Wilderness

The surgeons won't operate on you you have a "hostile abdomen," their note says, not suitable for "exploration" and upon reading this, I picture them dressed in khaki, holding torches as they descend a staircase into the cavern of your belly. Their torchlight illuminates the surrounding landscape: a thicket of scar tissue, a squirming heap of bowel, and far in the distance, the purple mountain of your liver. One surgeon takes a machete to the scar tissue, cutting forcefully through each diagonal, fibrous attachment as if it were a vine in a jungle, inching toward My stomach hurts, you say. I sit on the edge of your bed and examine your belly, and when you wince, it occurs to me that there is something very innocent, almost childlike, about abdominal pain. Chest pain seems a problem for the aged: the term conjures images of pipes clogged with grime, of white-haired people collapsing without warning in their driveways, but abdominal pain  it feels more grounded, more central, more primitive. Next, I am a small girl crouched in the bathroom, alternately vomiting into the toilet and resting my forehead on my mother's thigh; I feel the fabric of her housedress against my cheek, her cool hands smoothing back my hair. She leaves a metal mixing bowl next to my bed (just in case), along with a glass of ice chips, and whenever I reach for the glass, it clangs against the bowl, making a sound like a bell; for years thereafter, the sound of metal cookware clanging against itself would remind me of being sick to my stomach. I'm sorry we can't operate, I say to you, and you shrug your shoulders. You contracted HIV in the 1980s and watched most of your friends die of that virus; you're grateful to have lived this long. Your husband knocks on the door. He is holding a bag with blue cellophane sticking out the top: today is your birthday. He says, I came to bring you home

This post was written by Emily Silverman, MD. It was published in the fall 2016 issue of The Examined Life Journal at the University of Iowa Carver College of Medicine.

Autopsy

When we first met in the emergency room you said you liked jazz, so I played a few Herbie Hancock tracks on my iPhone while I examined you. There was a bloodstain in the corner of your left eye; at the time I did not know it was a harbinger of things to come, that you had already started to bleed internally a special, sinister type of bleeding, where the blood literally begins to curdle and that within days, you would be unconscious in the intensive care unit, on mechanical ventilation, with a grid of electrodes covering your bald head like a helmet. Typically this sort of bleeding has a trigger, you see, but despite consulting with four different specialists and subjecting you to numerous tests, we could not find one. During one of my twenty-eight hour shifts, I watched helplessly as you grew sicker and sicker, and when I arrived home, I sat alone in my bedroom thinking of you, the mocking daylight filtering through the blinds; when I finally did get to sleep, my dreams were suffused with numbers (your labs) and nonsensical thoughts related to your condition. I awoke, tired, to a night sky. Unsure of whether to eat breakfast or dinner, I decided to start by heating up the teakettle, and as it warmed to life, I tried to imagine what fills the space between knowledge and truth: undiscovered molecules moving purposefully through our tissues; elaborate pathways whose structures contains deep secrets of oncogenesis, autoimmunity, and longevity; and beneath it all, a seething quantum foam. I drank a cup of tea, but before long, I was back at the hospital sitting around an oval conference table with your family I had come to "answer questions." Your brother asked: Are you saying you cannot save him? Or that he cannot be saved? and I had to pause to consider the difference. 

When you died, I was relieved your family requested an autopsy. They were not the only ones who needed closure. When your body was ready, our team rode the elevator down to the morgue  a quick pitstop before lunch  and met up with the pathologist, who peeled away a green cloth to reveal your organs, sliced thin and splayed open like books on a table, just two weeks after we listened to Herbie Hancock together in the emergency room. The pathologist had not found the answer either, but he used the opportunity to review some basic anatomy: here was the tube of your esophagus, the ridges of your stomach, the trampoline valves of your heart; here was your dense, jaundiced liver. And there were your lungs. I touched one gently with a gloved finger. It felt spongy, full of air.

