneres about the gay marriage ban, and went to bed.

so first i dream i go to the psychiatry oral exam, and instead of a video about a psych patient, i am shown a video about a baluchitherium.

and yes, i have to figure out how to evaluate the patient, when once again no psychiatric data has been elicited, and in fact there's not even any interview, just stuff like "this primitive rhinoceros is believed to have been the largest land mammal of all time." do i pull it off? i pull it off. i report on what was NOT elicited, and avoid sarcasm.

then i wake up a little, and roll over and think, jeez, that was bizarre. then i dream i have the oral exam again, only this time i'm shown a video about two lesbians in vermont who have a commitment ceremony with the tree in their back yard, with which they have a deep spiritual bond.

once again, no interview and no psychiatric data to report. the tree in my dream was a blue spruce. and the video was about the spruce, not the lesbians OR their marriage to the tree. and when i woke up again, i thought, man, even in my dreams i'm cynical about the medical-educational process!

but you know? some of the folks i've interviewed and evaluated in our two psychiatric hospitals have really been like baluchitheriums and blue spruces, at least from the outside. ungraceful. dislocated. endangered. only superficially domesticated. impossible to communicate with by ordinary means. and usually, against the odds, and although it sounds corny, loved.

so, well, why not write up the ancient rhino and the tree?




here is what i have learned so far:

the jacksonian march causes no loss of consciousness 'til it crosses the midline.

if you wonder whether you should do a spinal tap, that means you should do one.

a salaam attack is not a stomach ache.

bye-bye doesn't count as a two-word sentence.

the fetus lives on mt. everest.

these are TRUE FACTS

a jacksonian auditorium

i have actually done this

result of google search for 'fetus everest'

result of google search for 'salaam attack'



found poetry:

pedestrian activity can be made to function
as a non electrical computer, able to perform
difficult calculations while the agent walking it
doesn't need any mathematical skill at all

--i did not make that up.


i got yelled at by a nurse this morning for putting a pink hat on a boy baby. she said fiercely, "it will confuse the parents!"


EDMONTON (CP) - The foreskins of hundreds of baby boys in Alberta are being used by the military to help develop an antidote in the event of chemical warfare. The Defence Research Establishment at Canadian Forces Base Suffield in southern Alberta has collected hundreds of foreskins over the last decade of circumcised babies from a hospital in nearby Medicine Hat... Dr. Cam Boulet, head of chemical and biological warfare defence at Suffield, said foreskins have been used as a source of human cells for experimentation for about 10 years... The research program is aimed at finding ways of counteracting chemical weapons which hostile forces might use.


i have done 5 circumcisions myself now. my time is 15 minutes. the doc i work for hates them so much, and he tries to dissuade the parents, but the parents we've seen so far have the usual cosmetic notions. the doc said once he had to do 11 in one day: "i had nightmares for weeks, i kept seeing babies bleeding..." his voice trailed off like that. what i have learned about this surgery is that some bottles of lidocaine are "good" (i.e. anesthetize what they're supposed to anesthetize), and some are "bad" (don't). even when they're "good" - it wears off darn quick.

our local foreskins go into the incinerator, rather than to the pentagon.

it makes me sad to see so many babies sliced up, even premature ones, when they are so little. so i felt a little funny when the doc told me i'm, like, the best and fastest and most careful student of penis-slicing he's ever seen. it's like being told you're really humane at drowning puppies. or, uh, something.


but what i'm REALLY good at is getting babies to stop crying. my advice: keep your newborn in your room with you EVERY MINUTE you're in the hospital. and for god's sake, nurse the dang baby!

my new pals


things i have been saving up to tell you

here is my literary role model:

also, today i realized i have been worrying about the safety and well-being of teenagers since 1994.

SINCE 1994. this is why i get tired.

also, today i met the new pediatrician with whom i will be working. the first thing i heard him say was, "God is some fucking asshole." and the nurses around him all nodded soberly in agreement.

they and the family had just been getting ready to turn off the life-support of an 11-year-old who had lost the left half of her brain to cancer, when she opened her eyes and started responding to questions (with eyeblinks). one might think this is a good thing. turns out it's not.

In the middle of the night
Miss Clavel turned on her light
and said, "Something is not right."

the "doubling time" of the tumor, which could not all be removed, is seven days. two weeks ago she was in school playing soccer, and her mother's biggest problem was a crackhead ex-husband. today i learned what decerebrate posturing is. the doctor is very pissed: "Now," he says angrily, "She gets to be aware that she is dying of brain cancer. God is one mean motherfucker."

And afraid of a disaster,
Miss Clavel ran fast and faster,
And she said, "Please, children, do!
Tell me what is troubling you!"
And all the little girls cried, "Boo hoo!"

since 1994 i have been worrying about the safety and well-being of teenagers and i have grown impatient and tired of the way they say i worry too much. and i know i was the same way. that doesn't change anything. since i was 19 years old i've been one tumor, one gunshot wound, one drunk driver away from a broken heart. i know it sounds harsh, and i apologize. i do worry too much. i suddenly got very angry while i was writing this, because i love you, i love you, i love you so much and i want you to be safe.

god-damn it.


here are some of the things i have seen around lately.

a baby with no thumbs. actually, one thumb is hanging on by a wee thread of skin, and that little nubbin has the tiniest thumbnail you can imagine. now let me tell you people, i loved this baby. she was in the hospital for RSV, the severe respiratory problem millions of babies around the US have at this time of year. her lungs, through the stethoscope, sounded like when i kick a cardboard box down the basement stairs (my preferred method for disposing of boxes). but she was extremely pleasant to hang out with.

her parents did not ever visit her or even call to see how she was, and she was in the hospital for 6 days. all alone, and so tiny (8 weeks old). so i spent a lot of time holding her and rubbing her head (baby loves head-rub!) and singing her name, and we had many meaningful eye-gazings.

