Rae · Lipson

It has been way too long....

Went on an ambulence transport last night. I don't get to do too many of these. It's normally a resident job, but our resident was 10 days short of her own due date and the ambulence only has facilties for one baby at a time.

Let me attempt to paint a picture. Ambulences drive at about 75 miles per hour. They routinely take odd turns and swerve around cars. You essentially have a bench seat in the back, facing the wrong direction, with one flimsy lap belt. Our infant isolette is secured to the center floor. I spend most of the ride, facing backward. my feet braced on the isolette, attempting not to get tossed around too much.

It's about a 55 minute ride, each way, to the hospital we are going to, so luckily, I have perfected the art of writing while bracing.

Anyhow, here we are on the highway. I can't see a thing, as I'm in the backward facing seat. We are headed southeast. And I have no idea what awaits on the other end. Small baby, came out a month early and much too blue. His blood pressure is too low. And there is no one on the other end of the telephone that can paint me an accurate picture. I've become good, however, about not worrying until I need to start worrying, so right now, I'm just enjoying the ride.

We're about 20 minutes in.

I really miss my dad. Sometimes I don't think about him for hours. So far, it's never been longer than a day. Sometimes, things that didn't bother you yesterday, hit you like a punch in the stomach today. My mom sent this article yesterday:
http://acsdevl.kennesaw.edu/access/story.asp?sto=350
Looking at her face is the hardest thing. She looks so sad. And I feel so helpless in how consuming her saddness is. People are always asking me how she is doing. And I think she is doing so well. But when I visit her, I often wake up at night hearing her sobbing. And when I go downstairs, she apologizes and stops. And I wonder if it's better if she gets to keep crying.

Looking at my face, I can hardly see it at all. Because I just know what I was feeling. That tension in my jaw when I'm holding on to calm. My arm behind my mom is supporting some of her weight.

30 minutes in now.

I have a loose hold on my sense of the future right now. It's not that I don't care, but I can't muster the will to worry. I know, in some sense, I want to be with someone. I want to have a family. Want to end up that way. But, in another (is it really another?) sense, I feel so utterly fine the way I am. And I know, at some level, I'm completely scared of screwing it up again. It's such a dance, this getting to know people. So, at some point, someday, with someone, I will make that leap again. But, whenever it is, it is so clearly not for a while, that it actually feels good not to worry about it. Not only feels good, but I would have to work on worrying about it. I someone feel that I know that this point will be clear when it arrives. That it will feel easy at the time. And perhaps I am fooling myself about that, but for now, it feels good.

45 minutes in.

Tomarrow, I have a day off. With no plans more significant than shaving my legs. The next day, I actually have a third date with someone in New York City.

Right now, we're getting off the highway. No idea what I will find in this hospital. And it's going to be a long drive back. But, after this many years, I feel equipped to handle whatever is waiting for in there. Sometimes it's awful. And sometimes it's wonderful. And many times I get to dig my hands in and make a difference, But the only thing to do at this point is to just enjoy the ride.

It seems I have finally been selected as a 'corset bunny.' Some folks I met a few years ago at a Ren Faire are coming back to town. They sell corsets at a downtown fetish fest. They normally need a few folks to wander about in corsets being friendly and handing out cards. They haven't been to Boston in years, but they are coming back, and want me for the job :).

It actually pays better than medicine.

Life is currently consumed by minutiae. I don't feel like I've had anything important to say for ages.

There are over $400 worth of people I need to tip this Christmas. That feels a little out of hand.

The dog is backsliding on house-training now that there is snow outside. But we've gone three days without an accident now.

I've taken on the job of publicist for velvet chain (www.velvetchain.com - look for me under 'news') In a way, that's a bit out of hand as well. But Craig was saying I needed a part time job. I like to keep busy. Plus, the stationery is much cooler than the hospital stuff.

