Currents Under Way

 

She lives her life, day by day,
Stoking flames of past.
Deals with strife in the way
Of sailing without a mast.

 

The wind is blowing on her sea,
While waves are getting rough.
Storms will show what she can be,
When times are getting tough.

 

Water’s cold and warm is air
While winds are stiff and brisk.
Stories told, and dreams are shared
While keeping up the risk.

 

Rolling quickly wave-to-wave,
Rising crest-to-crest.
Thinking backwards, try to save
The magic of his breath.

 

Sailing on, days go by;
Current’s under way.
Changing spirits with the tide
Keeping her at bay.

 

 

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

 

 

It’s been almost four months since coming ashore.  I can hardly believe it. Although I’ve been sort of a shape-shifter when it comes to my role here, I have also been able to get a reasonable amount of practical medical training accomplished. I realize how am lucky I am to be be a learner in the presence of the Simon’s, the staff, and these residents alike. I am feeling quite blessed that this unique experience is going to eventually help me to become a better physician someday, somehow.

 

I think about the limits of my previous “patient experiences”, and consider how much I have yet to learn. Granted that I am only headed into my third year of medical school, I  recognize the lack of exposure that most of my classmates and I share.  Most of us have primary experiences afforded by some bullshit EMS class we took as undergrads, or in the form of a personal presence during a loved one’s decline as they passed away in some dimly lit hospital room. Some of us have our own medical issues that paved our path into medicine.  Now this here, this was something different. Something real. Something poignant.   When faced with the end of life, it is amazing how these residents cut right to the point. All bullshit is shed and only what matters is focused on and discussed. I wonder if all medical students should be started in a place like this -to see what we are trying to save, and how it can be when we don’t cure or fix someone.

 

An  infusion company representative was visiting today from San Juan, Puerto Rico. He stayed for dinner and gave a presentation on his new drug delivery device / IV pump. he versed us in the intricacies of subcutaneous infusions for medicine and fluid delivery to patients with difficult intravenous access. As it turns out, a very appropriate topic for a hospice lecture. The only thing I knew about it before today was that I had a cat named Stanley who once needed this set-up when he got really sick.  Good old Stan – he was a hell of a mouser, but he certainly didn’t stand a chance against the speed of that mail truck.

 

There’s nothing quite like a side-dish of salesmanship to compliment a nice steak dinner.  This concept of powerpoint by candlelight is a combination that I am sure I won’t soon forget. Tonight’s cuisine was crafted by Jamie, and offered by Natalie Bartolli, one of the residents. The entrée was called Bistecca alla Pizziaola, and with a name like that, it was as good as it sounded. Natalie suggested this classic Italian dish the other morning during the clean-up after breakfast. Since then we all had been anticipating its greatness.

 

Tonight we were not disappointed.  Placed together with a grilled steak, grilled tomatoes, and a load of herbs fresh from the garden, was an amazing fettuccine.  If that wasn’t enough, a cappuccino tiramisu was the desert.  I think I ate too much.  Perhaps if I ran back the sales rep may have some free samples of insulin or a antacid to take. As I am back on my computer now, tucked into my bunk for the night; my blood sugar rises and my sedation peaks. My usual angry stomach rumbles have quelled to the occasional shrills and squeaks of pure intestinal delight.

 

In preparation for the evening’s meal, I was able to help Jamie in the kitchen by washing and cutting the herbs an vegetables. I also was tasked with puting together the salad course. All of this was done under the careful watch and direction of our culinary consultant for the evening, Natalie. Making my way around the kitchen with Jamie and Natalie, it struck me that given a few cameras and a live studio audience; we could have a pretty kick ass cooking show from this place. Maybe we’d call it “Death by Chocolate,” or some more euphemistic play on words that could represent who we all were in this time and place.