the research says the way to handle the no-thumbs issue is "pollicization" of an index finger. that means to take the index and scoot it down to the empty joint and attach it to the muscles there. it's called pollicization because pollix is the name of your thumb (whereas hallux - not castor - is the name of your big toe). but in her doctor chart it said they planned to use hallux instead. so go figure.

she also had 3 holes in her heart, which cause her no undue distress at this time - and no murmur either. but she will eventually need some heart surgery, all of this to occur in some major metro area. the parents are potheads who live in a small apartment with a cast of thousands, mostly unemployed, in a tiny village down here in the sticks. so how will the visiting issue go then - in the major metro area? i'll never know.

why do i casually call them potheads? the mom and baby both tested positive. and how unusual would it be for only the pregnant mom of the house to smoke up? you know. i'm not hatin'. i'm just sayin'.

pax polliscum

i also saw a five-year-old who had some kind of cancer and was getting chemotherapy, so he was absolutely hairless, no brows or lashes, and as pale as a ghost, practically transparent. he was in for a brief hospital stay and some IV fluids. the doctor stood around talking to his dad, and i stood around with the 2 other medical students watching, when the kid unobtrusively slid a large black pistol out from the covers and pressed it

meditatively to his temple for a moment, and then, with a gentle smile, aimed it carefully at each of us in turn, quietly whispering, "kew... kew... kew... kew."

stand aside, gents!

also, a two-year-old who had seizures the previous night and was in for observation. he had a speech delay, meaning he didn't say any words. what he said was "guh". and his mother made the most elaborate translations from each "guh" that you can imagine.

the child would point at the door and say, "guh," and the mom would say, "no, honey, we don't get to leave until after the doctor comes." he reached for an empty can of pepsi, "guh," and his mom would reply, "yes, honey, daddy will be here later after work, and maybe then he'll let you have some pepsi," turning to me and explaining, "his dad drinks a lot of pepsi." the baby smiled at me angelically and said, "guh," and his mom said, "oh, jeez, i bet you ARE hungry, let's see if we can order breakfast." this child also walks on his tiptoes. his mom said she did that for a long time when she was little, too. so although the pediatric neurologist frowns, she continues to smile.

how cool is that?

...in contrast to the patients, the doctors themselves as a rule are intolerant, suspicious, arrogant dinks. and thus the number-one lesson i am learning during my pediatrics clerkship is the same one i have been teaching for years: "kids rule, pediatricians drool."

you damn right.


feeding-tube news

VATICAN CITY - Pope John Paul II may have to return to the hospital to have a feeding tube inserted.

A US federal appeals court has agreed to hear a petition by the parents of Terri Schiavo to have her feeding tube reinserted.

Ronald Mack was kept alive for nearly 20 years through a feeding tube... Deanna Mack told 11 News she finally found closure in the case two years ago when her husband passed away, after living for 20 years on life support.

FAIRWAY, Kan. - Investigators said a feeding tube problem led to the death of a Johnson County teenager recovering from injuries suffered in a bicycle crash.

A licensed practical nurse was convicted Tuesday of cutting the feeding tubes of six patients at the Philadelphia Nursing Home last year.

There is a risk of infection with a feeding tube, because the stomach acids may leak... Medical experts say the level of pain depends on the patient and whether or not they are able to even perceive pain.

Healthcare professionals commonly rely on feeding tubes to supply nutrition to severely demented patients. [One] problem is the common urge by many such patients to tug or pull at the tube... The team of engineers at SWNM has potentially found a simple, plausible solution in a new design of a feeding tube.

Judge OKs Feeding Tube for Brad Pitt and Jennifer Anniston Marriage
LOS ANGELES – The marriage of Brad Pitt and Jennifer Aniston will be kept alive, at least for the time being, thanks to a temporary order issued yesterday by a superior court judge in Los Angeles.

Teeth are overrated... Contemporary medical science has graced us with a wonderful option - feeding tubes. I know I want one.

feeding tube is society's next great innovation
feeding tube is modern and quiet
feeding tube is popular in both new and remodeled buildings
feeding tube is a smooth curve through the selected positions
feeding tube is now approximately 90 years of age

feeding tube is the heart of a revolutionary
feeding tube is noisy
feeding tube is folly

feeding tube is reality
feeding tube is on track thanks to $ billions in modernisation

feeding tube is kept separate from the outside holes
feeding tube is used to measure the local velocity
feeding tube is used to drain from a tank
feeding tube is also a passage way for germs

feeding tube is not an immediate availability and it is definitely not a right
feeding tube is white because it is

feeding tube is composed of a confuser inlet cone
feeding tube is packaged with 1 rigged tiger and 1 replacement body
feeding tube is stable in air as it also is in molten glass
feeding tube is placed in the nipple/sleeve assembly
feeding tube is then conveyed to the accumulator
feeding tube is always conducting

feeding tube is transferred to the retaining nut
feeding tube is actually a replacement for the barrel nut
feeding tube is truly different from other feeding tubes on the market

feeding tube is designed to supply current up to 200 milliamperes from an alternating source
feeding tube is filled with the light given off by the phosphor that coats the inside of the feeding tube

feeding tube is inserted as far as possible
feeding tube is one layer thick
feeding tube is used in cats with diseases
feeding tube is where the skill of the artist comes to play
feeding tube is allowing scientists to study shock waves

totally tubular


oncology news

it turns out

if you don't have a boob or two, you don't
have to keep your tattoo/s covered up in public.