I've moved away from cardiology research to something more anthropoligal. We are addressing the question of decision making. How parents make critical care decisions. How we educate them in order to do so. And, my particular question, how does one walk the line between education and coersion. I'm expected to come out of this with a monograph. Which is appealing. It feels halfway between a scientific paper and a short story.

This weekend I sat in front of a blank piece of paper for an hour, trying to think of what to say to a friend who's horriblely ill.

Last night we discovered a liver bleed in a baby when he was 12 hours old. I only received praise for his management all night. Liver bleeding is an extremely unusual and usually deadly problem. Still, he was a puzzle, and the thought that I was sitting here all night as 2/3 of his blood drained into his belly still makes me sick.

I cried over the Christmas card Craig gave me. When I'm with him, I feel like things are right with the world. He's someone I respect. Someone I enjoy. And I'm still scared to death that I'm just not constitutionally cut out to sit still in a relationship. I can't express how comforting it is that there's so little he needs to know. It's like it's just enough that I'm me, now, here with him. It's more trusted than I've felt in ages. It's what gives me hope about the whole thing.

I think he would move if I find a job elsewhere. Strange feeling.

My court date is tomorrow. That means I'm 91 days away from being single.

If I don't start a baby within 18 months I will be officially AMA. Other than an accident of seasonally appropriate proportions, I don't see that happening.

It all looks so much more important set out on paper.

Just returned from a trip that is almost beyond words. I'll have to write details...or at least of some bits. But the short version is that I did a 200 mile hike between the coasts of England. Very challanging. Very beautiful.

As tradition dictated, I picked up a stone from the Irish Sea before beginning. After carting it accross the country, I tossed it as far as I could manage into the waters of the North Sea. I wonder what else I tossed away. It feels like a lot got shook loose after two weeks of being on my own.

Anyhow I have experienced brook fording, way finding in socked in mist with compass alone, cow frightening, stile climbing, and more blisters than I thought possible (on my hands...how do you get blisters on your hands!). And, those amazing moments, when the hill gives way to another 30 miles of valley before you, and you see your path more clearly than you ever thought possible.

I returned yesterday to C picking me up from the airport. I don't think I've mentioned who my frenzy of internet dating has led down to. Yes, the first one I've had the 'would you like to give dating other people a rest' talk to. (I'm told this is implicit in the UK, not so overhere) So....a ride home from the airport. Then he cooked jetlagged me dinner at my flat. Then, I discovered this morning, he has also done the dishes. I seem to have stumbled upon something real. Someone in my city. Someone available. Someone you have those rediculous 6 hour dates with where you mainly just talk. I have to be scared of something, though....so I just hope my timing isn't bad. It feels awfully good. As effortless as it should be at this stage.

But my mind says it must be awfully soon. Maybe, though, after two weeks, you get to toss a little extra baggage into the North Sea. It feels a little like the way it is.

Oh boy, my first tag.....

Um, last seven songs I listened to.... easy, as I've just had my palm playing down the playlist:

1) Leaving NY (REM)
2) Electron Blue (REM)
3) Blower's Daughter (?)
4) Uninvited (Alanis Morisette)
5) Fall Away (Velvet Chain)
6) I Don't Care (Velvet Chain)
7) Emily (Velvet Chain)

First of all, got my personalized copy of 'Terrible Twos'. Read it again. Laughed outloud.

Wheee book!

Second.....I've got my tickets, I will definitely be hiking Wainwright's route in August/September. I really can't stand the thought of not stopping by Edinburgh, being so close, so I will be around from Friday Sept 9th until the 11th. Hopefully, I will still be able to walk. Very much looking forward to catching up with old friends!

Finally, some advice? I have my international palm pilot charging set. (I need my mp3's!) Which plug should I take: two round plugs or three rectangular ones????

Thanks all!

R

So, what's a reasonable first date to second date ratio?