 

The only way I can describe Natalie Bartolli is by reflecting on my own stereotypes of a third grade school marm; aged beyond her years, and with a certain warmth only granted to those who she is teaching. It wasn’t until I was slicing the tomatoes the “wrong way” that Natalie has spoken directly to me since coming here a month and a half ago. “Lengthwise, not width-wise” was the lesson for the day. Maybe she was right, it did look much better…

 

Reading through all of the residents medical records upon arrival was now a part of my learning. My chart review and subsequent discussion with the Simon brothers was all I really had to base my personal opinion of her on. On paper, she is described as a sixty eight year old woman diagnosed with, and treated for, metastatic ovarian cancer. Since the time of diagnosis two years ago, she has received multiple chemotherapy regimens and a few courses of palliative radiation therapy to her pelvis, where there is significant tumor burden. Her other past medical history is significant for fibromyalgia, depression, anxiety, and post traumatic stress disorder spurred on by childhood sexual abuse perpetrated by a family member.

 

As I read through years of this woman’s medical treatments and examinations, I have been introduced to the jaded view that doctors must have of unknown patients when they first come into their office or hospital. Many might  have a hard time getting past her fibromyalgia and mood disorders ( as manifested in her affect).  I could see her just getting written off as initially crazy, or someone who couldn’t be helped.

 

Sure all this bad stuff had happened to her in her lifetime, but she had also been an amazing teacher for forty years. Nothing mentioned about all that… I am sure there are hundreds, if not thousands, of people that look back fondly on Ms. Bartolli and her giving presence. Unfortunately there is no ICD diagnosis code for the important stuff.

 

I was really stoked that everyone loved the meal… As usual, Jamie deferred all compliments to Natalie. Even though anorexia was a symptom that Natalie was plagued with, suffering with recurrent malignant bowel obstructions secondary to the tumors in her belly, she was able to sample a taste of her own creation and agreed heartily. I could see the satisfaction on her face as she watched us all eat what she had created. I am sure there is an immeasurable sense of being, when you can create something in the setting of internal destruction.

 

Selfishly I hope that given Natalie’s predilection for teaching,  I can get to know her better… Part of my intuition leads me to believe that because I am a young man, I may remind her of past atrocities that she had experienced….

 

On a night like tonight I look to the heavens and thank God for our also human ability to create. In whatever form or product that results, it is a great sense of pride.

 

 

 

 

Entered weeks later (September 6, 2008)

 

We toasted before our meal tonight in honor of Natalie Bartolli. She had died peacefully with the staff sitting vigil around her, and ushering her into the next world. We all had become her family.  She passed calmly after becoming septic from an infection that we presumed came from a perforated bowel. In the days before her death Natalie had some profound insights that she was quick to share with us.

 

In her final hours, she was able to detail what she was physically and mentally experiencing. She detailed her thoughts of what was happening in her body. We followed her lead and listened in awe. These descriptions and reflections were not only helpful for us managing her symptoms, but also for her in ascribing meaning to what was occurring within. From what I have learned, it is not uncommon for hospice patients to experience this blessing in their final moments.

 

This self awareness at the end of life is coined “near death awareness.” It is a phenomena that can manifest in many ways. In Natalie’s case, she was at first very specific and tangible with what was occurring, and then it progressed to more symbolic descriptions.

 

When she detailed the presence of her grandmother outside the window, I was reminded of a similar “hallucination” my own mother experienced before she died. Natalie also told us of her own visual perspective changing to that of her experiencing the room from a few feet above her own bed. She even joked that it felt similar to the time she “mistakenly” dropped acid as a college student in the 60’s. Moments before she died, she told us all that she was ready to go home. As she reached out her hand, we all knew what she meant.

 

Natalie’s death was a beautiful experience. As morbid as that sounds, I feel like I am immediately less fearful about what happens next. I can only imagine what would happen culturally if people saw moments like these, and understood there significance. Perhaps we would all be consciously reborn and work to treat death in a way that accepts it as part of life. Rest peacefully Natalie – thank you.