His Failing Heart

JVD is an anachronym for jugular venous distention, a phenomenon I observed Friday for the very first time outside a classroom. It's one sign of a failing heart, a heart that has virtually worn itself out pumping against the unrelenting resistance of untreated high blood pressure. Besides the accumulation of fluid in the lungs -- pulmonary edema -- which leads to shortness of breath, with heart failure the jugular vein becomes distended and you can literally see the pulse throbbing away, driving the rhythm of circulation like a drummer's foot on the bass pedal. Boom, boom, boom.

For clarity's sake, we aren't talking oxygenated blood here, the bright purplish juice of life that shoots out the left ventricle into the aorta. Nor is JVD the same thing as an aortic aneurysm. You've heard of those, I'm sure. An expansion of the artery in all directions forming a cul-de-sac typically (though not exclusively) in the gut with two openings, an entrance and an exit, instead of just one. As long as it stays intact, blood can make its way from the heart to the toes and back again. If it begins to leak or worse, if it blows, you get a STAT ticket to the surgical suite.  

The blood carried by the jugular vein is deoxygenated -- it's already given up its cargo of oxygen molecules in the name of everything that constitutes daily life. On its way to the lungs for more, however, it runs into a problem. Heart failure starts out with an overworked left ventricle but as it progresses, the right ventricle slowly turns into an anatomic approximation of a child's balloon that has been inflated a few times too many. Having lost much of its elasticity, the right ventricle can't pump as well and back pressure builds in the veins above it; naturally, they distend with the volume of blood waiting in the queue.

I'd read about JVD, but reading is one thing, seeing it up close, is another. I watched my resident turn our patient's neck to the left in order to tighten the skin on the right, then watched wide-eyed as his neck bulged outward every half-second. I'd been talking with him for fifteen minutes -- how could I have missed seeing it before? As must have been the case with my entering classmates when they were in my shoes, my mind raced through a litany of possible explanations, while I waited for the end of the day when we'd finally have a free moment to recap. I was glad my first best guess was the correct one.

Yesterday, going over material for board exams, I thought about my patient's physiology, why he was short of breath, why he gained excess weight in water only to lose it when he took his diuretic medication, why just sitting there talking with me was an effort. He was a good teacher who taught his lessons well. But I also thought about him, his experience, what it meant for him to retain his driver's license, why he was so determined to hold tight to his independence and live like there was no tomorrow. Why he continued to have heart. Despite his failing heart.

(GNU Free Documentation Image via Wikipedia)

Repeating History

Those who cannot remember the past are condemned to repeat it. ~ George Santayana

I don't know that remembering has much to do with it. Human nature being what it is, we seem bent on some things whether they've worked at all, worked only a little, or ended up in disaster. Knowing they've been tried before doesn't appear to prevent their being tried again with similar results. Mr. Hughes hid in Dylan's shoes and wearin' his disguise, as the late Rick Nelson put it.

I'm thinking about Germany in the early 20th century, in case you're wondering. High unemployment (30% in 1932), deficit spending, economic depression overlaid with inflation from the printing of large amounts of paper money, unable to meet foreign debt payments, national pride in the gutter. Whenever I watch something about the rise of Adolf Hitler, as did yesterday afternoon, I can't help thinking about the social conditions that made him possible. 

And then I start thinking about Santayana's quote.

I know, I know, Germany didn't have 1776 and the aftermath of two hundred years of democracy. Then again, she didn't have slavery and the subjugation of the western frontier. Let's play fair. I'm not one of those writers who makes a living telling you what's wrong with America, but neither do I want to ignore the obvious for the sake of good feelings. When something stinks, there's usually a reason.

What Hitler accomplished was masterful -- demonic, but masterful. Instead of taking reality on its own terms and leading Germany to do likewise, he fled into a delusional fantasy and created a massive marketing machine to sell it like Volkswagens. There are at least two ways to offer hope to those in need of it. One entails accepting responsibility for yourself, your successes and flat out, falling down failures, and by so doing, show others how to survive doing the same. Another is to imagine there's nothing wrong with you or wouldn't be if it wasn't for someone else. Say it often enough, sooner or later people will start believing. Say it long enough, maybe you'll win, and then you get to rewrite history so no one remembers the way it really was.