notes from the pediatric underground

today in clinic was a four-year-old suspected of having a urinary tract infection. her mom took her to the bathroom to get a pee sample. they brought back a sample-cup half full of cloudy, lumpy-looking pale green liquid. the doctor, who is a roly-poly balding egyptian man, said, "zat does not look like you-reen. has she been having ze diarrhea?" to which the mother shrugged and said, "i dunno." he said incredulously, "you do not know?" and she turned to the four-year-old and said, "have you had diarrhea?" to which the child, predictably, gave a noncommital shrug and went back to staring at the allergy pamphlets on the wall. so the mother said, "she says no." the doctor shot me A Look. then he stepped up to the child with his stethoscope, and the child's two-year-old sibling gave a scream of fear. the doctor joked to me, "i cannot work under zeze cirgumstances," wherepon the mother bitch-slapped the toddler for yelling. the doctor handed the you-reen sample to the nurse and said, "if you ever have seen any yoo-reen before, zat is looking like zis, please tell me immediately." and proceeded to the next patient,

another four-year-old, this one with a putative ear infection. the child was sitting alone on the exam table, and the mother was sitting in a chair pulled up to a full-length mirror on the wall, squeezing zits on her own cheeks. "and today we have kareena, yez?" said the jolly doctor. the mother gave some vague details, "a fever, tugging at her ears," still attending carefully to the zits. the doctor rolled his eyes at me, and began to examine the little four-year-old, and still the mom concentrated on her own reflection. i even went up and stood right next to her and looked over her shoulder into the mirror, but it didn't distract her. not until she was satisfied with the condition of both rough cheeks did she wipe her hands on her jeans and turn around.

"today is za strangest day," said the doctor. we went to the staff lounge to get some water and another employee came crashing through the door and slammed the doctor up against the wall behind the door. as she apologized, he stood there comically, with the door swinging away, rolling his eyes and saying to me, "you see? today zis happens! ZIS day!"

"If it looks like a 3rd year medical student, and writes like a 3rd year medical student, it is probably a sensitive, highly-intelligent person, who has not yet been broken by the insanity of surgeons, the cynicism of internists, the nihilism of emergency physicians, the obsessive-compulsiveness of pediatricians, the apathy of neurologists, and the paranoia of obstetricians. Notice I did not mention psychiatrists or family practicioners. Psychiatrists, because at least they recognize that they are crazy, and family practicioners, because essentially they are all these things wrapped up into a neat, little, megalomaniacal package."

--from the Evil Resident, online


FUN FUN FUN friday VA self-quiz FUN FUN FUN

pretend you are a 57-year-old homeless alcoholic vietnam veteran (an american one) with lung cancer who has just been diagnosed with two metastases in your brain which have rendered you somewhat demented. further pretend that you have fallen down and broken your hip and nothing can be done for the fracture because you are too frail to withstand any surgeries. you are admitted to the hospice at your local VA hospital. you have a mom, a sister, and two daughters, all of whom are a little estranged from you because of your alcoholism, but who have taken on the responisibility for your medical decisionmaking. now you're ready to play friday VA self-quiz!

10 things i'd miss doing because i'm stuck in the hospice:

9 things i'd bequeath and who i'd bequeath them to:

8 ways i'd wish my daily routines could be improved:

7 ideas about the afterlife, about which i'd be wondering:

6 things that would be totally freaking me out:

5 drugs i would ask for:

4 ways i'd blame myself for my situation:

3 things i'd look forward to every day:

2 things I'd try to stay in denial of:

1 person I'd want to apologize to:

...now go work on your advance directive and HAVE A GREAT WEEKEND!


and now
...Orientation to Obstetrics and Gynecology: we go around the table and everyone has to introduce themselves and say what medical field they are interested in. the instructor then gives each one a reason they need to learn about obstetrics and gynecology.

this causes the instructor to instruct one student, who most of us know is as gay as a (ridiculously stylish) easter bonnet, that even though he plans to go into child psychiatry, he still needs to learn ob-gyn because someday he'll have a wife who will ask him questions about her "female parts." the look on the student's face: priceless.


i am sick of being sick and i am sick of being tired and i am sick of having mixed connective tissue disease that gives me cankles and makes my fingers fall into a coma and i am sick of being scared of getting even sicker and i am sick of not getting a full education before i'm loosed on poor innocent sick people and i am sick of 90F heat and 90% humidity and i am sick of cock-rock on the radio and cock-docs who think they're midwives and i am sick of falling through bureaucratic cracks at age 44 and i am sick of bush's war and i'm sick of jingoism and i'm sick of american femininity and the amount of makeup and perfume it entails andi am sick of television and i am sick of having my heart beat wrong and this is NOT a good time to come to my house without being invited and i do NOT want to talk about it.

a realistic, yet flexible, approach to the science of rheumatology is practically mainstream now
a realistic, yet flexible, approach to the science of rheumatology is like television
a realistic, yet flexible, approach to the science of rheumatology is modern hope

a realistic, yet flexible, approach to the science of rheumatology is a delicate weaving of art and medicine
a realistic, yet flexible, approach to the science of rheumatology is based on thousands of years of practice
a realistic, yet flexible, approach to the science of rheumatology is magic

a realistic, yet flexible, approach to the science of rheumatology is not enough

a realistic, yet flexible, approach to the science of rheumatology is the best laughter
a realistic, yet flexible, approach to the science of rheumatology is a glorified endurance test
a realistic, yet flexible, approach to the science of rheumatology is god's approach to the science of rheumatology

a realistic, yet flexible, approach to the science of rheumatology is the only choice

a realistic, yet flexible, approach to the science of rheumatology is a weapon of peace
a realistic, yet flexible, approach to the science of rheumatology is available to those who qualify
a realistic, yet flexible, approach to the science of rheumatology is slowly dying in america

a realistic, yet flexible, approach to the science of rheumatology is a humane art
a realistic, yet flexible, approach to the science of rheumatology is a delicate weaving of art and science and ethics and philosophy
a realistic, yet flexible, approach to the science of rheumatology is made from willow bark?

a realistic, yet flexible, approach to the science of rheumatology is a glorified endurance test
a realistic, yet flexible, approach to the science of rheumatology is a glorified endurance test
a realistic, yet flexible, approach to the science of rheumatology is a glorified endurance test
a realistic, yet flexible, approach to the science of rheumatology is a glorified endurance test


1. during an obstetrics lecture, the retired white male obstetrician taught us that it's "cruel" to not circumcise infant boys. i and the other female in the class objected, and he told us, chuckling, that we had those objections because we are female. he said, "after all, it's not YOUR foreskin."

