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Raining Stethoscopes Water follows me everywhere I go. Tears. Sweat. Sometimes my own. More often than not, other people's. I had been awake for more than 24 hours straight juggling a primigravida's lengthy labor and a GI bleeder. Amniotic fluid. Lots of blood. I can't seem to escape the liquid phase of matter. The woman finally delivered a healthy baby girl. The old man with bleeding esophageal varices didn't make it. Add a life. Subtract a life. Homeostasis. It felt like internship all over again -- confusion, loss, exhaustion. Internship was more than twenty years ago. I've changed a lot but everything else, everything that matters, remains the same. By the time I finally get home, I'm wiped out. I don't even shower. I collapse onto my bed. The next thing I know I wake up drenched. Another example of how water pursues me night and day. I have had a disturbing dream, maybe even a nightmare. I'm in a place where everything is white. I'm in pain but don't know why. It starts to rain in my dream, but what falls from the sky are not droplets of water but rather tiny stethoscopes. At first dozens but soon hundreds and maybe thousands of little medical instruments descend upon me. Their shiny metal heads reflect faces but I can't make out whose. I find myself crying amidst this shower of stethoscopes. Suffocating. And then the dream ends. It is time to get ready for work. My wife and I are having breakfast. It's always the same -- a bowl of Cheerios and a banana for me, a mushroom omelet for her. Alexandra is a terrific psychiatrist. Before we were married, however, she vowed never to treat any family members and that included me. I love everything about her even though she has a slightly annoying habit of responding to all my questions with questions of her own. I have to believe it is an acquired trait from years of psychiatric training and practice. Last night's dream is still bothering me. Nine times out of ten, I can't remember a single detail of my dreams but for some crazy reason, I'm obsessed with making sense out of a dream that just might be unfathomable. It seems so real. I can't shake the feeling that if I can only solve the mystery of the swarming stethoscopes, I might be able to unlock my future or at least understand my past. I should know better, but I decide to ask Alexandra for her expert opinion. "I had the strangest dream I've ever had in my life," I matter-of-factly announce. "Would you like me to describe it?" As expected, her answer is in the form of a question. "Do you want to tell me about it?" I quickly summarize the bizarre dream for her. "Do you think it means anything?" "What do you think it signifies?" Alexandra responds. "I asked you first." I counter. "Did all the stethoscopes look identical? Were they the same model you use? Did any of them land on you or make physical contact with you in any way? Were you carrying an umbrella? What was your mood like?" Now we were cooking. I told you Alexandra was an exceptional psychiatrist. "There were so many of them coming down . . . but yes, they all looked the same although some were different sizes. Many, but not all of the stethoscopes, touched me. There was no umbrella, hat, or raincoat. In fact, there was no rain. Do you have an interpretation?" "Hundreds or thousands of stethoscopes and only one doctor? What's the point? How did you feel about those medical instruments? Confused? Threatened? Comforted? Ambivalent?" "How did I feel about a shower of stethoscopes? Smothered. And fascinated." "Hmm," Alexandra mused. "Have you considered the possibility that maybe it's just a silly dream after an intense day at work and maybe it doesn't signify anything? Do you think you're a bit too preoccupied with it? Why worry about it?" "Are you aware that you consistently answer all my questions to you with a question?" "Are you sure you're not exaggerating?" Alexandra smiled and planted a patronizing kiss on my forehead. "Besides, I don't do dreams." On my way to work, I consider what my wife had said. Maybe I am too preoccupied with the dream. I tend to have a hard time letting things go. I call it persistence and determination. Alexandra refers to it as stubbornness. Whatever you want to call it, I always thought that was a good trait in a doctor. A few years ago, I started running three miles a day. Once I even ran a marathon -- 26.2 miles of anticipation, confidence, apprehension, misery, survival, and redemption in roughly that order. It was hard but not nearly as difficult as telling my thirty-something neighbor she had acute m y e l o g e nous leukemia. Or as gut-wrenching as pronouncing a nine year old boy dead after his own mother had performed CPR on him all the way from the scene of the accident to the hospital's emergency department. Ten thousand people competed in that race. Most were ahead of me, a couple of thousand ended up behind me. Runners were shedding clothes like used-up layers of epidermis in a patient with psoriasis. Men and women alike were urinating in public so as not to waste a precious second waiting in line for the portable toilets. It was embarrassing. There were guys weighing over three hundred pounds and elderly kyphotic women who couldn't stand straight without the aid of a cadre of chiropractors. To this day, much of that marathon remains a blur. Roughly 16,000 moments of accomplishment and humiliation. At mile 21, I about