The Best of…. Creative Writing by Family Physicians 2004 Award Winners Presented at the 2004 STFM NorthEast Region Meeting By the Family Medicine Education Consortium www.fmec.net Sponsored by the Family Medicine Education Consortium The FMEC Creative Writing Project In 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 Practice clinicians in the northeast region of the US were eligible to participate. * Stories, poems, and other forms of unpublished fiction or non-fiction writing were welcome. * A panel of reviewers composed of Family Practice 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 Project 2004 Review Committee Julie Schirmer, MSW (Chair) Maine Medical Center Family Practice Residency Portland, ME Bertie Bregman, MD Columbia University, Center for Family Medicine New York, NY Andrea Gordon, MD Harrisburg Hospital Family Practice Residency Program Harrisburg, PA Paul Gross, MD New York Medical College Department of Family Medicine New York, NY Craig A. Irvine, PhD Columbia University Center for Family Medicine New York, NY Ms. Courtney Spencer Portland, ME Steve Williams, PhD Harrisburg Hospital Family Practice Residency Program Harrisburg, PA Administrative Support Laurence Bauer, MSW, MEd Ms. Lisa Schwieterman, CPS Ms. Diane Guernsey New York, NY Questions about this project can be Directed to Julie Schirmer, MSW at schirj@mmc.org or Laurence Bauer, MSW at Laurence.bauer@sbcglobal.net The Best of . . . Creative Writing by Family Physicians 2004 Award Winners Table of Contents Page Prose Winners 4 - 8 1st Place: Cancun . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2nd Place Tie: What do you want from our village? . . . . . 5 2nd Place Tie: Delusions of Grandeur . . . . . . . . . . . . . . . . 7 Poetry Winners 9 - 11 1st Place: The Plunge . . . . . . . . . . . . . . . . . . . . . . . . 9 2nd Place: Advanced Maternal Age . . . . . . . . . . . . . . 10 3rd Place: The Most Beautiful Word . . . . . . . . . . . . . 10 Prose 1st Place Winner: Cancun Mrs. Cunha is a hospice patient. That is all I need to know about her. In a hurry, I pulled her chart down off the rack and read the first sentence in the triage nurse’s Catholic-school handwriting (“84 y.o. hospice pt with mental status changes”) and stopped. There was more, but it didn’t matter. Hospice patients don’t come to the ER, so I can get her out of here quickly and clear the bed. She is parked on the last gurney by the door, a frail little lady with steel-wool hair and a face as fragile and translucent as bone china. The hollows under her cheekbones create bluish shadows and her clavicles leap out at me in stark relief. It has been a while since Mrs. Cunha ate anything solid, I am sure. A finely crocheted blanket is spread carefully over her knees. The brilliant white of the hospital sheet peeks through each lacy loop. There is a man with her who at first I take to be her husband but then, recalculating ages, I realize must be her son. He holds a sturdy pottery mug that says “Cancun” down the side, the liquid in it long since gone cold, but he is clearly unwilling to put it down, even to shake my hand. He sees me coming now and moves out beyond the bed to intercept me, so he can talk privately to me without his mother hearing. His hands, even holding the mug, are shaking. “Doctor,” he greets me, not needing to know my name. “My mother’s very confused. Something happened today. You’ve got to help her. She thinks I’m going to kill her.” “Okay,” I say in my most soothing voice. “Let’s go sit down somewhere for a second and talk. Mrs. Cunha?” I reach around him to pat her ankle. “We’ll be right back.” She looks me dead in the eye. “I want to go back home, you know,” she says. “I’m not staying here.” “I wouldn’t want you to,” I agree; the idea is that hospice patients generally want to die at home, and therefore don’t usually come to the hospital when they get worse. At least she hasn’t changed her mind. There is nowhere to sit, so Mrs. Cunha’s son and I stand in the corner of the hallway and he tells his story in an urgent whisper. Next to us in the hall is a woman who’s probably been beaten up by her boyfriend, blood seeping into a towel pressed to the side of her battered face. She is calmly trying to disengage her earring from her free ear with her other hand, but her eye is swollen nearly shut so she has to do it all blind. Mrs. Cunha’s son’s eyes keep straying to her with a mixture of pity and disbelief, but he neither addresses her nor suggests that we move away. Here is the story : Mrs. Cunha has had metastatic breast cancer for three years. She and her son share a sunny apartment on the second floor of an old house in Fairlawn, and she spends her days on the couch watching game shows and drinking tea. This, apparently, is what is in the mug he holds. She has always been lucid and never complains of pain. This