For instance, an editorial in an upcoming Southern Baptist theological journal, in complete ignorance of the wider social issues involved, described the fundamentalist takeover -- some have suggested "highjacking" is more apt -- of the Southern Baptist Convention a few years ago in terms of a restoration of biblical Christianity. The subsequent split with social-theological moderates, the virtual purging of non-strictly-doctrinaire seminary faculty, and the smear campaign against those who stood up to be counted, were conveniently overlooked. When the ends are used to justify the means, whether we're talking about theology, the search for weapons of mass destruction, or the virtues and vices of universal health care, a lot of things get overlooked.

Trouble is, this is precisely how we end up repeating history. And isn't that a hell of a thing.

(Creative Commons image of singer Rick Nelson via Wikipedia)

Graduation: Catching Up at Last

If the road to hell is lined with good intentions, I was well on my way yesterday, having fully intended to write and yet finding my brain utterly exhausted from the events of Saturday. To say graduation was memorable is so far from the truth as to almost be a lie: it was more like a dream and I was living it. Truthfully, though, Sunday morning I was almost certain it had been precisely that. It wasn't until I took the dogs out for their walk and looked in the car for my sunglasses, that I noticed the box my robes had come in. "Well, guys," I said, "I guess I wasn't dreaming, after all."

It sure felt like it and I'm sure it stems from the fact that I've never had any absolute assurance I'd make it this far. Not that I was a doubter, like Hero Boy in The Polar Express, who wanted proof of the existence of Santa Claus before committing himself to believing. I knew in my "heart of hearts," as my mother used to say, the obstacles and difficulties I'd encountered along the way would only make graduation sweeter. But still in all, our demons have a tendency to haunt us in the darkness of night, especially before exams, whispering wickedly, You're a fraud -- you're in over your head -- if you were meant to do this, it would be easier. 

Martin Luther, the 15th century church reformer, said the Devil was exquisitely sensitive to humor and the trick to banishing him lay in laughing in his face. I've wondered if that's a skill we must learn to employ and if so, medical school has given me a lot of practice.I was definitely laughing Saturday, along with my classmates, when my best friend placed my doctoral hood round my neck backwards. It wasn't intentional; he'd been handed it backwards and the rest will go down in Hooding Ceremony history. But what better way to thumb my nose at all those demons?

All the same, there is a tender, albeit bitter sweetness to graduation, that comes from having to hold off being called "doctor" a bit longer. I've gone through the exercises and taken my Osteopathic Medical Oath, but with rotations yet to complete, I won't hold my degree in hand until later this year. Like a teenager who is neither child nor adult, I'm in a liminal space. I'm no longer entirely a student, but then again, I'm not entirely a doctor. Thankfully, however, I'm closer to one than the other and the confidence I've gained from standing shoulder to shoulder with my graduating classmates, pledging my life, loyalty, and sacred honor to the practice of medicine and the care of patients, will see me through.  

To my beloved entering classmates, nearly all of whom preceded my graduation in 2010, I can truly say, look behind you, the footsteps you've been hearing are mine. I'm catching up at last.        

(Photo of the author and graduating classmate and friend Dr. Joseph Scott, copyright 2012, all rights reserved) 

Off to Graduation!

Since I can scarcely remember when, Brahms Academic Festival Overture has been synonymous for me with the fulfillment of dreams. I first encountered it as the sound track for the film People Will Talk, the movie that got me thinking of becoming a doctor when I must have been about nine or ten. I'm listening to it now, the version by Maron Allsop and the London Symphony -- my favorite -- because today is graduation day. 

I'm not done yet -- I still have boards to take, rotations to complete, but by the grace of my university I'm walking across the stage at 3.00 pm EDT to receive my doctoral hood and a few moments later, will raise my right hand and speak the words of the Osteopathic Oath, choking back tears, and joining friends from my incoming class at long last. 

Actually, I've got to leave in about 30 minutes, so forgive me for making this brief -- more to come tomorrow. In the meantime, please also forgive my absence these past months while preparing for boards. I've wanted to write but whenever I've begun, my conscience has spoken up, telling me to get back to studying or else. Thanks to all who've come by in the meantime, I appreciate it so very, very much.  Now, off to graduation!