called it quits. My lower back felt like someone had whacked it with a baseball bat. Three times I stopped to take my shoes off because it felt like I was running with pebbles in my shoes. All three times I found nothing there except pain. Twenty-one used to be my favorite number but not after that marathon. Now I like the number 23 because with a little over 3 miles to go in that race, I knew I would finish even if it killed me. I would crawl across that finish line if I had to. When I crossed the finish line and stopped running, I could barely stand. I was crying. They were not tears of joy. They were not from pain. I only knew it was over. After 26.2 miles, I still did not understand why I wanted to run a marathon. I had set a goal for myself and I had to see it through. I felt compelled to do it. There was no turning back. It's not much different than the path to becoming a doctor. Pain and struggle, accomplishment and purpose. How can you truly know a thing unless you have experienced its antithesis? Alexandra was waiting for me at the finish line, busy snapping photographs. "How do you feel?" she asked. It still ranks as one of the most inane questions I've ever heard. "Did you hurt yourself?" I wiped the tears from my eyes. She kissed me for what seemed like an eternity. It was the tonic I needed. I forgot about my pain and temporarily lost all sense of where I was and what I had just done. It took a kindly old lady weighing maybe 85 pounds and wearing purple running tights to bring me back to reality. "Nice race, young man," she told me. She had finished just ahead of me. I swore Alexandra to a vow. "If I ever start talking about running another marathon, promise me you'll hit me in the head as hard as you can." For a split second, she looked at me as if I were out of my mind and that frightened me since, after all she was a psychiatrist and had plenty of experience studying people who really had lost their minds. "How about some Haldol or Risperdal instead?" Alexandra suggested. I assumed she was kidding. I've not competed in another marathon since my first and only one. I continue, however, to run three miles every day. When I run, I can find a place where no one can reach me. Except, perhaps, for my youngest son, Jake. "Gee Dad, you smell awful. Please take a shower." He motions with his hands to circulate the air between us. "You're old and slow. Why do you run everyday?" The kid is a teenager so I feel obligated to give him some slack. "Do you have to have a reason for everything you do in life?" I reply. I instantly realize that I'm beginning to sound like Alexandra. Marital osmosis. "Yeah," he answers. "And it ought to be a good one." I have to admit that Jake is probably right. I live and work in a town so small that it can only find room for two traffic signals in the entire city. One stoplight stands guard at each end of town perhaps as a reminder to all those who contemplate leaving. Or maybe as a warning to those visitors poised to enter. Coal used to be King in our area but over the last several years the majority of coalminers have lost their jobs. All that remains of a once thriving industry is poverty, lots of black lung disease, and a fine layer of dust that hangs in the air like charred dandruff. I sometimes imagine ghosts with blackened faces wandering through those miles of abandoned subterranean coal mines. These restless spirits search for unrealized dreams with only the aid of a light attached to their safety helmets. It's silly, isn't it? What possible need do ghosts have for safety helmets? Besides, don't these stragglers realize that Hope had suffocated down here long ago? In place of the mining industry, prisons have sprouted. Methamphetamine production grows like a weed -- tenacious, ubiquitous, and nearly impossible to eradicate. Those that have remained in our hamlet are solid and kind people. If we had employment to offer them, they would be hard-working as well. Some of the inhabitants of our town are so peculiar that at first you might think that I'm making them up. But doctors can't lie. I think that fact is mentioned somewhere in the Hippocratic Oath. And even if it isn't, we owe it to patients to be straight with them. Many of the inhabitants of our town have only a first name. If they ever possessed a surname, it has either atrophied and ultimately vanished from disuse or was shed as an unnecessary extravagance. Some of the residents here are known only by their distinguishing characteristics. I treat patients with names like Stutter, Blinky, Slick, and Peanut. Every community has its own roster of notable citizens. Our town is no different. Take Thornton for example. He spends most of his life sitting on a bench in the center of town waving. From sunrise to sunset, this eighty year old man nods and waves at passing cars, acquaintances, and strangers but never says a word. I have often wondered why he is so frugal with speech when everyone else I know tends to be wasteful. Maybe Thornton's voice is so powerful that he fears using it. Perhaps he has learned that words hurt. Or it might just be that he has nothing to say. Thornton's skin is so sun-damaged that he looks jaundiced. When I shake his hand, it feels reptilian. He is ancient, leathery, and maybe even coldblooded in the biological sense of the term. No matter what the weather is like, the man always wears the same set of clothes -- a plaid flannel shirt and bib overalls. While