Right now, I'm 0 for 3 for every possible combination (he called, I wasn't interested; it seemed fairly obvious neither of us was intrested; and I was really hoping he'd call and no dice). Certainly, I expected the last would happen (I'm fairly certain I know what 'I'll be in touch' means), but I have to admit, it still stung.

- R

Warning, I think this one is kind of heavy stuff.....

It’s cold on the first floor. See your breath, shivery, almost like outside cold. No one uses the revolving doors, and it’s impossible to get the temperature up with the constant open and shut. I left the cafeteria at about 4 am, and if you didn’t look too closely, you’d never know what time it was. The lights are still on. There’s still a buzz of conversation from people walking back and forth. But on closer inspection, there’s an air of sadness around the place at this time. Conversations are held closer. The doctors walk a bit more slowly. Many of the people are obviously homeless, not allowed to sit, but trying to stay someplace warm. If you looked even more closely, down one hallway, you might even catch a glimpse of the priest, walking in the limping gait of an old, tired man, as he headed slowly down the hall.

Here’s how they train doctors. Back in med school (good lord, this was half a decade ago), I admitted a different old, tired man, sick with pneumonia, late one Friday afternoon. It was the last thing we had to do, and as my senior resident checked over my paperwork, I saw him check off the box ‘no code.’ What does this mean? That if the worst were to happen. If old Mr. Smith’s breathing were to stop, or heart were to slow, we would do nothing. No chest compressions, no epinephrine. Nothing. I stopped the resident and insisted that we go back and ask Mr. Smith what he would want. He was old. But he had been healthy, living on his own, just a few days before. He was competent, and, by rights, should make his own decision. The resident reluctantly agreed, truly not wanting to deal with this at 5 minutes to quitting time on a Friday afternoon.

The conversation went quickly. Mr Smith was very clear, he wanted everything done. The resident was less than pleased, but marked the paperwork accordingly.

The next day, I arrived at the ward to find that Mr. Smith had been transferred to the ICU. His heart had unexpectedly stopped the night before. If it had happened at home, you would have said he went peacefully in his sleep. But here, as per his wishes, a code was called. You’ve seen it in the TV shows. Beepers beep. People run. Chests are pounded upon. Drugs are given. And after 20 minutes without oxygen, his heart began beating again.

After work on the floor was finished, the resident dragged me down to the ICU. We stood by Mr. Smith’s bed. You could hear the hiss of the breathing machine. Faint beeps from the heart monitor. His jaw was slack and his eyes were blank. ‘Congratulations,’ the resident hissed, clutching my arm, ‘You saved someone’s life’

Mr. Smith died in that ICU one month later. He never woke up.

That’s how they train doctors.

I’m not having the best day today. Like I said, it’s past four. I have a cold. I just got back from the cafeteria with my fifth mug of tea.

I keep dancing around the subject…..

Baby L was born 16 weeks early. This is what we call the limit of viability. She is just over a pound. From birth, her eyes are fused. Her skin is smoothly pink and gelatinous. It marks easily, and she can be damaged by merely applying a stethoscope to her chest. She is small even for her age, and had been being monitored in utero for almost two weeks. When it was determined that her heart rate was low, her mother was taken to the OR, put to sleep, and the small girl was rushed into the world to get a chance to live.

But nothing went well after that. Her heart isn’t beating right. Her lungs are too stiff. Her blood isn’t clotting. But, most importantly, she is bleeding, slowly bleeding into her brain. I can’t stop it. And for all the blood we replace, her anemia continues.

Care at this stage, for this need, is almost continuous. We monitor, adjust ventilators, start lines, and change medications. There is a constant buzz of frustrated activity around this tiny girl.

When finally her oxygen saturations begin to drop and her heart begins to slow, we call her parents over. Mom is barely awake, still on heavy doses of medication. Dad is quiet, almost sullen, not knowing who to trust. We explain the prognosis. That no one survives, at this age, in this condition. We explain that it is our opinion that all this activity is not doing any good. We suggest they hold her. We suggest they think about letting us stop.