The Liebster Blog Award

Applications for medical school and residency usually contain a space where applicants may list the awards they've received for academic or professional achievement and it's usually at this point my hard-earned self-esteem takes a nose dive. Apart from a couple of work-related "pats on the back" and Scouting's Order of the Arrow, I don't have a lot to report. I'm just guessing, but it's doubtful committees are interested in my horse and I having taken third place in Western and English Equitation at Denver's National Western Stock Show when I was 13.

One never knows, perhaps I ought to list some of those accomplishments for good measure. But, in general, I'm assuming they'd prefer to know whether I managed a summa cum or summa cum laude or was recognized for an outstanding something or other. The truth is, I must have been out, literally standing in a field when they were handed over, because I ain't got any of 'em.

I'm not complaining, though, because the sparsity of awards has made me appreciate those I've been given all that much more -- rather like the one appended below. I'm deeply grateful to everyone who's visited this website over the past three years, validating my desire to write and have what I've written, be read. That in itself really is recognition enough; when someone decides it deserves an award, I'm blown away -- so much so that it takes me a week to get up the nerve to make it public. Pride goeth before a fall, says the writer of Proverbs, and the last thing I want to do is fall flat on my face, tooting my own horn. That said, I'd like to express my sincere thanks to rosewiththorns, author of but I'm beautiful, for her kindness in nominating my blog for The Liebster Award.

I'd also like to thank my mother, my father, my make-up artist, my fellow actors, my dogs and cat, and last, but not least, the Academy of Motion Pictures...oops, sorry, wrong speech. Seriously, please visit rose's blog as well as the others I've listed below as worthy of receiving a Liebster Award. And, as always, thanks for reading.

Trust Me, I'm a...Resident, written by one of my classmates who is currently a resident in Family Medicine in Pennsylvania.

Surviving Medical School and Motherhood, by another of my classmates, sharing her experiences juggling children and husband with one hand and medical school with the other.

Cafe of the Cosmic Dance, by Paul Sunstone. Although Liebster Awards typically go to blogs with less than 20 followers, I'd like to pass on the link anyway in the hope you'll find his writing as enjoyable as I do.

Garnet's Virtual Salon, by a pharmacist and fellow Mainer who lives in the mountains near the Maine-New Hampshire border and drives a Camaro -- wow.

The Student Epicure, written by a Massachusetts med student who has a way with food that I hope translates into medical magic once she's graduated and joined the work force of resident physicians.

The Liebster Blog Award

A Proliferation of Porcupines

Image via Wikipedia
I had just gotten out of the car, backpack and arms loaded down with books and miscellaneous school-related items, when I saw a shadow scoot across the ground in front of me. It was after dark, but the street light was bright enough for me to discern a basketball-size shadow with a little nubbin sticking out of one end and four legs. Then I noticed there were more of these NBA wannabees, maybe a dozen, multiplying so quickly, I couldn't keep up with their numbers. Suddenly, there were what I took for babies, hundreds of them, swarming around my feet like flocks of birds gathering to migrate south for the winter. Next, hundreds of infants swarmed behind the babies, and like Mary's lamb, everywhere I stepped, they were all sure to go.

Porcupines. Big ones, little ones, littler ones still, following me like geese in the film, Fly Away Home (1996). Sounds cute, you say? Well, I suppose it was, but cuteness wasn't going to solve the problem of getting into the house without a proliferation of porcupines clinging to my heels. Fortunately for me, dawn's early light intervened at that moment, accompanied by a full bladder and empty stomach. I didn't tell you? Shame on me. Yes, this was a dream from night before last in the wee, wee (no pun intended) hours of the morning.

Why was I dreaming about porcupines? I'm glad you asked. It all started with Freddy, a sweet little porcupine who lives under my barn, snitches apples from the tree next to the house, and has been growing increasingly comfortable having dogs and a person around. I won't use the word "tame" because he's still a wild animal, though one who's obviously nonplussed whenever the dogs and I go outside while he's gnawing away at lunch in the front yard. I speak to him, naturally, and he seems to respond to "Freddy" by looking my way.

Porcupines are supposed to be nocturnal, but this fellow's more of a day person who likes the warmth of the sun on his back. There have even been a few occasions I've discovered him lying in the flower bed, snuggled up against the house, right below my study window. The first time this happened, he had me worried because he hadn't moved in several hours and I thought, Oh, no, he's been sick, I didn't know, and now he's gone to the Happy Munching Ground in the sky. I got down on one knee, maybe an arm's length away, and gently called his name. He woke up, looked at me sleepily, and of course, said nothing, as is his way.

