Death by Doctor

Both locked into the roles
Commanded by badge and mood
Play out the passive action required
By mutual guns held and raised.
When one fires the other gets his
Own impotent destructive wish.
Protocol determines how we
Care for each other
In our locked-in selves.

*****************************

The telling look of a triumphant infant
From a grown woman
After she gained her goal from me
The parental physician
Should have been enough
For me to know the
Simple demanded injection
Of narcotic in a
30 weak pregnant woman
With spoken but
Intangible and mysterious
Pain
Needed greater exploration.


My excuse was turf.
I’m the beat patrolman,
No sniper or commander
Of her care.
I was just a surrogate
For her true physician
Who was crippled with
His own badge of limitations
That defined his role as he comfortably
And narrowly chose so that when
The pain persisted after
Delivery and no cause could be found
She aimed her weapon
At a surgeon with similar
Circumscribed
Badge and obligations of duty
And he did his duty
With sterile technique
Removed
At her insistence
With her consent
One of her
Perfectly normal
Kidneys.

*****************

Her list of medications long as her arm
She laid on the ER gurney short of breath
In a body burdened with layers of fat and fever
The two prongs of oxygen in the pudgy nose
Her purple Pickwickian face with dull angry eyes
Looked at me, the coming-on shift physician
Who wore no tarnished badge and no white coat
But still bore the authority and weapon,
With her either projected or reflected hatred.
I was thankful I’d missed the work up.
But then, maybe my watch would be quiet.

When the 2 AM nurse call came
For more narcotics
That repress the drive
To breath, but ease the pain
We think is killing us
And we’ve never learned to listen.
As the patient requested
And the nurse is doing her
Duty, speaking to her
Commanding officer
The antibiotics in now for
The pneumonia.
Now on
Ten liters non re-breather
O2 sats in the eighties
She's still supine
No cough, respirations 30
A 40-year-old woman
Unknown to me
Except by telling glance.
I had to ask the nurse over the phone
Never the patient directly
"Does she want to die?"

I said no.
I never asked her.
**************

He fell in the kitchen and
Came to me by ambulance
Since he could not get up
Off the floor. His nearly 300
Pounds bear down
On a lumbar spine the victim
Of six failed surgeries.

None have restored the disability
The pain, the weakness
Always worse
So he could drive his truck or even
Dance with his wife, half his size.
She is scheduled for hip replacement.
They both use walkers.
Their double-wide will not
Fit a wheelchair.
But his only focus
Despite my lecture
Of strength and rehab
Is to see his back surgeon again.
His weapon against this life
My profession.

* * * * *

Just 30 she has seen a dozen surgeons
Who wear our badge and uniform
And white coat body armor
They have helped her attain the
Twenty or more operations
From bones to bowels
And none have been able to
Find or remove or disarm the
Weapon she raises
That make them all
Do their forsworn duty.

* * *


The cop who shoots
Gets therapy and leave
Sympathy from colleagues
May balm the agony.

The Doctor who kills
Faces this suit. His balm
The same drug of denial
He silently shared
With the deceased.

And in this dance
We simply shrug
Duty first.

If you have a gun
You will shoot.

Free Enterprise

Free Enterprise

Hell, I don't know what I'm doing here. They got me waiting. They said it’d be an hour or two so I came over here for a beer. I've never testified before. Been arrested a couple times. Yeah. But that was when I was a wild youth. But testifying, Jesus. You got Fat Tire on tap? Jesus, two in the afternoon and I'm drinking in a hotel bar.

I don't know what they're gonna ask me. I don't know nothing. They said I didn't need a lawyer. And this isn’t a legal thing. It's just the State Board of Medicine. Yeah, go figure. They meet in a hotel conference room.

*********************************

Not much. I'm not a doctor. It's not about me.

******************

No, I'm not pissed off at any doctor either. I don't go to doctors if I can help it. But they're looking into this operation we started, this friend of mine. He's a doctor. He's in the hot water. I don't know what the big deal is really. Well, I think I know, but that’s not really the State Board of Medicine’s business, is it? The business thing. We didn't hurt anybody. And according to what my buddy the licensed physician says we haven't violated any rules or anything. Hell, I was just his assistant. I just helped out. But I tell you; I got my hands into it. And maybe that's what they're pissed about. No, I think it’s the money thing.

