The Best of... Creative Writing by Family Physicians 2002 Award Winners Sponsored by the Family Medicine Education Consortium The FMEC Creative Writing Project In May 2002, the Board of Trustees of the Family Medicine Education Consortium, Inc. created an award to encourage and recognize creative writing by Family Physicians. The idea was to promote the writing of prose and poetry that draws upon the experience of teaching/learning or practicing Family Medicine. The criteria for the awards process are as follows: " The submission must derive from the experience of teaching/learning or practicing Family Medicine. " Faculty, residents and students and all Family Medicine clinicians in the northeast region of the US were eligible to participate. " Stories, poems, and other forms of fiction or non-fiction writing were welcome. " A panel of reviewers composed of Family Medicine faculty and creative professionals experienced in manuscript evaluation was established. " Each submission was evaluated with an eye to its critical reflection, emotional honesty and technical merit. A blinded review process was followed. " Submissions could be no longer than 1500 words. Pieces previously published at a national level (magazines, journals, books with a national circulation) were not eligible for this award. " An author could submit a maximum of one poem and one prose piece. Creative Writing Award 2002 Review Committee Julie Schirmer, MSW (Chair) Maine Medical Center Family Medicine Residency Portland, ME Bertie Bregman, MD Columbia University, Center for Family Medicine NY, NY Andrea Gordon, MD Harrisburg Hospital Family Medicine Residency Program Harrisburg, PA Paul Gross, MD New York Medical College Department of Family Medicine NY, NY Ms. Diane Guernsey NY, NY Ms. Courtney Spencer Portland, ME Richard White, MD Burlington, VT Administrative Support Laurence Bauer, MSW, MEd Ms. Lisa Schwieterman Ms. Kristen Dennison The Dark Bridal Canopy (Prose: First Place Winner) She was beautiful in the illuminated glow of the floodlights, as she had been a few days before under her bridal canopy. A Druse woman in her early twenties, a member of a secret sect that had broken from Islam 500 years earlier, and after persecution, had sought refuge in the hilly sections of the Galilee. Streaming blondish brown hair, high cheekbones, skillfully applied makeup around finely sculpted features, and the fine curvature that would turn any eye. A large diamond ring decorated her hand, bespeaking of a new status, likely the new wife of the son of leading family in her village. Only now she was not breathing. I sat crouched near her head, the ambubag slowly expanding and emptying in my hands, matching the rising and falling of her chest. Silent desert night moon overhead. Along with an army doctor who had happened this way and my nurse, I huddled silently, as her new husband quietly whimpered some meters away. I had been called from my kibbutz a few kilometers down the road as I was putting the kids to sleep. I raced, if one can do that in a Subaru Justy, up the road upon hearing the news of a reported severe accident. It was pitch black, save for the lights of my car and the endless canopy of stars and moon on this warm fall night. She already lay on the road having been pulled from the wrecked car that had not made it quite around the curve, had probably caught on the soft shoulder and flipped. They were returning from their honeymoon in Eilat, the Miami Beach of Israel, the place of luxurious abandon and celebration. Had they been talking about their future, their love, their new discovery of each other? Their first kisses and touches still fresh. ABC - airway OK, breathing absent, pulse thready, but present, her blood pressure was barely palpable, her body warm. We began CPR, cut away her constricting clothing, and placed line after line, trying to resuscitate with IV fluids where her blood should have been flowing. The army doctor had been on his way to reserve duty in a nearby desert base, by chance an intensivist and anesthesiologist in civilian life, and had stopped to help. The regional civil administrator, who quarreled with me at every chance, save at such critical times, brought in the newly acquired mobile floodlights and illuminated our surreal scene. Nothing changed for the better. The thready pulse disappeared. Think! ABCDE or Scoop and Run, Scoop and Run!! But to where? We were nearly an hour from the nearest hospital by ambulance, and calling a helicopter would take even longer. The husband asked the ambulance driver, who was bandaging his small head wound, whether his wife was OK. He had been united with her after all his male relatives had taken him joyfully through the village, accompanied by drums, singing and dancing, to the wedding canopy, while the women and girls of the village had prepared her for this moment. "I am my beloved and my beloved is mine." The army doctor and I conferred. I hoped he knew what to do now. We tried a few maneuvers and waited. No response. We stopped talking, continuing CPR against hope, against the wisdom of