that ensemble makes sense in the fall and winter, I can't begin to imagine how stifling it must feel when the temperature hits one hundred. Yet I've never seen the man sweat. He has no past and no address. Where does he sleep at night -- under his bench? In contrast to Thornton who just might be tethered to his bench for all eternity, Rudy is a man in perpetual motion. I figure him to be in his forties and he is the quintessential collector. Of everything. I would estimate that half of our town's litter is "recycled" by Rudy. Bottles. Aluminum cans. Newspaper. Hubcaps. Plastic. I haven't yet deduced what he does with his collection or where it ends up. Rudy pulls a rust-crusted red wagon across town full of treasure or debris, depending on your perspective. Unlike Thornton, Rudy talks continuously but is difficult to understand. His speech impediment is accompanied by a steady production of foaming saliva that conjures up images of a rabid animal. I always slip a Kennedy half- dollar in his wagon when he's not looking. On those rare occasions when Rudy or Thornton require medical attention, I feel privileged to treat them. Without charge. I doubt either of them have any money to pay a doctor but even if they did, I couldn't take it. Befitting a small town doctor, I work out of a little office. It only has two small exam rooms. Even so, fifty percent of the time one human being, half undressed and frequently worried, is still waiting for me to enter. I scan the list of scheduled appointments. I notice that my receptionist has already double-booked four slots. Not surprisingly though, she has reserved thirty minutes for a single patient. Lizzie Greersin. It would border on a miracle if I could actually complete her office visit in just half an hour. Lizzie is an unmarried woman who is thirty-six years old and a hypochondriac. She is well educated and a nurse by training, but to my knowledge has never worked a day in her life. After she turned twentyone, Lizzie's parents died and she inherited a substantial sum of money. I don't know how her parents died but there are lots of rumors. Most of them aren't very nice. Rumors thrive in small towns and occasionally become more reliable than the truth itself. I hate to say this but I find Lizzie a bit creepy. It's a safe bet she'll show up in my office at least once every couple of weeks. Lizzie defines "an emergency" as any problem no matter how minor that can't wait until tomorrow. Diarrhea, low back pain, a temperature of 99.9 degrees. She's tracked me down outside of the office more than a few times for my medical opinion. She requires lots of reassurance. I've been asked to provide a diagnosis and treatment plan for Lizzie while waiting to pick my kids up after school, filling my car with gas, and shopping at Wal-Mart. There are times when I'd swear she was following me. Even in a small town, it can't be coincidence that she shows up almost everywhere I go. If my life were depicted in a made-for-TV movie, I bet they'd cast Lizzie's character as a stalker. Once I came home at 9 p.m. to find Lizzie sitting in her car parked on my driveway waiting for me. I knew who it was right away. She is the only person in town who owns a Volkswagen Beetle. Florescent green. The woman was making a house call at my home! She wanted to know if the 30 second long episode of pain in her leg that occurred four hours earlier was a blood clot. I assured her it was not a DVT, but Lizzie wasn't done with me. "What about the mole on my neck?" she asked. "Do you think it might be a melanoma?" It was dark outside for God's sake. All her skin lesions looked suspiciously black under the moonless night sky. The woman's spooky. I try to be nice to her but it isn't always easy. There are clearly some boundary issues that need to be addressed, but the biggest problem with doctoring in a small town is living in that same town. Despite my best efforts to stay on schedule, I often run behind. I notice six people sitting in the waiting room and it's only 10:30 a.m. How is it possible? Then I realize that three of them are extremely attractive and impeccably dressed. They are drug reps patiently waiting for an opportunity to pounce on their prey -- me. Armed with briefcases, shopping bags, and notebooks brimming with glossy graphs and statistics, they'll sit there all morning just for the five minute opportunity to tell me how wonderful their drugs are. Their presence remains long after they depart my office. A trail of pharmaceutical company trinkets including pens, notepads, cheap calculators, boxes of facial tissue, and coffee mugs all emblazoned with the name of their product litter the office. I am reminded how American Indians were tricked into selling Manhattan Island for about twenty-eight dollars worth of junk. I force myself to stay awake and look interested during my precious lunch break while each of these salespeople recite the glory of their prescription-only products. They deposit oodles of drug samples on my desk. Although I can distribute these medications to my needy patients, I certainly cannot prescribe these drugs to the same group of patients since the medicine is outlandishly expensive. My office practice is hectic, but I enjoy being busy. Doctors are like sharks. Inactivity kills us. We've got to patrol the water -- keep moving, keep swimming. I love listening to people. And usually they've got plenty to tell me. Except of course Thornton. One