Now, why my dream has porcupines in such numbers is probably due to there having been another one in the yard lately, a big one, easily twice Freddy's size. He or perhaps, she -- I'm not getting close enough to find out -- lives in the forest behind the house and when the dogs and I go out at night with a flashlight, s/he looks at me as if to say, Do you mind, I'm eating here?! and ambles off into the bushes. I'm guessing Freddy's mentioned something about the quality of the menu and as with any good restaurant, the word gets around. Either that, or he's left his scent on the grass like a sign reading, Porcupines Welcome Here. The point is, now there are two -- well, actually, three. Last evening we had a new customer who took off before I had a chance to ask how they liked the service.

Jung or Dr. Freud would likely say my dream was a portrayal of how my unconscious views the coming months of board preparation, graduation, fourth year rotations, residency interviews, and the Match. I'm not going to argue; they know dreams better than me. But that doesn't change the fact, I'm honestly a bit worried. The last thing I want is to become so popular my best customer (Freddy) takes his patronage elsewhere simply because he doesn't like having to wait for a table. Porcupines are particular about these things, you know.


(GNU Free Documentation image via Wikipedia)

OB/GYN: A Dream of Women

As of last Friday, my obstetrics and gynecology rotation has come to an end, and as you've probably noticed, I've been uncharacteristically reticent to talk about it. Don't worry, nothing bad happened. As a matter of fact, in retrospect, this has been one of my favorite rotations. Scrubbing in on surgical procedures several times a week was an absolute kick and being able to act as first assist because I'd just completed surgery was like the icing on German Chocolate Cake. And, naturally, there were the babies. One, a few weeks premature, had the most beautiful, delicate, perfectly formed little fingers. Another fell asleep in the crook of my arm with her lips sealed against my left shirt pocket. No, darlin', I'm not mommy, but thanks anyway.

The truth is, I really had a wonderful six weeks and when it came time to leave, I felt almost as wistful as on the last day of my psychiatry rotation and that is saying something. What was holding me back from writing, though, took a few days to reveal itself, and unexpectedly, it did so in a dream. I was a student on the obstetrics unit in an unnamed hospital one evening, sitting on a counter ledge in the nursing station, watching a group of women. A few feet away on my left was a new mother breastfeeding her infant. Directly across from her, on my right, seated on a soft, pillowed couch, were five other women -- nurses -- mostly in their 40s and 50s. They were smiling and singing or chanting, I can't recall which, and clapping their hands in unison, swaying from side to side. I couldn't hear the words clearly, but they were obviously enjoying themselves immensely.

Everything was so totally natural no one, not even the woman breastfeeding, seemed even remotely self-conscious or uncomfortable because a man was present. I got up from my seat and approached one of the older women whom I knew well, just as the group stopped singing and began laughing, with the intent of whispering to her, "This is the first time I've seen breastfeeding have cheerleaders," because that's how it appeared. In the dream, of course, I thought this terribly funny and was sure she'd think it uproarious. It's easy to be Robin Williams in Dreamland.

What strikes me about the scene were the colors. Everything, including my clothes and those worn by the women, was done in shades of white. Not paper white, but more like the pastels used to depict heaven on film, with boundaries fading at the extremes and an absence of sharp lines. It reminded me of heaven as Maxfield Parrish might have painted it, ethereal yet earthly, mythic yet real.

It seemed to me, I was seeing womanhood in a way few have the opportunity. The women themselves knew this to be true and graciously permitted me a glimpse of the way they are privately, when they're amongst themselves. As a man, I wasn't exactly an outsider, but neither was I an initiate. I don't know what I was, a guest, perhaps? All I know with any certainty is, I was witnessing a young woman in the company of older women, all of whom having done as was she, feeding their children from their own breasts, and the feeling I had was of joy and serenity.

Rotations are about a lot of things, I suppose, learning and practicing new skills, adding to a growing body of knowledge, feeling more confident in oneself, but this one was far more. Frankly, I'm still having trouble putting it into words. I'll figure it out eventually; right now, I'm still in awe.

(Creative Commons image "White" by LaWendula via Flickr)