2. yesterday, when i complained to some pals that soon i would have to wear house slippers to clinic every day because of my cankles, i received an enthusiastic chorus of support for "bunny slippers!" it seems the young women of today would feel more comfortable visiting a gynecologist that wore bunny slippers than otherwise. that's encouraging.

3. the online journal service just notified me that i am now obliged to post to the future because of a mistake i made in the past. i think there's a lesson in this for all of us...


things tested for which i am being:

sed rate
c-reactive protein
creatinine kinase
anti-thyroid-peroxidase antibody
anti-thyroglobulin antibody
anti-double-stranded dna antibody
anti-centromere antibody
anti-scl-70 antibody
anti-rnp antibody
anti-cardiolipin antibody
c3 complement
c4 complement
lyme disease antibody

nine tubes

this involved nine tubes of blood.

i do not think i have lupus, but rather rufus, the smaller, subtler cousin of lupus. i asked the rheumatologist whether my a.n.a. (antinuclear antibody) titer could be a mistake, and he laughed and said, 'not at that level!' i asked him whether he'd ever seen one that high before, because i cernly hadn't, and he said, 'hmmm...'

he pimped me a little bit on the physical signs of dermatomyositis. happily, i had recently seen a pediatric case. he tried to be tactful about the possibility of mixed connective tissue disease, which was genteel of him, as it carries what some gently refer to as "a poor prognosis." however, he also said this all could just be a very bad case of thyroiditis.

so now i am going to be taking plaquenil (a quinine derivative) and procardia (a calcium-channel blocker) and hoping to feel better in a couple of months, which is how long it takes antibodies to fuck off and be cleared from the bloodstream. at least i won't get malaria.

the procardia is for the raynaud's. it turns out that raynaud's which is associated with an autoimmune screwup can indicate the presence of "internal raynaud's" - like in the heart and lungs. that would be, uh, ischemia.

i gotta go

i got up at FIVE
so i could DRIVE
75 miles and ARRIVE
in scrubs, gown and gloves, by 7:30 a.m. because a lady whose baby died 2 days before the due date got pregnant again and has a placenta previa
which could easily make her bleed to death and she could not possibly be more anxious so we are having a preterm caesarian.

after that, we'll cut up a bunch of other nice ladies, and they will thank us kindly.

i kind of forget what regular life is like.


you know what's nice? i'm writing a paper, and trying to remember what-all microscopic findings one looks for when one takes a "wet mount", i.e., a microscope slide with a drop of water and a coverslip on it, of a vaginal swab.

so i do a google search on ["wet mount" "vaginal"] and guess what? no porn! weirdly touching, eh? ...and the matching image search has only four fotos, none of them pornographic in any way.




here is what a myositis is like: on the endocrinology service, day one, and i thought i was going to conk out. the long long long hospital hallways, and the normal people striding up and down them - it's too much - one has to just fix one's eyes on the bench just ahead and listen to your breath go in and out and in and out until you get there.

i feel better when helping someone - i mean, physically, i feel more well, plus i get to sit down while i talk to them. so it's a snap to focus on hospitality in the exam room - downhome gestures, honest questions, gentle humor. folks are pretty nervous at the endocrinologist's. you don't go there, or get sent there, unless something mysterious and debilitating is going on. so i try to help them relax a little before they see the endocrinologist, before he goes all clinical on their ass.

i tried to tell the endocrinologist - the man with the lightbulb head - about my own recent mystery debility, since it might make me, for example, lose consciousness in the middle of an exam - or so it appears. he changed the subject, twice, back to controlled randomized studies recently reported in the new england journal - gracefully reminding me that it is vaguely rude, for members of the doctor's caste, to mention one's own sickness to another.

it is threatening, it is embarassing, it reminds them of all the unkind, frustrated jokes they have made about patients with exactly that mysterious and refractory set of complaints. i stand rebuked, in the nicest possible way.

the man with the lightbulb head warned me there are a lot of psychiatric diagnoses in endocrinology, meaning there are a lot of folk troubled by depression coming to his office. which comes first? how you answer that depends on the fundamental attribution error. if it happens to me, it comes from outside. if it happens to you, it's the way you're put together. the trouble is, our medical system is founded on diagnosis rather than symptoms.

we treat diagnoses rather than sicknesses. so you come in with fatigue and lightheadedness and pain, but you go out with an antidepressant. the funny thing is - it just might do the trick.

my glamorous new husband is worried because sometimes i cry, simply cry from fatigue, and from how small the things are that cause this fatigue - whether or not to brush one's teeth becomes a real cost-benefit analysis, and it's so scary and frustrating and stupid. he is very loving and sweet. i do my best to be loving and sweet to the sick, scared, angry people who come to the hospital... god, how much we take for granted, how easily and gaily we forget about that enormous building in the middle of the city, full of "the lame, halt, blind, and withered," and what the presence of that big, big building in the middle of our busy lives really portends for each of us. when i feel sad for myself, it's partly because i know how sad things can really get, and it's scary, and also, i wish i could help, just help all of us better, and i can't right now. there are limits. my inner bodhisattva rattles the bars so hard!