the books and our teachers. The road was quiet save for the sound of the floodlights generator and the whoosh of the ambu. How beautiful the desert wind and view at night. All colors of the earth - browns and black, save for her pale skin and open eyes. Time spread out and slowed to a trickle.. The army doctor looked up and said, "all is done". We stopped, we covered her body with a blanket, not thinking to close her eyes. I went to the side of the road as she was placed on the stretcher and into the ambulance. I am unsure of whether I spoke to the husband or not, unsure of whether I cried or merely slid into my car and the enveloping darkness as I drove home. My wife and children were asleep when I returned. I shed my bloodied clothing at the door, ritually bathed long and hard - trying to clean off the pale of death, had a glass of wine, said a blessing on each of my children, and feel into a troubled sleep. The husband likely returned to his village, his honeymoon turned into a funerary march. The Druse believe in reincarnation, so perhaps a child was born with her soul somewhere. Perhaps a different journey in the next life, one that would not end in the desert. Author: Jeffrey Borkan, MD, PhD Rhode Island University Department of Family Medicine Pawtucket, RI New to this Doctoring (First Place Winner: Poetry) I don't know what to do with these nuggets of humanity my patients keep giving me amidst their chief complaints "I was hoping to ride my bike down to the lake and watch the air show this weekend," he says, while waiting for a definitive diagnosis of pancreatic cancer, too sick to eat, pee or shit. "It's my birthday tomorrow, Doc", Oh, happy birthday. You're going to the OR tomorrow, aren't you? "Yeah. Do you think they could fix my ileostomoy site while I'm under?" You'll have to ask the surgeons, I say, knowing the answer is no. He's tired of the bag. Not because it disgusts him, but because he's been wanting to go for a swim, to roller skate, to fearlessly play basketball for these 25 years. "As soon as I can afford it, I'm going to treat myself to a breast lift" I laughed to myself, and thought I'd do the same for my own sagging breasts telling her she was beautiful and complete in her forty year old body. The words stay with me longer than expected. I toy with them late at night while waiting for sleep. I don't know what to do with these stories and lives I feel have undeservedly fallen in my lap. At times, I give in return my own humanity, selfishly and awkwardly. Other days, I hand the words back, Barely seen or heard, wanting only problems I can name and cure Author: Jessica Small, MD The Anesthesiologist (Prose: Second Place Winner) I don't know why they never had children. I can piece together their story in my mind, from the bits she told me, from the pulmonary fellow who took care of them for two months, and much from what I imagine. She must have been tough as nails to make it in an all male world of medicine I really can only imagine. Maybe they met at a conference. Or maybe one of her fellow Vienesemen introduced them. A famous anesthesiologist from Hungary. That I learned from the nursing home face sheet that gave his vital information. A niece in Maryland. A wife, Dr. Greta. A phone number, a contact person, an address. And here he is now, a hundred blocks north of that address, their apartment, and the other ICU he left only a week ago. It's hard not to think of how many A-lines he must have put in, as we stick and stick his pulses, futilely trying to thread a catheter over a wire. At the end of the day, he would change out of his scrubs--always spotless, even after the messiest case. He would leave the main entrance of the hospital in his jacket and tie, hat tipped slightly to the left, and greet passing colleagues and the man he bought the paper from every morning, as he headed back toward their apartment. She spent the day seeing the children of their friends and neighbors, prescribing glasses, drops. Always giving her opinion of a boyfriend or a school, or a blouse. There is a wonderful program on tonight at the symphony. A prodigy; in from Italy. She tells her assistant as she puts on her coat. They must have made quite a couple at the Opera or Philharmonic. He never could stand the Ballet. When their niece came in from Maryland they would see the latest show, go to a fine restaurant, and dine with colleagues and friends. In her own, second-generational way, she too is proper, just so, and just as successful. His wife will tell you of her high university post, of her responsibilities, her honors. But she isn't their child. She is in Maryland. She wants us to place a chest tube. She is not here. His wife is here. And yet, she should be with her husband, the Famous Anesthesiologist. At the opera, out to dinner, dancing. Anywhere but the ICU. Anesthesiologists know critical care well, but ophthalmologists rarely visit the ICU. Maybe it was because of their professional drives, their focus and their love of the life they led together; maybe that is why they didn't have any children. She must