morning, when her son went to get her out of bed, she was crying. “My head hurts so much,” she told him. “That man banged it last night.” Later, enthroned on the couch, she looked up to where he was chopping vegetables on the cutting board for her homemade chicken soup and said, “Why don’t you use that knife on me?” I imagine the scene, frozen : the son poised to decapitate some celery, slowly raising his head to look across the room; the mother tucked in under her afghan and lap robe. “What?” he says he asked her. “Why don’t you just kill me now,” she said. “With the knife. It’s quicker.” He looks at me imploringly, this man who has gone from being a computer salesman to a stay-at-home caretaker, who has learned to make chicken soup, lift his mother into her chair, witness her daily diminishing in front of his eyes – weighing less with each hoist, sleeping less with each week, and now today, for the first time, allowing herself to crack. He went into the bedroom to get his car keys so he could bring her here, he says, and this is what he saw : an old man who is not strong enough. I can’t do this, he says to me, quietly, so she won’t hear. His fingers grip the mug so tightly I am afraid it will break. Can’t you make it so she’ll be like she was? So she won’t be confused? 4 I look at him for a long moment, wishing I could. “You know I can’t,” I tell him. “I’m sorry.” He nods quickly, like he’s sorry he even asked. “Let’s go see her,” I say. Mrs. Cunha sits regally upright, her fingertips bluish, her skeleton prominent under her skin. It won’t be long, I think, but I don’t tell her son this. After talking with him, I am not sure he would find any comfort in the prediction. “Everything hurts me,” she says distractedly. “I’m sorry to complain, but I just don’t feel good. I just want to go home and fall asleep and not wake up.” Her son, across the gurney, is staring silently at her, the hospital’s fluorescent light reflected in a glimmering tear snaking down his cheek. He takes her left hand, and I take her right, and she looks back and forth in a calculating way, trying to determine which of us can grant her wish. Joanne Wilkinson MD, Narragansett, Rhode Island ???????????????? Prose 2nd Place Tie: What do you want from our village? Rough hands scraped the nylon wall next to my head. I awoke to a soft voice loudly whisper, “Doctor! Doctor! Mi nina esta infermo! Por favor, doctor!!!” I roused from my sleeping bag and unzipped the tent door. A full moon illuminated a woman holding a child. The woman wore a tattered dress, layered with sweaters and shawls. Her arms supported a brightly colored, handmade papoose, in which lay a sick girl. My headlamp cast across the child’s face, revealing weathered, sun-damaged cheeks and a runny nose. The child stared blankly at the sky. Occasionally a raspy cough shook her body and showed strain across her face. She was not crying. The few medications we had were in our expedition’s first aid kit. The kit was mostly pain medications and first aid supplies, but we did have some old antibiotics. However these were in tablet form and adult strength. As I fidgeted in the dark with the tablets and a Swiss Army knife, the child had a coughing fit. It lasted a few minutes. By the time the toxic-appearing girl caught her breath, her lips, though sun-scorched and dry, were clearly blue. ? We spent the morning drinking fresh coffee and asking for seconds on omelets. We showered, got dressed and checked out of our rooms. Our outfitters carried all our bags, as custom dictates that loading your own gear is rude and implies that one’s “staff” is weak. We watched, lazily, as they lashed duffels of expensive gear and crates of food onto the top of three Toyota Land Cruisers. On the way out of La Paz we napped behind $100 dollar sunglasses and listened to personal CD players. Occasionally we would stop and take out our auto-focus cameras to take photos of the dramatic scenery. A colorful marketplace. A woman washing clothes in a river. Children playing soccer. The dusty road to base camp winds across the Altiplano, or “high-plain.” There’s very little water and not much sign of life, other than an occasional small herd of llama. On the horizon are the magnificent peaks of Bolivia’s Cordillera Real, our climbing objective. Over 20,000 feet in elevation, their granite shoulders are draped with hanging, blue glaciers leaking fine ribbons of meltwater from their snouts. The only settlement on this route is the small agricultural village of Chunavi. The entire town shares one car. It has no tires. There is no running water. One building is wired for electricity, but there’s usually no power. There are no phones. No doctors. No market. It is a cold, sad town, 15,000 feet above sea level with not a tree in sight to protect it from the howling winds that scour the plains on their way to the Andes. 