**************

Yeah, I’m kinda rambling. And I haven’t even had one beer yet. Ok, here’s the story.

So the deal was, we did colonoscopies in his garage see? I don't know, it sounds pretty stupid to say it like that, but it didn't when we got started. See, he's a family doc. Medical school, residency, license, all the credentials. He worked for years in our little town. Yeah, he's a little weird. He drives an old pickup. He doesn't wear white coat. But he's never done anything crooked, at least that I know about. Or that I’ve heard people accuse him of. Now he doesn’t always make everybody happy. He tends to say things a little blunt at times. Well, he and the docs he was working with in the big clinic in our town stopped seeing eye to eye I guess. I don't really know all the details. So him and them parted. He had this noncompete arrangement. He couldn't practice medicine within 45 mi. for 2 years after he quit. So he worked out of town. Emergency rooms and stuff. But he didn't want to move. He liked his home and this little town. Had family and kids growing up.

*******************************

Oh yeah, the colonoscopies. Ever had one?

***

Me neither, but I can tell you, they’re no big deal. Yeah, I seen hundreds of ‘em. They are easier than hanging kitchen cabinets.

*******************************

Yeah, that's what I do. Or did anyway until the housing market dropped. I did small remodels. That's how I got into this mess. See Doc Hawthorne knew me from when I put a second-floor on his old house back in ’95 when the kids were starting grade school. Then a couple years ago he called me to do this makeover of his garage. Bathroom, walls, tile. See, he'd found he could buy used colonoscopes on eBay. No shit, you can get anything there. Well, he'd come up with this idea to do colonoscopies in his garage. He knew what the docs in town were charging. And the hospital. See, you get a bill from the doc who does the scope and from the hospital who “provides the facility”. And he knew what Medicare and insurance paid and all. He said he knew how to do them and he'd just underbid the local guys. And they ain’t cheap let me tell you. Figured it would pay better than covering those small-town ER's. I thought he was crazy. Sounded like doing brain surgery in the backyard to me.

***********************************

Yeah. I did the remodel. I got a good look at the scope and how it worked. He showed it to me. Looked a lot like what I've seen those city guys use on old sewer pipes, looking for leaks. Yeah they run a long tube down and take pictures. Well it's a lot like that. Only the pay scale is a bit different than Roto Rooter.


********************************

Oh yeah, there can be complications. He explained all those to me. But he said he’d done a lot before, back in residency and thought he could handle the risk. It turns out he hadn’t ever done ‘em when here in town, at the hospital ‘cause there was one doc who wouldn’t let any other doc “have the privileges”. Yeah, these docs fight like sorority girls it seems.
He was pretty sure he could do ‘em safe. He would back out of ones that weren’t going well.

**************************

Well, see; once I got the remodel done, the doc was practicing and he let me watch the first two or three. I don't think he charged those first folks. He was working out the sedation, the drugs and all. You know, you can give them a drug that makes them so they don't remember a thing. Yup. Versed. Ever heard of it?

***************************

So, I'm finishing the trim on the garage makeover and watching him practice his procedure on some guy. Well, it wasn't just some guy. I knew him. He was a buddy from town. He didn't have insurance. He thought since he was 60 he needed this thing done, you know, I guess he believed the Katie Couric sell, and Doc Hawthorne said he’d do it for free just to work out the kinks so to speak.

*****************************

Yeah, there can be a lot of jokes about this sort of thing. But he was always real professional. Honestly, I could tell he didn't really like to do the procedures. It got kinda boring for him. About the second or third one I was watching the screen.

***********

Yeah, the picture shows up on a screen, a TV screen. You look at the screen to steer the scope. It’s a lot like a video game. Only no joy sticks, you gotta turn these knobs. You can feel the resistance. It’s more delicate. Anyway, Doc Hawthorne he was kind of leaning one-way when he was getting a little stuck and I suggested he turn left when he’d been trying to turn right and sure enough, it opened up. There's a real feel for how hard to push, when to let up, where to go. Kinda like nailing trim. You can't force it, but it will bend.