She soon made out that she was in the pool of tears
which she had wept when she was nine feet high. "I wish
I hadn't cried so much!" said Alice, as she swam about,
trying to find her way out. "I shall be punished for it
now, I suppose, by being drowned in my own tears! That
will be a queer thing, to be sure! However, everything
is queer today."

everything. everything is queer today. but thanks for listening.


numb with fatigue.

i was going to go to go to sleep, but a family member sent me a message in a bottle saying they might or might not need me to drive across town and fetch them in an hour - then dropped out of sight.

life is better when you have a plan. is that correct? no, life is better when you don't need a plan, but when you need a plan, it's better to have one than just plan to make a plan sometime real soon.

i have been driving across the midwest to work in a pain clinic. one of the doctors has thick black hair and a thick cuban accent and told me to call him ricardo. i am worried i might slip up and call him ricky. the other one has some kind of a middle eastern or central asian accent i don't recognize, and he wears a little flag pin on every garment he owns.

the doctors are very kind. almost all their patients have had back or neck surgery that made their back or neck pain much worse. they do not like surgeons one bit. they think the surgeons are cruel. the patients are in pain, which makes them kind of spaced out and blank, and they are almost all white. the doctors inject things into them to relieve the pain, and they schedule their appointments long enough so that they can do something material for every patient right away, instead of finding out what's wrong this time and making the patients come back later for treatment.

i did not try to conceal my debilitation this time and it seemed to go over pretty well.

due to fatigue + obligation, i haven't been able to have a conversation with anyone yet about how the last two days have gone, so i'm telling you now. and it's almost time that i should hear whether my family member wants a ride or else not hear that they already have a ride. so soon i will either go to go to drive or go to go to bed. i am sleepy baby who is starved for attention.

on the long drive, i was listening to a cd of psychiatrists discussing the neurobiology of depression, cognitive dysfunction, autoimmune disorders, and chronic illness - autoimmune disease in particular. it turns out that when your immune system gets alarmed, t-cells start making wild revved-up chemicals that put you on red alert. but one of them starts to chill out the rest by causing cortisol to be made as well, which anesthetizes the immune system and calms it down again. and cortisol makes you depressed. and you cant think gud.

not to mention that if you were ever exposed to anything horrifying in your life, you are extra-vulnerable to activation of your amygdala and your limbic system and junk, which by themselves, independent of the pituitary gland, make cortisol-releasing stuff, so there you go, more cortisol.

and to put the icing on the cake, the limbic system, the seat of emotion, is one of the special parts of your brain that has stem cells and can renew itself when it has suffered the slings and arrows of outrageous fortune. but guess what cortisol does? kills 'em.

so my question is, what about someone like me, exogenously supplying myself with 250 times the physiologic amount of cortisol? i will become dumb, then blue, then numb, and my brain will shrink until it rattles in my head like a dried up old soybean pod.

but at least i am cankle free.

oh bondage! up yours!

from National Velvet:

"That'll be a dispute to the end of time, Mr. Brown: whether it's better to do the right thing for the wrong reason or the wrong thing for the right reason."

"What's the meaning of goodness if there isn't a little badness to overcome?"

"Things come suitable to the time."

-- mrs. brown, zen master


it's what's for dinner!

so there's this kid who has been throwing up a lot, and the only thing that tests abnormal is he doesn't have any tonsils. that can be a sign of an immune system disorder. so i did a journal search for "absent tonsils" and got this:

The abattoir source of culturable psychrophilic Clostridium spp.
causing 'blown pack' spoilage of vacuum-packed chilled venison.

when i first read the title, i thought it was one of those random gibberish strings of words you see on the web sometimes, but then i read this, and now i get it:

To identify the abattoir sources of culturable psychrophilic clostridia
causing 'blown pack' spoilage of vacuum-packed chilled meats, clostridia
were isolated from hides, faeces and tonsils of deer slaughter stock, and
from a meat plant environment... Gas production in packs inoculated with
vegetative cells of clostridia was first evident after 14 days at 2 degrees C.
The prevalence of these clostridia was similar in hide and fecal samples from
slaughter animals... The data suggest that soil particles attached to hide or
present in faeces are the most probable primary reservoir from which 'blown
pack' clostridia are introduced onto carcasses.

..."psychrophilic" means cold-loving and is the opposite of thermophilic, from the greek "pskhros," cold. clostridium is botulism. you can inject it into your wrinkles to look like nancy pelosi, or you can eat poisoned meat and get kilt dead by it.

cf. also:
Psychrophilic Clostridium associated with 'blown pack' spoilage of chilled
vacuum-packed red meats and dog rolls in gas-impermeable plastic casing.

Detection of Salmonella from chicken rinses and chicken hot dogs.

Tremorgenic neurotoxicosis in cattle fed sprouted grains.

The prevalence of Cryptosporidium in beef abattoir water supplies.

The accumulation of potentially toxic elements in edible body tissues
of lambs grazing after a single application of sewage sludge.

Discontinuity patterns in stages of the precaution-adoption-process model:
meat consumption during a livestock epidemic.

one of the heroin kids up the street died last week.

oooh baby

i never met him, but what i heard was, he went out dancing and drinking to celebrate his birthday, then later did up a bunch of heroin and drowned in vomit and died. and his friends were very sad and had a memorial party for him on saturday night.

this summer, one of the cute teenaged girls in the neighborhood had those bruises on the insides of her arms. i was happy when i saw her a month later and she did not have those bruises on the insides of her arms.

i remember the last time uncle sam liberated an opium-exporting nation from the grip of oppression. speaking of laos, here's the latest -

Nobody knows how many surviving fighters from the CIA's secret tribal army
are still out there... still at large and probably still committed to battle
against the government. There are signs now, however, that their lonely
50-year fight against communism, still officially the ruling ideology of
Laos, may at last be drawing to an uneasy end. In the last year, there have
been a couple of large-scale surrenders to the Laos government, mostly by
bands of exhausted, hungry women and children...

and speaking of afghanistan:

On the eve of the fourth anniversary of the launch of U.S. military
operations... Afghanistan still ranks among the half-dozen poorest countries in
the world, and, according to a State Department report published in July, has the
highest level of malnutrition in the world at 70 percent... The U.N.'s drug
agency estimated earlier this year that the cultivation and trafficking of
opium accounted for 60 percent of the economy... According to a recent U.N.
report, Afghanistan has in the past year moved into actual heroin production.

it's making me crazy

meanwhile, back at the ranch:

Drug users frequently witness the nonfatal and fatal drug overdoses
of their peers, but often fail to intervene effectively to reduce
morbidity and mortality... Among 1184 heroin, crack, and cocaine
users interviewed between November 2001 and February 2004,
56.8% had witnessed at least one nonfatal or fatal heroin-related
overdose. Of those, 67.7% reported that they or someone else present
called for medical help for the overdose victim at the last witnessed
overdose... Fear of police response was the most commonly cited reason
for not calling or delaying before calling for help (52.2%).
Attempts to revive the overdose victim through physical stimulation
(e.g., applying ice, causing pain) were reported by 59.7% of respondents,
while first aid measures were attempted in only 11.9% of events.
Efforts to equip drug users to manage overdoses effectively... and the
reduction of police involvement at overdose events may have a
substantial impact on overdose-related morbidity and mortality.

every time i look around,
every time i look around,
it's in my face.

two wonderful quotations by mathematical weirdos of the past:

"the most Devilish thing is 8 times 8 and 7 times 7
it is what nature itselfe cant endure."
--Marjory Fleming 1803-1811

"I know the answer! The answer lies within the heart of all mankind!
The answer is twelve? I think I'm in the wrong building."
--Charles Schulz 1922-1999


owner, your problem is ready for pick-up

"For physicians-in-training, this schism between home and work is especially sharp. The hospital literally becomes home for many medical students when they are on the wards... Many physicians may feel more comfortable at work in the hospital culture, and the familial home may seem like a burden or a game with shifting rules and expectations that may seem to change daily."

this is exactly what i resist.

"Over 30 years of follow-up, the divorce rate was 51 percent for psychiatrists, 33 percent for surgeons, 24 percent for internists, 22 percent for pediatricians and pathologists, and 31 percent for other specialties... Female physicians had a higher divorce rate (37 percent) than their male colleagues (28 percent)."


"In one large national questionnaire (sample size: 4,501), 47.7% of female physicians reported experiencing gender-based harassment and 36.9% reported experiencing sexual harassment... [Also] in that study, 62% of African-American female physicians reported experiencing ethnic harassment, and 25% reported that it occurred during at least three different phases of their careers.

"...In a recent study of internists in Pennsylvania, women reported being more likely than men to spend fewer hours seeing patients, practicing in the least lucrative settings, and choosing lower paying specialties as salaried employees. Yet, even after adjusting for these differences, hourly earnings were significantly higher (14%) for men.

"...Approximately one-half of 200 female physicians who were polled reported experiencing continual high stress levels because of their multiple roles, 44% felt mentally tired and 17% took antidepressant medications... 31% indicated that they would not become a physician again."

i blame the patriarchy.

"The gap in suicide rates evidently begins as early as medical school, where overall suicide rates are higher than in the age-matched population. This increased rate of suicide is driven largely by higher rates among women... The combined results of 25 studies suggest that the suicide rate among male doctors is 40 percent higher than that among men in general, whereas the rate among female doctors is 130 percent higher than that among women in general."



found poetry: the one-minute medical education.

According to Chinese philosophy, when you save a person's life,
you are responsible for that individual forever. E.J. Pugh did not
fully grasp that Asiatic credo until she spotted teenager
Brenna McGraw jumping off of a bridge.

Some people think that when you save a person's life, you become
responsible for that life. In this story, a world-weary sex worker
impulsively takes in a drunk, fragile young woman who is in distress,
hoping to force some measure of redemption.

I believe it's a Native American idea, that if you interfere to save a
person's life, you're responsible for them for the rest of their life. This
sometimes means sitting with him for hours in the Social Security office,
taking him for medical check-ups, finding out why his rent check bounced.

The Chinese have the right idea. Save a person's life and
you are responsible for them until they die. Perhaps you could
have saved her. Perhaps she would have dragged you into
her pit. These are not matters to be taken lightly.

"When you save a person's life, you become responsible for them,
a Blessed Protector, and you're responsible for them the rest of your life.
You're stuck with me. I'm gonna help." The hospital room quieted.

Supposedly, once you save a person's life, you are responsible for it,
and Antoine takes that to the extreme. Louis is a sad sack who fell apart
after his girlfriend left him. Antoine feeds, clothes and houses him, pays for
his medical bills, gets him a job and finally tracks down Blanche in hopes of reuniting her with Louis.

Like many Pacific Islanders, I believe that if you save a person's life, you
are responsible for him for the rest of your life. And that is no longer a responsibility I am able or willing to take. What if I gave him a reason for
living and that reason turned out to be a lie?

In the eastern tradition, when you save a person's life, you're responsible
for them for life. Since your teachings have saved my koi's life many times over, you're now responsible for them. Unfortunately for you, I come along
as part of the deal. So - when's dinner?

Mac: "You save a person's life, it makes you responsible for them."
Harm: "Saved your little green Marine butt that day."
Mac: "You're the one that put it in jeopardy in the first place."
Harm: "Ah, you still owe me."
Mac: "Oh, I paid you back."
Camera tilts down
The BACK of Harm's HAND briefly brushes the BACK of Mac's HAND.
Tilt up
Harm and Mac stare straight ahead - neither acknowledging the touch, neither daring to look at the other.

In the Orient there is this old Confucian saying that when you save a person's life,
you are responsible for that person for the rest of their life. If that rule were actually practiced, I suspect that very few people would ever want to become doctors.

In certain cultures if you save a person's life you become
responsible for that person. So it is with a Holy Union.

i think maybe i became a doctor because i really do sort of believe that
if you save a person's life, you become responsible for them. accepting/pursuing
such a thing does not sound socially acceptable, even though i could give a bunch
of complicated ethical reasons for it. it's not very "american," which in this neighborhood means it's completely impractical. but i learned at an early age that if you get your heart pierced, it's able to let more love in. THAT idea sounds too corny to be believed. but it's the truth. it's the truth. it's the truth.


i am telling you this for your own good!!!

note that the wrist bones are named,
from thumb-side to pinky-side and wrist to palm,
scaphoid, lunate, triquetrum, pisiform,
trapezium, trapezoid, capitiate,
and hamate.
the mnemonic for remembering these is
Scared Lovers Try Positions That They Can't Handle.
but if you only want to remember the ones that are likeliest to cause wrist pain,
it's simply Scared Lovers Try Positions Happily.