have been tough as nails to make it in medicine when she did. He must have been tough as nails to make it to 90 years with her. But she nourished him and he nourished her. She is the one keeping him alive now. I can understand how she can't see surviving him. Two elegant, proper, tough cookies. How could they be apart. Part II It was easy to write about their life. The day after I admitted him, I was so disturbed, I had this knotted feeling inside my stomach. I came home and wrote about their life. But after she made him DNR, and after he died, I didn't have that twisted feeling inside me like I had had 11 days earlier. I knew the stories she had told me, and the stories I had imagined, but still I needed to write about what had happened inside the ICU. I admitted him 11 days ago. That was 7 days after he was discharged from another hospital, to the nursing home that put him in the territory of our ICU. The call from the ER made us all roll our eyes. Nursing home resident. Vent dependent. Ugh. Does he need to come to the ICU? He looks like death. Then I met his wife. Her thick Austrian accent, her pocketbook, her Bergdorf Goodman shopping bag. A small lady, but a lady not to be ignored. She told us about his pleural effusions, his infections, his tracheostomy. Suddenly she clenched her fists and squeezed her eyes shut. Are you all right? I have supra-verntricular-tachy-cardia, pronouncing each syllable. We felt her pulse. Do you want to be seen by a doctor? She continued to bear down. We felt her pulse again; she had valsalva'd herself out of it. A few hours later I reached the pulmonary fellow who had taken care of him for two and a half months. She filled in the details of his metastatic cancer, his infections, hemorrhage, respiratory failure. His wife had fought the discharge to the end, she questioned every medicine and treatment, swallowing up hours of the team's time. But please remind her to go to that doctor I gave her the name of. And please give her a hug for me. I don't know who his time in our ICU tortured the most. He got arterial lines, venous lines, foleys, blood draws, pleural taps. His lungs were drained of their fluid, and filled up with fluid again. He barely had any oxygen in his blood, even on 100% oxygen, and his heart kept on beating. The team discussed it every day on rounds. There is no point. We aren't doing anything. I hate going in there. We followed numbers in circles. If one was low, we raised it. If one was high, we lowered it; if we could, which most of the time we couldn't. Thankfully, discussion on the chest tube faded after the first few days. We'll just continue chasing numbers, doing nothing, but doing too much, until his wife finally lets go. And his wife. With her never-ending questions, her thick accent. But what about the pulse. What is his oxygen saturation now? At the other hospital his blood pressure was always 100. Shouldn't he get a little digoxin, he was on digoxin at home? I tried every tactic, every answer. But her questions really had no answers, certainly none that I could think of. And so I spent hours on the phone with her, trying to explain the gravity of her husband's condition. And so she came in, and she called on the phone. She traveled from their apartment on the other side of the city, and she stroked his head, and gave him kisses, and called him her dear. And she asked and asked, What will I do without him. What will I do. And so we kept on poking and testing, infusing and treating. Until there was nothing left to treat, and the machine was breathing for him, and he no longer moved, and drugs maintained his blood pressure, and his kidneys were failing, and his liver was failing. And still, what will I do without him. And finally their niece came in from Maryland. And she cried with his wife, and saw that he was gone, but was still here in our ICU. And the attending, who so dutifully had cared for the patient and his wife, spoke with them both, and told them this was the end. The medicines aren't working. But still, what will she do without him. And I talked with them both. And the niece cried, and the wife stroked his head. And the machine breathed for him. And the blood pressure medicine was raised and raised, but his blood pressure continued to fall, so we stopped raising the medicine. And he didn't move, and his lips were dry and cracked. And I told her to think about her husband, how he had cared for his patients, how they had lived their life together. How this was not her husband. And she told me how he was a sculptor and violinist, how their apartment was filled with his works. How he loved classical music. He was the first anesthesiologist to put his patients to sleep with music. So I took the clock-radio from the clerk's desk and put it in a bag to protect it from his multiply resistant infections, and I went into his room and plugged it in, and put it on the floor, and turned it on. And the Bach or Brahms or whatever it was played in his room. And she stroked and stroked his head and gave him a kiss and left the room. This is the end. Yes, this is the end. It's over. Yes. And she signed the DNR, and she gave me a kiss. And I said goodbye to his wife and his niece, and they left the ICU. And I sat there with my medical student, and an hour later we stood up and went into his room, and we watched his pulse on the monitor. 