5 We pulled off the dusty road, down an alley between two rows of crumbling, adobe homes. In the schoolyard patients were already waiting. They were all women and children. The women were dressed in ornate, colorful, traditional garb. They talked, breastfed or spun alpaca yarn while they waited for the clinic to start. Out of the school, which had been closed this week to allow its use as a medical clinic, came the village mayor. His face was badly scarred. He smiled and shook my hand. He spoke to me in Quecha, a pre-Inca language, which I did not understand. A high wall surrounds the schoolyard. It was cracked and dry, with the tails of reeds in the adobe mixture poking out between the blocks. A few blocks were missing, leaving a hole. Through the hole, I saw a group of men walking across the adjacent field and toward the school. “The village leaders,” Carlos, my Bolivian contact, whispered to me. They entered the schoolyard and surrounded me. Suspiciously, and through two translators, the mayor spoke. “What do you want from our village? Why do you want to help us? What do you demand in return?” At first I was surprised. I expected a warm welcome, not skepticism. Then, I glanced across the courtyard at our three shiny SUV’s, loaded high with gear and food. I looked at the work-hardened faces of the men who surrounded me. I looked down at my boots. I was embarrassed. “This is your land. Your mountains. Your Altiplano. We climb here. You live here. We are your guests, and would like to offer a gift. We bring a doctor, a nurse and enough medicine to treat your village.” The men mumbled, exchanged looks and broke out in laughter. They closed in on me and ruffled my hair. The mayor raised a steer horn and pressed it to his lips. He blew it into the sky. Within 15 minutes there were three hundred people in the schoolyard playing ball, chatting, waiting to see the doctor. The school was one room. It held two handcrafted benches and a table. The walls were adobe and the roof was thatched with reed. Carlos’ nephew, a neurologist from La Paz, was helping us with the clinic and translating. The two of us worked while giggling children kicked balls and drew with crayons in the courtyard. The “triage table” was littered with stickers and candy, brought by our team. Within a week we treated the entire town. Parasitic infection, fungal infection, tuberculosis, low back pain. Some things we could treat. Others we couldn’t. It was frustrating. As doctors we want to heal. We want to cure, but sometimes all we can do is examine and listen. Often pain control was all we could offer, and this was understood. They townspeople were incredibly grateful, often asking when we were returning. They hugged us and thanked us. Before we left, the mayor and his advisors again circled me in the courtyard. They presented me with an ornately decorated, notarized letter from the Government of Chunavi. Translated, the letter read “Your gift was like that brought to the children on Christmas. We feel like we have been visited by Papa Noel.” As we loaded into our trucks, one of the townspeople, Jose, approached me. He had walked six hours through the night to ask for our help. He urged me to visit his wife before I left. She was too ill to come to the schoolyard. She had been sick for a year and had never seen a doctor. We drove across the plains for an hour to Jose’s one-room home. We entered, walking past a rusty, tireless bicycle, a hitching post and a mule. In the corner of the room there was a tattered single mattress. Jose’s six family members shared this bed. It had no sheets. On the bed was a woman, lying perfectly still, wrapped in soiled shawls and blankets. She made eye contact with me and then looked away. I approached her. As I eased onto the corner of the bed the mattress shifted, moving the woman very slightly. She wailed in pain. As a tear ran down her cheek, her husband dashed to her side. In Quecha, he told me: “She went blind a year ago. Her arms and legs hurt so badly she can’t move them. She has trouble breathing and won’t eat. And this has happened....” He unwrapped her dry, cracked hands to reveal them. Her fingers were severely subluxed, characteristic of rheumatoid arthritis. As I gave her steroids and explained her disease to her, a gust of cold wind sliced through the house and rattled the uninsulated tin roof over the woman’s bed. ? After the clinic we sent all leftover medications back to La Paz to be donated to a hospital. I hadn’t anticipated a woman bringing a one-year old girl with pneumonia ten miles up the trail on a mule, through the night, to seek the help of the nearest doctor. Feverishly I crushed tablets and stirred Gatorade 6 mix to create a makeshift antibiotic suspension. We force-fed it to the child, gave a Ziploc bag of the concoction to the patient’s mother and crossed