This post was written by Emily Silverman, MD

Space

I came home late from work and found you sitting in bed, ankles crossed, laptop hot on your thighs. You looked up at me with that crinkle-eyed grin and said, C’mere, so I dropped my bag, climbed over to you, and put my head on the thumping cave of your chest, knowing I had to be back at the hospital in several hours. I shifted my position until your heartbeat was no more than a vague vibration – those precious sounds are not mine to analyze – and then, a few minutes into our conversation, I began to cry. It was nothing you said; these bouts of dysphoria had been happening for months, and for no particular reason; rather, it seemed all the hospital's anguish was a liquid column that filled me up until I could no longer contain it. You accepted these stochastic episodes with love and patience: Here, you said, pulling up a photograph of Pluto, which had been beamed back to Earth weeks ago by the New Horizons space probe. We examined the image together. Do you like it? you said, and I nodded. Then you pulled up an interactive map of the solar system, cranking up the speed of time until the planets looked like marbles rolling around at the mouth of a funnel. When the clock struck 2006, a symbol representing New Horizons was ejected from earth’s atmosphere; it careened through space until 2015, when Pluto swung around to meet it, the two objects nearly grazing each other, the timing so perfect it hurt – this was it, the Say Cheese moment – and then the probe sailed off the screen into oblivion, and Pluto swung away from it like a boomerang. We looked at each other and smiled. Then you lifted my chin and kissed me, slow and deliberate. When we turned back to the screen, the planets were still in orbit and the clock read 2232. Look, you said, stroking my hair tenderly, now we’re dead.

This post was written by Emily Silverman, MD. It was published in the fall 2016 issue of The Examined Life Journal at the University of Iowa Carver College of Medicine.

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Ignorance

Your blood was thick with sugar – around six hundred milligrams per deciliter, far above the threshold where the urine begins to sweeten – and as a result, you could barely lift your eyelids. After a shot of insulin, you were sitting in a chair, wearing fleece-lined slippers and guiding a spoonful of scrambled eggs to your mouth, but one of your blood tests was still askew, so I ordered an ultrasound of your abdomen, only half conscious of what I was looking for. I was in the cafeteria chewing on a sun-dried tomato when I got the phone call from radiology: there was a large tumor in the head of your pancreas, and it had infiltrated your liver. I thanked the voice on the phone and looked down at my sandwich. It did not feel true. My thoughts turned to last fall, when I noticed a vague, recurrent ache in my abdomen; I'd felt the pain on and off since medical school, but it had become worse, so I saw a doctor who sent me for an ultrasound. That afternoon I lay on an examination table covered in goosebumps as the technician slathered hot gel onto her instrument; when the probe touched down on my skin, a white oval appeared on the screen, casting a dark shadow across my liver, and I realized immediately and with great surprise that it was a titanic gallstone. This fact penetrated me sharply, sending off waves of simultaneous thought: like Galileo peering through his telescope, I felt humbled to have discovered the rock and satisfied to know the truth, but also deeply alarmed, even betrayed, to know that crystal of bile had been present in my body all along, enlarging slowly, forming a new shell every year like the trunk of a tree. They cut out my gallbladder around Christmas, but they would not cut out your cancer – no one could. When we told you, you handled it with remarkable grace; I won't forget how you raised your chin and said, I have no regrets. Your family was standing outside in the hallway. They didn’t know yet. There must have been eight of them.

This post was written by Emily Silverman, MD.