******************************

So, I started helping out. Hell, Doc said nurses did stuff for docs in surgery all the time. And sometimes better too. And hell, there weren't any kitchen remodels coming my way. Our town’s way overbuilt. Doc had me do some support things too. He needed a cleaning room. I built this cleaning apparatus out of 2 inch PVC pipe with little nozzles that sprayed off the scope. He'd bought two, so he could do two a day. He only charged 500 bucks. Yeah, only. Well, the local docs were charging 3000 and what with the hospital fees and everything so, when the word got out we started getting real busy. If we did six a week, so that's just three mornings of work, he's making a real good living. And I was helping with the cleaning and moving the patients through in the beginning. He even had me wear a white coat even though he would never wear one. Pretty soon he was wanting to talk to the folks. He had me build a little consultation room in one corner of the garage where he could talk to the patients before the procedure. That's what he really likes doing. He likes talking to folks. And he’s good at it too. Figures things out that other folks haven’t. But, as you well know, you don’t get paid for the talk now do ya? So what do I owe you for the beer?

******************

Yeah, he got me so I could do the scopes. They're really easy. Like I said, you gotta get a good feel. If I saw anything bad I’d biopsy it. He would come over and look, interrupt his consultation. And I could video feed to his laptop. We gave all the patients a DVD of their procedure so they could show their friends.

Yeah, the biopsy is really where the decisions are made. Most of the time it’s just a screening scope and you might find a polyp or two. Lots of diverticula. I found a couple cancers. You can kinda tell they don’t look the same. But it’s the pathologist who looks at the tissue we send em under the microscope and makes the official call.

******************************

Yeah, I was doing them.

*******************************

No, I don't think that's why he's in trouble. I think it's the $500 issue. No, the local docs filed this complaint and started this hearing thing. Patients haven't complained that I know of. I think it's because Doc Hawthorne would take time with them. It got so he'd meet with them in his consultation room and it would turn out he’d only scope half the people. Sometimes, he told them they didn't really need it. I bugged him, he was hurting business. We could've done a lot more if you just shut up and let me run the scope on everybody.

***************************

Oh well, it's about time. I'll head back down to the conference room and see what's up.

************************************

Yeah, you could send people to us. At least I think, if this thing today doesn't put us out of business. Sure, we're in the phone book. No, I don't have a business card. I probably should.

TIME for her and me

TIME
for her and me

15 years old
25 weeks along
FHT 152 beats a minute
2 hours pain LLQ
Constant and sharp


Adopted at 10 years age
Known pregnancy 2 weeks
One-second of eye contact

Three generations
This is passed
The biblical curse

This next, a boy
Moves regularly inside
Her beating belly
Beneath pendulum breasts
And face as blank
As a kitchen clock.

Symbiosis

Symbiosis

Everybody’s favorite
He’s so hard to see
His treatment just right
Wealth comes with popularity

Booked out months ahead
Delivering babies or raising the dead
His skill a public certainty
Who would you want if not he?

But the months of refills
Signed by his nurse
With no office visit
Belie popularity’s curse.

Patients have needs
And doctors do too
The balance in deeds
Rewards just a few

For the public loves the love they cannot possess
His care cures them as theirs gives him happiness.

Fallible

The patient was attractive
And friendly, a single
Woman about my age.

If I’d only known
The meridians and
Flow of vital force

Her balding might not
Have been investigated
With blood and biopsy.

When I learned four
Years later of her
Inoperable brain tumor

My sadness and shame
Made me fear my own
Thinning scalp.

Actualization Biopsy

A biopsy is a surgical procedure designed to obtain tissue for microscopic and other forms of study to obtain a diagnosis. It is usually considered a definitive procedure. That is, this test has a high degree of certainty. When the outward appearance may not clearly look like a certain disease, the tests on the tissue sample obtained can be conclusive. And life changing. Or not.