The parents are very clear, however. They understand. They know what we are saying. But they want a miracle. I am quoting. They know what this means. They want a miracle.

Baby L is wrapped and placed in their arms. I watch as the monitor showing the amount of oxygen in her blood drops from 80 to 70 to 50. Within 20 minutes, it hovers in the teens.

It is almost a relief at that moment. Soon, there won’t be any decision to make. But, at that moment, the mom cannot watch any longer. She asks that the baby be placed back in the bed.

And I cannot explain it. Perhaps a small tubes shifts position. But without intervention, the oxygen levels actually begin to rise. 20 to 50 to 70. All the way back to 90. Confused, we begin activity. It is almost automatic by that point.

This is almost 12 hours ago. I am bleary from almost no sleep in four days. The priest has finally left, and our little girl is assured her place in heaven. The nurse in the room finally breaks down and starts to cry. She wants to know why we are doing this. The baby is in pain. Isn’t she? She must be. Why are we doing this? Why won’t I let her just stop? The attending physicians clutches at my arm when questioned. It’s not your baby, she tells me. It’s almost a sneer. You don’t get to decide. It’s not your baby.

Her lungs are too stiff. Her blood isn’t clotting. Her beautiful smooth skin is yellowed and bruised. It is cut and oozing from just a blood pressure cuff.

You are not my baby. You are simply my life’s work. My passion. I promise, darling, you will never leave this room. You will never smile at us. You will never talk or run. But look at what we do. You are alive. Your heart beats. Your lungs deliver oxygen to your bloodied brain. Congratulations, little girl. You are not my baby. You are my miracle.

Sometimes your hands shake. Sometimes your heart pounds. But then, you do what has to be done

So, here I am in a centrally located, yet rather old hotel in the middle of Boston. I got the deal off Hotwire, so even my car is costing more to park than this room.

I've had just enough clarity for today, so i ordered a bottle of red wine from room service. Came with an extremely cheesy corkscrew, so I've spnt the last 20 minutes wrestling with the cork.I finally gave up and decided to attack the thing directly with a butter knife. And, wouldn't you know, synthetic cork. I can't even cut through the fucking thing.

If I weren't laughing so hard, I might have to start thinking again. But, so far, the only conclusion, is that if this is taking charge of one's life. It's overrated.

House of God is the truest book about medicine I have ever read. We should all learn the fat man’s rules.

I. GOMERS DON’T DIE.
II. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
III. THE PATIENT IS THE ONE WITH THE DISEASE.
IV. THEY CAN ALWAYS HURT YOU MORE.
V. THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

There are many more, but those were the ones that applied to today, and I cannot possibility get into it all. But, I will present…..

A Lesson in Emergencies

There are three great emergencies in obstetrics. One, uterine rupture, occurred just last week. It’s the first case I’ve ever treated. One moment, the mother is laboring. The next, the fetal tracing deteriorates, she is rushed to the operating room, and suddenly the baby’s head, moments before lodged in the pelvis, heading outward, just disappears. The baby is found in the abdomen, floating in a pool of blood. That baby lived. That mother lived. That was last week.

Yesterday, we had emergency number two. The pediatric resident and I were at a routine delivery. You can tell when things go wrong for the obstetrician. Outside, snow has settled across the landscape, inside a similar quiet drifts outward, from the OB, to encompass us all. The baby’s head is out. We are committed to delivery, but the rest of the body will not come. My resident and I are at the warmer, prepared for the infant. We have checked our equipment. We have run our procedure. All we can do is wait for the OB’s to do their job. I whisper to her to just keep breathing. There’s nothing we can do yet.

Sometimes your hands shake. Sometimes your heart pounds. There’s often nothing to do but take your own pulse. We keep breathing, we get it done.