60. 40. A few beats, then none. And we stood there. That's it. That's it. The famous anesthesiologist from Hungary, husband of the famous ophthalmologist from Vienna. Author: Miriam Hoffman, MD Chief Resident Columbia University Family Medicine Residency NY, NY Could You Know? (Second Place Winner: Poetry) Baby, who are you? Could you know anything about the life you would have, or wouldn't have, outside your mother's womb? Could you know of your mother's anguish or guilt during her time of carrying you? Would you ever know that you were an "accident", then accepted by devout parents? Then the anguish when your doctor and parents learned you were not wholly formed? Without a brain you would never know these things, but could you sense? When you moved your arms and legs and spun around, could you know the confusion and denial your mama would feel? How she would disbelieve her doctor, miss her appointments. She didn't want to abort you, nor bear you. She blamed herself; your father blamed her, too. They blamed your doctor together. Could you know the day of your birth? Warm and wet inside your mother, swimming in the dark comfort; could you hear her heartbeat? Nourished by her blood could you know you wouldn't be nourished by your own breath, couldn't be nourished by your own blood? Finally you were born, face first. You went to your mother's chest. Your father gazed at you, touched you. The chaplain baptized you with water, but you were baptized too, by the tears of the chaplain, the doctor, the nurses. All Saint's Day. You were loved. Author: Colleen Fogarty, MD Boston Medical Center Department of Family Medicine Boston, MA The Things I Carry (Prose: Third Place Co-winner) A worn black leather bag sits on a shelf in the rear of my closet. It is a doctor's bag, and my grandfather carried it for nearly twenty years, caring for his patients in their homes. Its leather is dry and cracked and the key to its tarnished brass buckle was lost long ago. My father used to keep spare electronic odds and ends in it. If you ever needed a speaker wire or a camera battery, chances were you might find it in the bag. When I was accepted to medical school my father cleaned the bag and gave it to me. I accepted the gift with gratitude, but in my mind I categorized it with the faded antique copy of Netter's anatomy on my bookshelf: both seemed relics of a time gone by, of interest to a historian but not very relevant to medicine today. So that summer the bag took up residence in my closet, and it stayed there through all of medical school, while I memorized biochemical pathways and struggled to bring myself to violate the flesh of a cadaver with my first halting incision in Gross Anatomy lab. The bag never moved through my third year of studies as I woke at four to pre-round on surgical patients or as I experienced my first delivery on the obstetrics service. One afternoon in my last year of residency I was busily looking over job opportunities (1:6 call, salary guaranteed for 24 months) when a local ENT paged me. He had just diagnosed a patient with advanced, inoperable squamous cell carcinoma of the larynx and she had no primary care practitioner. Would I see her in the hospital and assume responsibility for her? Then he told me a little bit about the patient. She had schizophrenia with paranoid delusions that kept her from seeing a doctor about her multiple medical problems. She smoked three packs of cigarettes each day and had visited the emergency room five days earlier when the pain in her throat became unbearable. The ER physician sent her for laryngoscopy, but the police had to be called to cajole her into keeping her appointment because she so feared leaving her home. The more I heard, the more impossible my task seemed. How could I possibly help this woman? I first met her that day in the hospital. She was still groggy from the anesthesia but seemed far different from her description. She spoke to me softly and helpfully discussed her condition with me. We agreed that she would come to my office in a week. I asked one of my faculty mentors about her. I described her suspicion, her cancer, and her poverty. He looked at me quizzically when I told him she would be in to see me later. "Why don't you just plan to visit her at home?" he asked. My patient arrived later that day with her caseworker and I described that plan to them. "You mean you could just come to my house and see me for checkups?" she asked, incredulous. "Really?" She turned to her caseworker inquisitively, as though she though we might be making a joke. Finally, she accepted my offer. "That would be wonderful," she sighed. That night I retrieved my grandfather's bag from the closet and filled it with things I might need for a house call. I went to her home a week later. She lived in a small house behind