of my patients, Junior, is a genuine philosopher but he doesn't know it. He's a self-destructive guy who often fails to show up for his scheduled appointments and doesn't call. My receptionist always double-books Junior's time slot. His chart is thick like the man himself and littered with the familiar notation "NO SHOW." Junior is a behemoth. He measures six and a half feet tall but his weight is unknown since our office scale refuses to work past 400 pounds. Junior is as nice a guy as you'll ever meet, but in many ways, the man is a medical nightmare. He has lots of chronic health problems but little interest in their solutions. I read him the riot act every time he comes to the office, but in reality it's hard to get angry with him. "You know you're going to die if you keep smoking, don't lose weight, and fail to take your medication faithfully," I reminded him for at least the hundredth time. "We're all going to die someday, Doc," he answered in earnest as if it were a fact I was unaware of. "Sure, but do you really want to check out this early in the game?" I asked as I measured his blood pressure. Even with the large cuff, the Velcro was slowly ripping apart. 178/102, better than usual. "What's to be will be," Junior continued. "Life is all about failure. How we avoid it and how we minimize it." "Do me a favor," I asked him. "Don't fail to take your medicine and come back to see me in three months." I end up seeing thirty patients in the office. Much of the work is mindless. Lots of sore throats, coughs, sinus problems, and rashes. As usual, getting people to help themselves is the highlight of my day. I am able to convince a woman that she needs to begin insulin injections for her diabetes. One of my patients with a drug addiction finally agrees to enter a detox program. I head to the hospital to round on five patients. I've been too busy to give any further thought to my strange dream. I'm too embarrassed to discuss it with anyone other than Alexandra. I'm hoping that the answer will miraculously fall in my lap. It happens that way sometimes with difficult diagnoses. A gift. Enlightenment. Dumb luck. Easter is a 91 year old woman in severe congestive heart failure. Her chances of resurrection are nil. The family wants everything done -- tubes, machines, chest thumping, whatever it takes. Watching her kept alive like this, if that's what anyone can call it, makes me sick. Everyday, Easter's family circles around me as I proclaim the grim news. "There's no change. It's just a matter of time." I gently urge them to let Easter die in peace. They listen carefully but do not hear. "Don't you think she looks much better today?" her grandson asks me. "Mom's I & O has been great. Have you checked a BNP lately? What are her electrolytes today?" her youngest son, an accountant, wants to know. The family has spent so much time at the hospital that they begin to sound like the medical staff. I see this phenomenon frequently and am reminded that knowledge can be perilous. My other hospitalized patients are in considerably better condition. Pete, an octogenarian being treated for pneumonia, is packed and ready to go home. He doesn't want to hear it and I'm really quite tired of telling him, but it's my duty to remind him for about the thousandth time over the past twenty years, "You must quit smoking." He wants to go home badly so he lies. "I'm trying. It ain't easy." Pete gets admitted to the hospital about every three months with the same problem. He can't breathe. He's got bad emphysema and wears oxygen even at home. The nurses like him. He's a charmer and an easy guy to care for. Pete can use the bathroom by himself and doesn't drive the nursing staff crazy by over-utilizing his call bell. The man knows the system. I find the hospital to be a depressing place. Running will make me feel better and I've got plenty of time to get my three mile run in before it gets dark and the mosquitoes are out in force. Most doctors are creatures of habit. I'm no exception. I run the same route every day along a scenic stretch of road separating a large farm on one side from a heavily wooded area on the other. I never encounter anyone else along this road -- no other joggers, cyclists, or walkers. Only rarely do cars even come this way. Maybe that's why I enjoy running here. Seclusion. No beeper, cell phone, or problems for twenty-five to thirty minutes. Bliss. The rhythm of my feet striking the ground and my arms slicing through the air relaxes me. The cadence of my labored breathing is soothing. It's going to sound morbid but I've often thought that when it is my time to die, there would be no better way to go than running. I feel a few drops of rain falling on the top of my head and soon a gentle, but steady, drizzle arrives. I am grateful for this simple but satisfying sensation. How rare it must be for a man to experience a moment when his body, mind, and soul are totally in sync. And then everything changes in an instant! A searing pain shoots through the left side of my body and I crumble to the ground. I see a flash of green. I am a mangled lump of flesh on the side of the road. Even worse, I am paralyzed -- initially by fear and later by the realization that the left side of my body isn't working. Consider the irony of my "hit and run" accident. I am helpless and alone. A fragment of my left femur protrudes through the skin. The sight of the injury along with its pain makes me so