Suddenly a noise like a gunshot. I cannot believe that sound came from a human being. The infant is delivered quickly to the table. I know I have a good resident. I have to train them. So I keep my voice low and talk her through the resuscitation. 3.5 endotracheal tube. Laryngoscope blade. Position the head. Open the mouth. Visualize the vocal cords.

I measure the heart rate. 80 and falling. She has about 5 more seconds to get that tube in.

She does.

Remove stylette. Attach suction. Visualize, as I suction the trachea. Obtain bag mask. Apply mask. Begin to ventilate infant. The heart rate rises. The color turns from pale blue to ruddy pink. And moments later, the little girl opens her mouth, opens her eyes, and, in a grand display of common sense, lets out a wail.

It’s only then we notice the arm. Bent where it shouldn’t be. The upper bone, snapped neatly in half. I cannot believe that sounds came from a human being.

That baby is going to be fine.

Afterwards, I told the resident that she did a fine, fine job. Some of the time all we can do is take our own pulse. And then, when the moment comes, you do what has to be done.

I wore silk tonight. It was a warm evening, but when the breeze blew, I could pull the stole tight around my shoulders, and it was almost as if your fingers were tracing down my skin.

Earlier still. In the heat of the day, I lay on a white sand beach, headphones in ears, music just drowning out the sound of crashing waves. The clouds had learned to move in tempo. I watched one stubborn dragon drift right to left, stretching his dragon mouth wider, and wider still, until he faded to haze. But it's the music that kept me so still.

When I close my eyes, I can be anywhere. And sometimes I do close them against today. The inexorable pull futureward. The trap of silken bonds that keep us here. So I apologize for cringing when you want me to attend. When I complain about the bruising fingers pulling at my wrists, it really isn't you.

It's just that the question lately has been: How does one justify the space one takes up in the world? You have a solidity that begs that question. A place in the present that astounds me. But me, I think too much, and want too much, and want even the clouds to dance to that music. But opening jaws, insatiable, they fade away to nothing.

ISmell is the closest sense to memory. I haven’t been home to Georgia in too many years. It’s the smells that bring it all back. Oil and dust in the garage. Mustiness in the basement. And outside, grass and dew. I can remember 16 again, like it was yesterday. The heady freedom of just having a car. And having nowhere better to go than the park to find a quiet place to sit. There aren’t enough warm nights up here.

II
We had the traditional fight about when to take the turkey out of the oven. Honestly, I was about 20 before I realized that the stuff didn't have to taste like sawdust. I managed fairly well, until dad spied that the skin wasn't yet charry black and threatened to put it under the broiler. (Brining back horrible memories of anniversay dinner 1998 and seeing my first attempt at filet, which was supposed be resting, rotating in the microwave)

III
Happy Thanukah. It's thanksgiving. It's Hannukah. Who gives a flip when you're mom's born on Christmas. (Who's birthday are the rest of those guys celebrating?) My mom opened her gift, a coffee table book of portrait photographs, first. Somehow, she managed to flip to the page of male nudes. 'Ummm ... my,' she stammered, trying to say something. My brother, never at a loss for words, bounded over and announced to the room that it was a page full of privates. Mom quickly regained her composure. 'Oh no', she responded, snapping the book shut, 'Those are generals'.

IV
I tried to play Beethoven’s Sonata 17. Hampered slightly by just how out of tune b flat was, but even more so by the treachery of my fingers. The brain remembers, the ears remember, the fingers let me down. They used to know where they were without thinking. Now, if they lose contact with the keys, they are lost, and I have to look and purposefully replace them. When I finished, Lee said it was pretty. It’s Beethoven. A decade ago, it was beautiful.

V
The best gift was from my brother. A signed photograph of Peter Davidson ‘To Doctor Rachel, From Peter Davidson ‘The Doctor’’ The night before, I had been cleaning out my few remaining dresser drawers. I found diary number 1. Circa 1982. And I quote ‘I think I am in love with George Peppard’ Frightening. But also, stuck in the pages, was my first DixieTrek Program. Headline guest – Peter Davidson! My brother may go to Avril Levigne concerts and have an uncanny knowledge of gourmet cheese, but sometimes, really, I love him best of all.