Glitter

Goodness gracious, Annie, you smoked so much crack! Your blood pressure is soaring, up up and away in the 200s – the red number blinks urgently on the monitor – and I feel a pang of discomfort, knowing the clenching pipes of your arteries are transmitting that brute force to your brain, which is swelling in protestation. You are sedated and on mechanical ventilation in the ICU, and when I examine you I notice your gold glitter nail polish – the only hint of playfulness in a room of blue and gray – and the lice in your hair, which is fair and thin and matted to your scalp. Your arteries surrender easily to our medications – the pipes unclench, permitting your brain to shrink back to its usual size – but the lice, on the other hand, are far more difficult to treat; the nurses go to work on you, taking turns vigorously shampooing your scalp and sliding a comb through your hair. On the third day you wake up and slur your name, and on the fourth day, you’re sitting up in bed, cross-legged and speaking in paragraphs as if we were catching up over brunch. You tell a good story – the pitch of your voice fluctuates expertly, and you pause in all the right places – and during our visits, I learn all about the patch of sidewalk you sleep on, the saga of your parents' marriage, the time you were raped by a stranger in LA – that last part you mention quickly, casually – and I realize I like you very much. What is it like to be you, Annie? I could never tap into all the channels of your consciousness, absorb your history, comprehend your despair – or that of anyone else, for that matter, because all human beings, from the love of my life to the Sultan of Oman, contain an infinite world: scaffolds of knowledge, iridescent moods, memories that coalesce and dissolve, and deeper still, a voice, a grain, a secret. The best I can do is listen and point my light at your pupils. You have moved on to the subject of watercolors now, but I must admit, I am a bit distracted; you are using your glittergold fingertips to comb, over and over again, through your clean blonde mane, and I see the lice are gone.

This post was written by Emily Silverman, MD. Along with Progress and Two Deaths, it won second prize for Best Essay in the 2016 LitQuake Writing Contest.

Two Deaths

It’s two in the morning and I have to go pronounce you dead. I have never met you before, so I cycle through my stack of paper sign-out sheets until I find yours, which contains a few details about your medical history and a handwritten, asterisked note: *may die overnight. My white coat hangs on the back of my chair, sagging under the weight of the stuff in its pockets – papers, handbooks, granola bars – so I slip it on (suit up, kid!), chug whatever water is left in my Styrofoam cup, and start down a long, beige hallway toward the ward. I have pronounced a person dead once before, months ago, in a different hospital; I took care of her for almost three weeks before she started vomiting blood and was promptly moved to the ICU. Am I dying? she had asked me, desperate, her face stained with blood behind the oxygen mask – she was only forty-six – and I had not known what to say, so I gripped her arm and said something canned, like We’re doing everything we can. Several days later, she drifted away in the golden haze of renal failure, surrounded by friends and family in one of those rooms with a shattering, panoramic view of San Francisco. When I arrived at her bedside, I was startled to see her white lips and sallow cheeks, her utter stillness. Her family knew she was dead, so my little routine – listening for a breath here, feeling for a pulse there, announcing the time – was but a formality, and afterward, our team debriefed and reflected. But now, I stand alone in the middle of the night at the 5A nursing station asking, Does anyone have to come with me? and when the charge nurse replies, simply, No, there is nothing else to do but swivel on my heel and go to you. The door to your room is closed, so I press it open – it is heavy – and find darkness. Suddenly I feel afraid, like a child at night who doesn’t want to enter her closet, so I switch on the light and the room instantly reveals itself: the folding chair poised against the wall, the side table where someone left behind a few saline bullets and a stack of four-by-fours, and directly opposite me, the bed and your body. I sit down and look at you. You are a thin man, black, with a gray beard. The blanket is pulled all the way up to your chin. Well, this is awkward, I think, half expecting you to sit up and roar SURPRISE! but you do not, so I lift the blanket and place my stethoscope on your chest, which is still warm. Listening, I consider how grand it is that we, who dwell in a freezing void, are capable of generating heat: that glorious, thermodynamic signature of cellular metabolism. I conclude that you are dead (of course), announce the time of death to no one in particular, and then add, May God be with you, which surprises me, since I am an atheist. I go back to the nursing station where the death packet is waiting. I fill it out, sign my name, and tell the nurse, It's done.

This post was written by Emily Silverman, MD. Along with Glitter and Progress, it won second prize for Best Essay in the 2016 LitQuake Writing Contest.