"scaphoid" is from the greek skaphos, little boat.
The scaphoid and hamate are the most common bones to have nonunion after a fracture because their blood supplies are delicate and prone to complete disruption. Symptoms of nonunion and avascular necrosis may not become apparent for years after injury.

what is avascular necrosis?

it means the blood supply is cut off (a-vascular)
and the bone dies (gets all necrotic).

you can diagnose a scaphoid fracture by seeing
if it's tender in the anatomic snuffbox:

it's called that bc folk used to be just crazy about snorting powdered tobacco off the back of their hand. so much so that they had vending machines for it - note the populace loading up their anatomical snuffboxes here, long ago in germany:

here are the "Seven Rules of Taking Snuff," from Dr. Ernst Poschl:
1. Begin with small doses...
2. Take the snuff lightly...
3. After snuffing, wait a moment for the aroma too take affect. This gives a goose pimpling feel to the nose...
4. The experienced sniffer also sneezes...
5. You can take from the top of the hand or the point of the finger...
6. If the tobacco doesn't come out of the box easily, tap it on the table...
7. Take the pleasure to try all the different kinds of the Poschl-Snuff.

one website notes: "Few if any schools have rules about taking snuff... You would probably get away with taking snuff in lessons." okay, enough about snuff. the point is, you can tell if your scaphoid might be suffering avascular necrosis by seeing if it's tender in the anatomical snuffbox. you should do this why? because 20% of scaphoid fractures (or many more) do not show up on x-ray. and folk break 'em ALL THE TIME, usually by falling.

here is one result you get if you do a google image search for "avasular necrosis":

this is all i have to say.


being interviewed for a doctor job can be a drag.

when you are not to the manor born, and you have already dangled an intriguing partial history (e.g., homelessness, single motherhood, welfare) before the gentry, you will naturally be obliged later to fill in the details, and you had better have an entertaining horatio-alger version ready, too, or you'll just sound sketchy.

"do you think, in your heart of hearts, that you will ever be free of it?" as crazy-neurology-guy is wont to ask his patients of their chronic pain. i don't think, in my heart of hearts, that i will ever be free of being 'buked and scorned, hit hard and mocked, a runaway and a thief, a high-school dropout and a pregnant teenager, a hater of doctors and of men, as anti-american as americans come.

one keeps these things under one's hat.

i am a grown-up lady, in real life, mostly unapologetic. but sometimes it takes one by surprise. sometimes someone who is actually your own age seems, by comparison, to be the real grown-up. mittens might recall the little play we performed, in which she portrayed the Evil Women's Studies Professor. what made the Evil Women's Studies Professor so bitter was having to lecture in clinical/demographic terms about what she, like all of us, is necessarily obliged to regard as personal. in the world of professors and lectures, there is "sexual violence" or "child assault" or whatever (name that social problem), while in the world of the person, there is "what they did to me," "what became of me." when both occur at once, a bitter tone of voice - or, worse, a whining, apologetic one - ensues.

i am painting this with thicker layers than the interviewing experience deserves; all i'm really saying is that the well-known "impostor" problem is especially messy for me, and i have to scramble now to decide how much of my darkness to keep under a bushel, and how.

as they say.


overheard in NYC

Queer: Stop calling your arms "guns"!
--Times Square shuttle


i worry

touring the metropolitan midwest, talking to family medicine residents, is making me nervous.

these are people who have entered a lower-paying doctor eschelon on purpose, because they are idealistic, which to me would spell different. many of them do regular stints in e.g. haiti, honduras, etc, to help out; many do prenatal care in prisons, and so on. yet my hopes of kindred spirithood are dwindling fast.

all the females - gosh - well, all the females in several cities, 80% of the females in the rest - wear the same ring on the same finger:

it's the kind of ring i mainly saw, in my youth, used as a Mad Magazine cartoon-trope for tacky social-climbing consumerism. i actually never realized that some folks actually aspire to it.

and all these youthful idealists get very excited telling about their excellent adventures going to - the symphony. this is usually in reply to, "how's the local music scene?" and when i say, "the symphony?" they hasten to assure me that there's plenty of community theater in town, too.

i am not kidding.

AND they just can't wait to get together with everybody to go - bowling. AND many of them stoutly deny enjoying movies. the last place i visited, i asked one guy - the husband of a diamond-wearer - what they do for fun at night, and he replied enthusiastically, "we have a dog."

it gives me the feeling they're covering something up, some kind of exotic subversive debauchery, drug abuse, or kink, with their diamonds and bowling and symphonies. and of course, i am the one who must cover up - and conceal the shocking fact that they will never, in fact, ever, not in a million years, see me in these -


tangentially, i must also note that i have never seen so many steak-eating south asians in my life.


a wee parable

nurse sheena and i used to work the late-night shift in the youth psych ward. one evening one of them went wild and started smashing things up. the tail end of the evening crew hauled him into the seclusion room, where he continued yelling and punching and raising hell behind the thick door. there was a camera in the seclusion room, and we could watch him on a little tv monitor. sheena waited until the evening shift left, then picked up a copy of the local "alternative" newspaper, and went in and sat on the floor by him, leaving the door open.

she was in there a long time. i could see them both sitting on the floor, with their backs to the camera. finally she came back out, leaving the door open. "he said he'd hang out in there for another twenty minutes and then he'll be ready for bed," she said. i asked her what she did to calm him down, and she said she was reading him that year's "best of" selections - best bookstore in town, best gym, etc. - and he was very interested in the "best martini" entry. he didn't know what a martini was. so they sat there talking about martinis. after a while he wandered out and went to bed. and the rest of the night was quiet.

when i think about compassion, i think of sheena handling the psychotically violent youth of america by sitting on the floor with the door open, talking to them about martinis.


the number one question asked by medical residency interviewers is, "where do you see yourself in five years?"

i knew a woman who had to drive an hour back and forth
to work every day, through the flat featureless central illinois void.

i speculated that it must be hard to stay awake, but she said, no,
she used the time to improve her imagination. she said she'd always
been a little ashamed that she did not have a good imagination.

i asked her how she was doing it, and she said,
"i try to have thoughts i've never had before."

she said it was going pretty good.



i went to the doctor today.
i do not have lymphoma (at this time).
nor do i have buboes (technically speaking).

i have cushing's syndrome, from taking all this prednisone.

i will get better (i.e., look better) when i stop taking it -
maybe in april.

i am very resentful of this situation,
sometimes cry, and wake up nightly
consumed by fear.

thank god for wellbutrin.