our fingers. The child stayed overnight at camp and was taken on muleback to town in the morning. A week later the mother reappeared, in the afternoon this time, with the girl in her arms. She approached me and held out her child. The young girl smiled and giggled. We plodded up the glacier as the sun rose over the Amazon Basin far to the east. It flicked orange light onto the summit of the peak across the valley. In the crisp morning air I could see each breath as I heard the metronome of my pulse deep inside my ears. I thought of the people on the Altiplano, already working in their fields. I pictured a sick woman on a bed. A woman washing clothes in a river. A rusty, tireless bicycle. And a little girl with blue lips. Brian Irwin DO, Maine-Dartmouth Family Practice Residency, Augusta, Maine ???????????????? Prose 2nd Place Tie: Delusions of Grandeur Somehow I always thought that if I were the first on the scene I would save the day - not in the hospital where there are residents, intensivists and cardiologists, but out in the real world. I half-expected for years to hear the urgent announcement “Is there a doctor in the house?” in a restaurant, theater or plane. I remember the chairman of our family practice department telling me when I was an intern how he had once saved a man on a plane with a chest thump. I never thought of myself as having delusions of grandeur. I simply thought that I would be able to do more than the average guy on the street would – and that more would make all the difference. So when my family and I came upon a middle-aged man having a heart attack near the top of Pike’s Peak, I grabbed my medical bag and almost eagerly jumped out of our van to help. The man’s twenty-year-old daughter flagged us down with one hand while the other clutched a cell phone. His wife and mother-in-law sat with him in the car. I was relieved to find the man alert and talking. But he was experiencing severe chest pain identical to the pain of his heart attack several years before. He was able to tell me his medications – Norvasc, Atenolol, Lipitor, Nexium and Aspirin - but he was lightheaded, nauseated, diaphoretic, and looked pale and gray. I could barely find a weak thready pulse. The family was reassured by my title, my old fashioned black medical bag and my stethoscope. The daughter reached 911 on her cell phone and was told help was on the way. While we waited, I had him take an aspirin. The man’s pain became even more severe, his pulse was no longer palpable, and his color looked worse. I felt useless. I looked at my black bag and felt embarrassed by my lack of preparedness. I somehow thought it would be like Mary Poppin’s carpet bag with its never-ending supplies. Where was my portable oxygen tank? My automatic electronic defibrillator? My CPR medications? I hadn’t even remembered my blood pressure cuff. Instead I packed like a family doctor and mom from New Jersey on a cross country vacation in a minivan – plenty of bandaids, bandages, a suture kit, antibiotic ointment, Acetaminophen, Tums, diphenhydramine, Zithromax, and an Epipen. I felt guilty that I wasn’t equipped like a rescue vehicle. After all, how could I presume to offer help that was somehow better than the ordinary citizen when I didn’t even come prepared with the right tools? A hailstorm with flashes of lightning began as the man started to lose consciousness. I stood there in my sundress and sandals and silently prayed for help. At that moment, a ranger vehicle arrived with flashing lights and an oxygen tank and I momentarily breathed a sigh of relief. But the news wasn’t good: the storm prevented a helicopter from landing at the summit and an ambulance would take thirty minutes to reach us. Our only option was to transport him down ourselves. Two rangers picked the man up and laid him in the back of their SUV. Then he coded. We were able to deliver only one shock with their AED but with no response. The rest of the trip down the mountain was a blur of hope, fear and sadness. The drive up Pike’s Peak in good weather was nerve racking. The drive down in a storm at forty miles an hour, in an SUV with its back door open, while doing CPR, was petrifying. 