Progress

You did not know what it meant, friend, when a lump started growing in your neck in college, but now, over a decade later, that node gnarled and dead, a new immune system churning in the pulp of your bones, you sit across the table from me wearing green scrubs, humble and bright. It’s a quiet night at the VA, and you and I are talking science – the hard stuff, your territory – and while I knew you were handy with a pipette, I did not know you could launch, off-the-cuff, into beautiful descriptions of modern cancer therapy. It’s microscopic warfare: let’s subdue this overzealous enzyme; let’s unleash a lymphocyte army; let’s enlist antibodies that sail, with great precision, toward their targets – and the more you talk, the more I lean forward, feeling very conscious of how (thanks to you) old pieces of knowledge, rusted from years of disuse, are flying together like magnets from remote corners of my mind and taking cohesive shape. Consider the average prostate cancer, you say, turning over a sheet of paper and sketching as you go – this was my favorite part of your monologue – it feeds on hormones, so shouldn't chemical castration starve it to death? Well, the cancer starves, to be sure, but no one expected the subsequent backlash: a cellular identity crisis! Sapped of its testosterone bath, that delicate prostate cancer may become confused and start to wonder, Am I even a prostate carcinoma anymore? Perhaps now I am a neuroendocrine tumor? and then proceed to experiment – dye its hair purple, for example, or start playing loud music in the basement. Sadly, these rebellious growths, deprived of their hormonal lifeblood by oncologists, are more vicious and resistant to therapy than ever before. Conundrum! But science keeps moving, doesn’t it, friend? It’s a stalling game; we whack the mole with our molecular mallets and wait for it to change positions and rise again. What new mallet will you build? How far could we go? Some speak of a Cure, and while I hate to talk about cancer that way (because cancer is so many different things), I sometimes dream up a cancerless world. Can you picture it now? What do you see? I see oceans of people with dementia, and the brain – oh man – that one might take a bit longer to figure out.

This post was written by Emily Silverman, MD. Along with Glitter and Two Deaths, it won second prize for Best Essay in the 2016 LitQuake Writing Contest.

Night Shift

One Saturday night my friends Andy and Jane, who had just consumed a lavish meal, decided it would be a good idea to come visit me at San Francisco General Hospital, where I was working a night shift. The hospital was stripped, as it is every night, down to a handful of essential staff, but fortunately it had been a slow evening so far, and not knowing how raucous they would be, I told them to stay outside, that I would come to them. I found them standing under the front awning in formal wear looking drunk and beautiful. They erupted in cheers and produced a cardboard McDonalds Happy Meal box, which contained a pouch of salty French fries and a collection of snacks they had picked up at Bi-rite, including sheets of dried seaweed and an alien beverage which, they taught me, was kombucha with chia seeds. Andy had brought a laptop, which he placed on a nearby bench and fiddled with until an electro-pop song began to blare from the speakers, which prompted the two of them to dance, unapologetically, under the fluorescent EMERGENCY ROOM sign. My hospital ID dangled from my white coat as I videotaped them with my iPhone, and as I did so, I felt acutely sober, tethered, and wistful. I hadn’t known these people for long, but I already loved them, and felt deeply touched they had done this. I craved their lightness, and imagined what sort of adventuresome thing I would do on my next day off, all the while knowing I’d likely spend it repaying sleep debt and doing laundry. A security guard, hearing the noise, came around the corner and paused to take in the sight – a on-duty physician, with an inebriated, dancing duo – and before he could say anything, we knew it was over. Andy and Jane packed up their things and floated off, and I went back inside the building. The resident room was empty, its dozen or so computers projecting lazy screen savers; I sat down next to one, opened the McDonalds box, and began to gnaw on a sheet of dried seaweed, suddenly recalling in perfect clarity the opening scene of Beauty and the Beast, where a goat bites a few pages out of of Belle’s romance novel. Sadly, the dancing was over – that brief interface with the outside world – and now I was back where I started. I watched the video on my iPhone a few times, noticing eventually, as Jane squatted and twisted, that she was not wearing underwear. As for the kombucha, I never drank it; I thrust the bottle in my gym bag and forgot it was there until a few days later when it came loose and spilled everywhere, covering my white coat in patches of brine and clusters of seeds.

This post was written by Emily Silverman, MD.