He was an overweight young man. With children. Probably a worried wife. Boring job. I assumed his appointment for a physical was the result of the wife and the low copay and the pervasive perception that a complete physical was a path to health. It is folly to dissuade those that provide one's livelihood. So I do them. Annuals, as they are often called. Annual physical exams. Though they are rarely done yearly. And honestly, I discourage them. I am a doctor. I have a special knowledge. And my livelihood is about suffering. But the question of whether my special training coupled with my limited listening skills are any more perceptive at ferreting out incipient illness or serious disease than the patients own awareness of their symptoms has not been answered. And truthfully, I am better than any three-tesla magnet or Fourier driven tomographic x-ray. And still, I'm not as good as a truly aware, self-conscious, self-centered, actualized person. The data supports this conclusion. It took me years of attention and study after my medical indoctrination to come to this. It is not widely accepted. And it does not pay the rent. But that is the direction I took in my practice. Not to promote myself as a source of health, but to encourage the patients to be their own best resource in this dance we all shuffle, of health.

But I know where to spend my time. This guy isn't interested in self-actualization. Maybe, after the screening cholesterol, blood pressure, heart, lungs, unclothed exam he would listen to my well-rehearsed plea for moderate weight loss and exercise. It was hard for me to believe it might be worth the $200 we charge. I think that's what his insurance allowed. But then, after overhead, taxes, I would take home maybe $50 for this hour of giving him advice he could have gotten from Reader's Digest. What’s the sense in this system? Oh well, do your job.

When I go to look in his ears the dark spot in the hairline behind the right one caught me. "How long have you had this?"

"What?"
"You've got a mole back here."
"I don't know. I've never seen it."

It was a dark, irregularly pigmented lesion. I told him I needed to remove it. I checked with my nurse. She said I had time. So he got a physical and an excision in that hour we had dedicated to his health.

A 2-cm lesion excised, sutured, bandaged. He got the abbreviated weight loss and exercise speech. Cholesterol printout, diet advice. But the pathology report three days later of a Clark's level two melanoma changed things. Or did it? I cut off some of his skin. A doctor 200 miles away looked at it under a microscope, interpreted his knowledge and observations and gave me his diagnosis. Then I share this with a man who thought an hour, covered by his insurance, might help him be healthier. The surgeon did the wider excision and lymph node dissection, all negative, and the patient even came in to seen me, grateful, that I had saved his life. But I wondered. Will he live to a ripe old age? Would he bounce grandchildren on his knees? Would he lose weight, lower his cholesterol? Was I a hero? Was he?

I thought back to the breast biopsy two years before I had done in my office. It was a small round lump I considered benign. But when no fluid came from my probing needle I anesthetized and cut. A pathologist I did not know, covering due to vacation or some other absence called me to say I had removed a cancer. I was surprised. This determination changes this woman's life. And mine. Of course, like always for a busy practitioner these calls come on a Friday afternoon. We tried to call her. I told my nurse to leave no message on a machine. And she didn't. Could girl. So we waited. I had a long weekend. It was on top of my Monday list of things to do. But I got a call from another pathologist I did not know midmorning Monday. It came before we could contact the patient. She told me that she and all the other pathologists had reviewed the slides and disagreed with the fill-in doc’s diagnosis. This woman did not have cancer. It was a purely benign breast lump. I thanked her for her diligent work and I thanked my nurse for her professional demeanor and, when we finally got the patient to talk to in person, we gave her the findings. The final diagnosis. We skipped the earlier interpretation. She was not worried. Never had been. Just me.

I remember my mother telling us children, my two older sisters and me, an eighth-grader, that she was going into the hospital to have a lump removed. She was casual, but serious. My oldest sister had her license to drive so we all went in to see her that Friday afternoon after school in our small-town hospital. I expected to talk with my serious but always pleasant and properly polite mother. We three stood at the foot of her bed and looked at her unconscious pale face. She roused, drugged, speech slurred and mumbled. We all took in the bandages and absence of her left, comforting and balancing breast. My oldest sister, the one with good sense and the driver's license said quietly, with no alarm, "They took her breast." We left. I remember the shaken feeling, like something was now very different in my life, that things have changed from what was before to what they are now and we needed to understand this monumental change. We did. In our own private ways. Mom did radiation. She bought the prosthesis. But she always had a weak arm since they took the muscle as was the mutilating practice in those days. Best to be safe. But she never looked like her old self in a bathing suit. When she died 40 years later, a survivor she would proudly proclaim before she lost her speech. She died demented, 80 lbs., withered, the scar on her chest a mere presence I had come to accept.