The elements of fiction:

Setting, Character, Plot, and Theme

Exercise for the student:

Allow your exposition to arise naturally through anecdote.

1) Setting – It’s winter now. Two days ago I looked out the window and saw the first snowflakes falling. I was on the phone at the time with someone who asked me to be careful on the drive home. What a funny thought. This is baseline in New England, the months of ice and cold. It used to be different; the first few winters, I would be so nervous driving home. But after a while, everything becomes natural, from clearing a windshield to controlling a skid.

But part of me certainly hasn’t adjusted. It’s so bright out, it seems like there much be some warmth in all that light. Not like the greyness of Scotland that warned you of how dangerous it was outside. And so, I almost always find myself just that much underdressed. I was looking so sharp this morning in black calf length coat and knit scarf. But I was rubbing my hands together to bring the feeling back by the time I got from parking lot to hospital.

2) Character – There’s no sitting still; no settling in. Forget returning to reality and letting the rest fall away. I will always be in motion in some respect. I am bad at lazy Sunday mornings. I need music playing almost constantly.

Sometimes you’re just talking and you notice you hands have begun some activity on their own, unbending paperclips, or tearing paper into tiny, tiny pieces.

3) Plot – Saw a movie last night. Lee insisted that he wanted no popcorn. So I get a small. And, of course, before the previews have even ended, he’s eaten half of it. So I had to bat him mercilessly about the chest with the remaining popcorn bag. And it’s not like I even finished the rest myself.

We exited the theatre and both starting whistling the theme at the same time. Him well; me badly. Ice was crunching underfoot. And we just laughed and laughed.

4) Theme - This last I leave as an exercise for the reader.

That is what the human mind does. Make stories out of the meaningless. I’ve heard there are only seven plots in all of literature, themes in all of pop music, different babies in the ICU.

But, here I am, finding myself caught in my personal tyranny of small numbers. Or, as has been said before, the danger of learning all your lessons a day too late.

Or the danger of didacticism. Because, somehow, unexpectedly, illogically, it is working. It’s not as if I feel settled. I thought I would have to strip away what doesn’t fit here, forget, bury parts of me, make the plotlines clean, and the characterizations typical.

And it’s not happening that way. I expected the touch of melancholy. I expected the feeling of being cramped in my own skin. But I didn't expect it to be quite, quite so sweet, like a piece of the puzzle just snapping into place. That’s not the way the story is supposed to go.

Ok, October's not quite over. But I've been in the hospital every f'ing day for the past 3 weeks, and I have one day left! So, time to celebrate. One goofy post. One more full day. Then it's off to New Hampshire for hiking and Halloween.

October Recap:

Hours in the Hospital: 323

Dead Babies: 0

Number of times I told a friend that only I get to make the dead baby comments: 1

Smallest Baby: .460 kg (That's just under 15 oz)

Moments of triumph: 4

Moments of terror: 2

Best Baby Name: Caliph Flowers

Best Clueless Moment: Shreaking aloud when I forgot I turned my beeper to vibrate one morning ties with not getting what was so funny about Caliph Flowers (for two weeks!)

Bitchiest Moment: Tie between telling the surgical nurse she needs to watch what her bunnies suits get up to(after being sent all over the hospital looking for one only to find she was hoarding a new box) and following the blank look I gave the dorky lab guy who hit on me with the comment that often all this science talk goes right over my head.

Questions about when I was planning to get pregnant: 3

Bad habit I've indulged: Drinking alone and internet shopping (but never at the same time)

Good habit I cultivated: Lot's o' gym time.

Bad habit I've avoided: Smoking (damn those things still smell good)

Good habit I've avoided: Breakfast. And occasionally lunch. And once in a while dinner