"...which is reminiscent of my histology class..."

i had an histology lecturer who spoke english with an extremely
thick accent. as an assiduous note-taker i found this very frustrating,
so i'd just write down what it sounded like, hoping i could
translate it later with the aid of the textbook. for example:

the nervous sister is very complicated,
defied into a modal component and a sensory component.

the number of processes divides into bipolar by polar action,
and unipolar, only one process.
you guys only know 6 days.
neurons from different days have different neurons.
looks like a fish eye -

here we see annoying process in more detail:
fish eye appears,
clowns of basophilic appearance,
not in exo-helots -
liberal fusion in the old university system.
miso bodies are the frightened system of the raphael -

and in between, for the sensitive of the proteins,
where the exo-helot is totally absent -

it's like cocaine in most cases: regular
through gap junctions for la puta. for bhutan.
it's smoking - smoking through somatic vesicle.
until somatic ventures arrive. the identical
eye channels - sometimes a single puta
en moustache - a puta, as such.
we will talk about the mole when we talk about my nation.

let's talk about my nation.
my nation is carried out as you can see in this cartoon,
with different seculars for the final product.
these moles are the moles of memory
each secular is called intermole.

my nation is walking,
walking the cyto membrane,
and the cyto plasma is squeezing back.
they will be close together and will touch each other,
walking the walk,
squeezing back,
touching each other,
packed together,

you can see it's still proscenium.
the moles of memory can laminate different moles.

swan cell is some kind of frightened cell,
only violated by a single mole.

here's a close section -
they only walk around actions.
when they both squeeze together, they go to memory lines,
but opposing outer leaflets.

sorry, sorry stuff.
enemy stuff.
they follow around.

get outside, get outside, swan cells -
we will see my nation's action in a minute -

thick domestic violence surrounds the action.
you can see that this is temporary.
we will reverse the final lectures.


i know i keep sayen this, but there really ARE four kinds of renal tubular acidosis, type one through four, and they're not that hard to remember. thing is, don't forget you are thinking about acidosis - too much acid in the blood.

there's the one where you can't dump acid into your pee. then there's the one where you can't stop dumping bicarb into your pee. then the third one is that there is no third one. and finally there's the one with too much potassium (the weird one).

well, somebody had to say it.


sample medical licensing board exam question

You determine that a patient diagnosed with a deep venous thrombosis is a good candidate for outpatient anticoagulation therapy. The patient agrees and is trained in self-administration of injectable Lovenox by a nurse. The patient's brother, who is a psychiatrist, arrives at the ER to drive the patient home. He informs you that while in training he "pulled a lot of shifts" in the local ER and "almost went into the field, but wanted to get 'specialty training' instead." He further states that when he was working in the ER, "we never sent deep vein thromboses home." He has a few questions for you, and as he asks them, he casually mentions - three times - that their other brother is an attorney. What is the mechanism of action of low-molecular-weight heparins?

...well, i thought it was funny.


ADVANCE DIRECTIVE: morphine and blankets.

that's the ticket.


fifteen fun facts to know and tell at cocktail parties,
from the Journal of Nutrition 2005-6.
these are the titles of Real Articles.
i especially like All The Caps!

Cinnamon Supplementation Does Not Improve Glycemic Control in Postmenopausal Diabetic Women.

Consumption of Bing Sweet Cherries Lowers Circulating Concentrations of Inflammation Markers in Healthy Men and Women.

The Tomato Is a Functional Food.

Goat Milk Oligosaccharides Are Anti-Inflammatory in Rats with Colitis.

Garlic Reduces Dementia and Heart-Disease Risk.

Vegetable Proteins Enhance the Growth of Milk-Fed Piglets.

Lycopene Supplementation Prevents Smoke-Induced Changes in the Gastric Mucosa of Ferrets.

Rye Bread Enhances the Production and Plasma Concentration of Butyrate but Not the Plasma Concentrations of Glucose and Insulin in Pigs.

Long-Term Administration of Green Tea Catechins Improves Spatial Cognition Learning Ability in Rats.

The Nutritional Status of Astronauts Is Altered after Long-Term Space Flight.

Interstitial Glucose Level Is a Significant Predictor of Energy Intake in Free-Living Women with Healthy Body Weight.

Middle-Aged and Older Chinese Men and Women in Singapore Who Smoke Have Less Healthy Diets and Lifestyles than Nonsmokers.

Fish Oil Affects Blood Pressure in Danish Infants.

Children's Experiences of Food Insecurity Can Assist in Understanding Its Effect on Their Well-Being.

Homeless Youth in Toronto Are Nutritionally Vulnerable.

how to have a match day

what is match day? it is the day when, at noon eastern standard time, all senior medical students in the US open envelopes that reveal where they have "matched" to their First Real Doctor Job. thence all those job interviews; hence the first day of the rest of... well...

first we gather to open the envelopes

and all the news is good

everybody whips out a cellphone

anxious significant others leap at the first ring

then we brag about how great we are

and start realizing we'll never see each other again
which may be a good thing

the dean of students delivers hugs

(sorry girls, she's straight! ...i KNOW!)

now for some kind of food
and this really bright sauvignon blanc
from new zealand with citrus overtones

have three, they're small

then i pin the residency on the wall map

and announce my intentions

and go to the head of the class!

or at least the center.


...it's all over.
it's all over...