And there was the time I watched my oldest sister, the one with good sense; deal with her diagnosis. This was closer and more intimate. She too had the lump and surgery but at a much younger age. I was well into my medical training and followed her chemotherapy and struggles. After the year of poison, hair loss and puking she came to visit my four daughters, her only nieces. The persistent dry cough worried me. A few weeks later she told me in her no-nonsense voice "I'm dying." When I hung up the phone I cried.

Her acceptance, her stolid demeanor were just her person. That's who she was. So the time she called and she told me of the planned MRI the next day I was unsure. "What are you looking for?" She told me she had collapsed that week at home. She was wasting. There were metastases to the liver and bone. Pain medication. But she told me she was fearful of brain metastases. "I don't want to lose my function." Her brain was everything to her. She wanted to know how she would die. If the cancer robbed her of her consciousness she could not tolerate that. So in my distant get sibling self I could understand the need for this test, one I would try to discourage in most patients. What would we do with the results? I did not know. I had a deep sense of futility.

I remembered my middle sister, long ago eschewing our family’s values, moving to Japan to rid herself of the burden of our pragmatism and cynicism. She was evangelically centered in her Western and Christian thought, even though she made her life and family there in Japan. She told how Japanese doctors did not tell a patient of the diagnosis of cancer. "The doctors will tell the family, so everyone knows, but it is kept from the patient. No one tells them they have cancer. It is an act of respect. If the patient knows they have cancer and are to die, it is like telling them they have no worth. The family, everyone expects them to try to live as long as possible, and if they're told, the fear is that the patient will give up and want to die."

My oldest sensible sister had her MRI. There were no brain mets. She died at home three weeks later. My sister from Japan was by her side.

So, my wife in her kind and loving way encouraged me in my later years to go visit my sister, my only living sibling in her home in Japan. She had made many visits to this country. To see her mother as she faded into dementia. To be with my oldest sister as she died. To see my daughters. Indeed she welcomed them to her home, when we sent them to Japan on weeklong vacations with Grandma before she got so she couldn't fill out the custom forms as her mind failed. So now, we went, her generation. All our girls were grown. I had moved on from my practice. It was a good time.

We arrived in spring. Cherry blossoms. Lots of train connections and tourists since it was Golden Week. Japanese students out on vacation. We stayed in their home. My sister told me of her life teaching English, her husband's work demands, her son's schooling and the myriad local customs and venues we would visit.

"Oh, I had this lump," she mentioned as she was cooking the rice as we sat at her table. "It was nothing. The doctor removed it last week. I thought you would want to know." Every one wants to share their medical adventures with me. But I froze. What to say? My silence, my deep and perilous reflection kept me quiet. Silly me, I searched for meaning, when it was just conversation.

"Oh," my wife interjected, intent on polite congeniality, "is everything okay?"

I twiddled the chopstick.
"Oh yes. They told me it was okay. Nothing to worry about."
"Oh that's good."
We all smiled. Rice and fish for dinner.



If we ask
Can we know?
If we tell
Does it show?
When I comes
Will it go?
If I know
Will you too?
What's the way
To be true?


Please help me
And all I love.
Let us see
God and above.
First and last
Comes and goes
Life is passed
Who of us knows?

Senseless

The foul odor of dead flesh
Drifted down the hallway
From a pleasant man in the waiting
Room who only wanted some Tylenol
For the ache in
His dead diabetic foot.

Wafting up from the belly
Wound of a week-old surgical
Scar, the oozing brown goo told
Of the growing culture below.

Comatose and hyperventilating, the
Man lay in a darkened
Hallway and hid
His ketotic breath from me, as
I felt for a thready pulse.

A loaded diaper filled the room.
Undistracted, I heard the infants
Asthmatic breaths on the lap of
The mother whose hair spoke tobacco.

We put stethoscope in ears and eye radiographs and
Computer printouts of blood chemistries right under
Our nose.