7 When the man coded, I started mouth-to-mouth resuscitation while waiting for the face mask and ambu bag. The feel of skin against skin, lips against lips felt wrong. Not because of the fear of disease or worry about delivering an inadequate breath but because of the impropriety of what felt like an obscene kiss. As we performed CPR, the man’s wife sat in the front seat alternately calling out my first name and the name of her husband. Stripped of my title, I felt exposed. The EMTs finally met up with us and initiated ACLS in the back of their ambulance en route to meet the helicopter near the base of the mountain. The helicopter transported the man to a nearby hospital. The wife was taken there in the ambulance. Still hoping to somehow help, I drove the daughter and the mother-in-law in their rental car. I agonized over whether to prepare them for the inevitable news of his death. We arrived as the emergency room physician was telling the wife the bad news. I left the family with their grief. When I walked out into the waiting room, my husband and three daughters had just arrived to meet me. They looked at me proudly waiting to hear the good news, only to have me shake my head and say he didn’t make it. I felt ashamed. That evening, it felt good to be surrounded by the warmth and comfort of my family, to hear their laughter and share our meal. But for hours after, the taste and smell of the man’s breath and aftershave lingered with me like a lover after an illicit tryst. During the eighteen-hundred-mile drive home, I knew that my husband was there to listen to me as he has been since medical school. But I needed the absolution of my colleagues. When I told the story to my partners, I said I felt terrible that I was not able to do anything to help the man. My partner responded that I did a lot to help the man but that he died anyway. When my daughter was two, she choked on a piece of bacon. My husband immediately called 911 and I performed the Heimlich maneuver. After several attempts and a blue limp child, the bacon was dislodged and she was fine. I never felt like a hero. I felt like a mother and a doctor doing my job. Yet when my attempt to rescue someone failed, I felt like a failure. I want to blame the man for driving to 14,000 feet elevation with a heart condition. I want to blame the dangerous road and the poor weather conditions. But in my heart, I blame myself and sadly know that I really do suffer from delusions of grandeur. Carla Jardim MD, Delaware Valley Family Health Center, Milford, New Jersey ???????????????? Poetry 1st Place Winner: The Plunge Meconium-stained fluid, a few decels Just another midnight delivery, I thought Stay calm The Muslim couple asked my attending, a man, to stay outside the labor room Banished to the hall, he coaches from behind the curtained door Finally, the birth, a boy Joy, and prayers made on his knees from the father The thin and twisted tether, fragile, refused to finish its final task Tearing, slowly shredding in my hand, forsaking the placenta A brief conference with the man behind the curtain Seeking answers like Dorothy in Oz And then, the plunge If this primip could endure labor without a drop of painkiller I could enact a rescue mission for the placenta, something I’d seen but not yet done 8 In to the elbow, scooping, separating, trying to remember to breath Now a death grip on that slippery sack, pulling, coaxing The cervix closing on my small wrist Fear that too much more will tear to bits The special prize the family will take home for holy rites The afterbirth comes, relief is born in me More profound than when the baby emerged It is a miracle! It is wholly intact The mother smiles. What a lovely birth she says, the next day Never knowing my fear, the courage it took for me to take the plunge Amy L. Lee MD, Tufts University Family Medicine Residency, Wilmington, Massachusetts ???????????????? Poetry 2nd Place Winner: Advanced Maternal Age Blonde helmet hair, she sits proud. The oldest mom I have examined – 43—“I missed my period took three pregnancy tests all negative, went on a cruise to Turks and Caicos, a mom’s thing we do you know, each winter, just us girls. And a young Mexican waiter said ‘You carrying something there?’ and he put his hand on my belly and Daisy my friend gave me the strangest look, staring at my stomach and I threw up right there.” Joanna Brown MD, Brown University/Memorial Hospital of Rhode Island ???????????????? Poetry 3rd Place Winner: The Most Beautiful Word I know the most beautiful word in the English language. You may not know it unless you too have waited to hear it Waited for hours, or days, or God forbid, weeks. I know it because when I heard it The world began to spin again, slowly, and on its axis. There was once again a tomorrow I could imagine As my deepest fears fell away. It revived my ability to dream And pulled me back from a premature glimpse of the abyss. If you hear it when everything you have ever hoped About the rest of your life hangs on it You will know it too, with the same certainty as I. 9 You will know it as it caresses your ear and its full meaning Registers in the back of your throat While the sweetness of it fills your being. I don’t know if the translation of this word is equally Beautiful in any other language on this earth, But I’ll bet it is. I know the most beautiful word in the English language. The most beautiful word is Benign. Catherine M. Weber PhD, University of Connecticut School of Medicine, Farmington Connecticut ???????????????? 10