nauseated that I vomit. My lower leg is crushed and a small pool of blood is collecting beneath it. I quickly take inventory of my injuries and my predicament. This road is not well traveled. The driver who hit me has not returned to the scene of the crime. I have no means of calling for help. I am losing blood from at least one compound fracture. The pain in my leg is excruciating and I have no feeling in my left arm. There is a strong possibility that I'm going to die. Human road kill. Seconds, minutes pass. I lose all knowledge of time. I become lightheaded and cold. I suspect I'm going into shock. All I can think about is Alexandra and my children and how much I will miss them. What a wonderful life I have been given. Please Lord, I'm not ready to go just yet. And just like that, I sense a presence. It might be God. Is He here to give me another chance or carry me away to heaven? Perhaps it is an animal, some scavenging beast preparing to feast on my carrion. Maybe I'm just out of my mind and having hallucinations due to pain and hypovolemia. No, I'm not imagining it. I hear a voice in the distance. It is the voice of an angel. "I'm coming," the heavenly messenger says. The combination of nightfall, blood loss, and pain dims my vision. I can barely make out the shape of a figure approaching me. I have no strength to speak. I am unable to call out to this apparition. "I'm coming," the angel announces once again. I know I'm seconds away from passing out and maybe even dying but I will not give up until I see her. And before I know it, her hand is stroking my hair. She is kissing my forehead. Her words are comforting and the last sound I hear before losing consciousness. "I'm going to help you . . ." her voice drifts away. She is close enough now that I am able to get a glimpse of the face of an angel before I fade out. I squint hard to see her. It is the face of Lizzie Greersin. I cannot begin to describe the dreams I have immediately after the accident. Morphine dreams. I spend many more hours asleep those first few post-accident days than I spend awake. Of course, it's often better not to remember everything. At least that's what I tell my patients when they fret over their partial amnesia following severe illness, surgery, and major trauma. The first thing I remember is seeing Alexandra and Jake in my hospital room. I've already had emergency surgery on my leg. I am still not convinced I am even alive. But when the pain medication begins wearing off, I know I have survived. And that is all that matters. I drift in and out of my narcotic-induced fantasy. When things finally begin to make sense, I learn that I have already been in the hospital for three days. Alexandra brings me a copy of our local newspaper. It is only four pages long and published once a week. The front page headline reads "PATIENT SAVES DOCTOR!" "I'll be damned," I say out loud. According to the newspaper's account of the incident, Lizzie "just happened to be in the right spot at the right time." With her nursing background, she knew how to correctly apply a tourniquet to my leg and called for an ambulance. She never left my side. The newspaper article went on to elaborate how "It was touch and go" and "Ms. Greersin's quick thinking is credited with saving the life of her family doctor." Lizzie came to see me every day during my hospital stay. I don't want to sound ungrateful but there's still something very creepy about the woman. I'd hate to be alone with her. Thank God, I have a roommate. He's a 25-year-old guy who slipped on a wet floor at work. He tore his ACL and fractured his ankle. He thinks there's something wrong with Lizzie, too. Just before lunch, my office nurse pays me a visit. She is carrying two Hefty trash bags. I assume it's some kind of a joke. Maybe they contain insurance forms needing to be signed. "Open them up," she commands me. I still don't have much use of my left arm so Alexandra helps me. Inside each bag are hundreds of small stethoscopes cut out from paper or cardboard. Some are fashioned from straws and pipe cleaners. They are "Get Well" greetings from my patients. Some of the miniature medical instruments have pictures of the sender or myself pasted on the head. Tears begin to flow from my eyes and coalesce into tiny streams. Once again I realize that water follows me everywhere I go. It is the essence of my life. "Why are you crying, Dad?" Jake wants to know. "Do you want me to cheer you up?" It is his voice but I sense his mother's influence. Jake reaches into one bag and grabs a handful of the paper creations. Throwing them into the air, he shouts, "Look, it's raining stethoscopes!" Soon everyone else in the room begins tossing handfuls of the artwork into the air as if they were pieces of confetti. Some of the stethoscopes fall immediately to the ground but others float briefly in the air, not quite ready to submit to the laws of aerodynamics. Visiting hours are now over. My roommate and I are bored. We don't know how to cope with inactivity. "Hey doctor, what do you know about dreams? I've been having some weird ones lately -- women chasing me, conversations with dead people, being underwater. Do they mean anything?" "What do you think they mean?" I ask him. He proceeds to tell me the story of his young life. I realize it will be months before I can officially return to work but am thrilled to still be able to do what doctors do best. Listen.
Tony Miksanek, M.D. |