the YMCA on the top floor. I ascended a staircase that managed the seeming impossibility of being simultaneously vertiginous and claustrophobic. Finally, I reached her door: 5B. I knocked. She greeted me warmly and I followed her up another staircase, this one even narrower than the one in the hall. A snow globe sat proudly at the top of the stair on a low wooden box. Inside the glass was a miniature replica of the Statue of Liberty, and a small brass plaque on the base was inscribed with the words "New York City." Grace led me to her kitchen table. First we talked about her pain, discussing analgesic options. Later she told me about her family, and about her new caseworker. She brought out her photo albums, telling me about her estranged family. Grace offered me coffee and then demonstrated how she could prepare food in her tiny kitchen without ever leaving her seat at the table. She smoked constantly while I was there. I noticed her hands trembling as she brought the cigarettes to her lips. Over the next few weeks we became friends, and I learned about the rhythms of her life. I followed her to the drug store around the corner and watched as she bought an entire weeks' supply of groceries from the Revco's sole snack aisle. Each visit she told me even more about herself and she never tired of chiding me for not drinking her coffee. "It tastes too strong!" I always protested. One night that spring I was finishing up with Grace when she put her cigarette down. She looked over the rims of her glasses at me and I saw her lip tremble. "I know that I will die soon," she said. "I'm really not afraid. It seems like the right thing for me now." She laughed softly. "Someday you'll understand." Grace was right; she died in her sleep the next week. The Hospice worker called me to Grace's apartment that morning to certify her body. As I walked up the stairs to her tiny home for the last time I carried my grandfather's bag in my hand. Inside it, jumbled with the stethoscope and the reflex hammers, lay a connection to my past and a promise for my future. I sat down at Grace's table and drank a cup of coffee to her memory, black. Author: James L. Glazer, MD Resident Maine/Dartmouth Family Medicine Residency Augusta, ME Her body is in ruin (Third Place Winner: Poetry) Her body is in ruin A city nearly uninhabitable. Newark comes to mind. But, to be fair, Perhaps ancient Athens or Constantinople. She stares out of dark blue eyes Looks out from under somehow Her expression clenched like her hands Her knees polished spheres on wires Backbone a sickle. Her abdomen another smooth roundness Breasts folds of flesh over boney ripples. She tries to speak but her mouth is full of eggs served an hour ago. A touch on her shoulder produces only wider eyes An upper denture falls across a capital O. A stuffed bear sits on her table Surveying all of this. It's eyes are bright, its smile stitched It's paws clench a card "Dear Mom," it reads, "Get well soon." Author: Scott Paist III, MD Lancaster Hospital Family Medicine Residency Lancaster, PA Terror on the Home Front (Prose: Third Place Co-winner) I have spent most of my life trying to prevent violence. My story began when I was young. Sixteen years old and pregnant, I married and left home with a few dollars in my pocket and great hopes for my future. My husband didn't start out being abusive. He drank a lot of beer, but so did most of the men in the small midwestern town where I grew up. After I finished 10th grade we left for the mountains of Colorado to pursue our dreams, or so I thought. The life I had hoped for would soon become a nightmare. My husband's physical assaults started several months after leaving home but I had lost contact with my family and there was nowhere to turn for help. Five or six months into my pregnancy, we found a public clinic and I went to see about my unborn child. The doctor examined me, found an interesting heart murmur, and called in his training physicians. Everyone listened for the murmur in my heart, but no one listened to my pain or thought to ask why a pregnant, 16 year old, young woman with no family was seeking care in a public clinic. That afternoon I left the clinic feeling proud of my healthy pregnancy, loving the idea of becoming a mother, and fully expecting that my husband would be excited about the news. As I stepped up into our old, beat-up pickup truck he started to look strangely at me, often like he did before the beatings began. Nervously I said, "What? What's wrong? The baby is fine." Before I could move, I remember him slapping and punching me, over and over again, crying out obscenities and derogatory terms about me all the while. "Why were you there so long?" he screamed. After he stopped, I thought it would be the last time that something like that would happen. I believed that the abuse would end, that my husband would get better, and somehow, miraculously, it would all work out and life would go back to normal. Instead, it was just one more episode in an escalating pattern of violence that would last several more years, and that could easily have taken my life. We were lucky. My son and I eventually escaped. I had reconciled with my family after my son's birth. They gave me a roof over my head and food to eat, a sense of security that I had not known for several years. But the road back to life was long and slow. Worst of all was the emotional damage. I had completely lost my sense of self worth and belief in my own abilities. I remember watching a group of young people working in a fast food restaurant, envying their jobs as they laughed and talked together, wondering if I would ever be able to work. It was as if there had been no boundary between my husband's ugly accusations of me and what I had known of myself before this all began. In vulnerable moments he had broken open the innermost part of my being with his cruelty and I began to believe his repetitively degrading comments. I felt permanently tarnished. Somehow I went back to school, found childcare at a charitable organization, and got a part time job. Taking the GED course wasn't so hard because I'd been a good high school student but starting out in college was not easy: it was terrifying. I had to take remedial courses, one in math. A group of guys sat in the back row of the class, laughing about how easy the material was. I hated them as I sat in the front row taking notes furiously, struggling with concepts I'd never seen before. I'd forgotten how to think. Gathering my strength slowly, my talents blossomed in the nurturing environment of a university town. I knew that I wanted my experience with domestic violence to somehow make a difference, to prevent the same thing that had happened to me from happening to others. In a million years, I would not have imagined becoming a doctor. My grandfather still teases me because when he suggested that I apply to medical school, I told him that I was not smart enough. He told me then that I was wrong, and thank God, I believed him. I have since dedicated my life to domestic violence prevention and intervention as a family physician and clinical researcher. My terrorist was personal, a perpetrator of domestic violence (a term I learned many years later). Domestic violence is premeditated pattern of personal torture. The terrorists of the women I serve are their loved ones, those most closely related, intimate partners as it is now called. There are parallels between this intimate terror and the political terror perpetrated against whole societies. Until September 11th, those of us in the US had no idea how it felt to be terrorized as a society. Similarly, survivors of domestic violence have no idea of what can happen, how a once seemingly normal relationship can lead them into being hopelessly trapped, and how the person they love could feel justified in committing acts of personal terror. Like the assailants from the attacks on the US on September 11th, many perpetrators of personal violence don't believe they've done anything wrong. It is striking how after committing an inhumane act they speak in ways that justify their actions. They often believe the violence was necessary and unavoidable: They were provoked; they needed to keep the situation under control; the victim needed to be taught a lesson; it was the only way to keep the status quo; she was getting out of hand. I thought of Raskolnikov in Crime and Punishment who believed that "his design was not a crime" before murdering the landlady. He was doing society a favor by removing her. I remember my husband holding a gun to my head, telling me that his violence was my fault. On the news the night of September 11th I heard a weary N.Y.C. fire fighter ask with all sincerity, "Did this really happen?" I know that feeling, when nothing makes sense any longer as if it's not really happening. More than a little teary eyed and with a swelling in my chest, I thought back to the young woman who started out with that feeling more than 25 years before. She could not have dreamed of my future today. While the wounds from my past may never disappear completely, my scars have become a source of power and strength, a fortitude that has transformed my own life and helped many others in the journey back to life after domestic violence. My personal overcoming has contributed to the lives of hundreds of women and to a research agenda aimed at improving the health and wellbeing of survivors of domestic violence. Terrorism is terrorism on all fronts. Domestic violence kills, it hurts, and its damage is long lasting. Nevertheless, the difficulty of this and other violent experiences can bring out the best in us, despite, or maybe because of the intensity of the tragedy. My hope is that as individuals and as a society we will use our experiences with violence as an awakening, a process for overcoming, a touchstone for growth. My prayer is that we will find the courage to transform our personal and collective pain into a powerful force of change that will one day create a future free of all violence and terror. Author: Mary J. Glazer, MD Albert Einstein University Department of Family Medicine and Community Health Bronx, NY