Dreamgirl

Dream Girl

I had a dream last night. I stop the car I was driving at an intersection when three stray dogs dash across my path. The smallest dog, that looks like a dachshund or something, however, changes direction and leaps inside my vehicle. For a confused moment I couldn’t find it in my car and think that I may have been wrong, but then I spot it sitting on the back platform behind the rear seats.

I pull the car over and coax the dog out, and then the dream-thing happens where causality is sort of fluid or squishy, and I start driving after it or it starts chasing my car down this long, long hill towards a little park and community center.

And then it turns in to a little girl, with her hair in two little puffs atop her head the way I’ll sometimes do my own child’s, she looks vaguely like my own three year old only the skin on her face is puffy, red, and scaly from being exposed to the elements while living on the streets. The little girl in my dream keeps calling after me to give her “huggies”, which is the way my own child will ask me to cuddle her, but I keep running away from this dream-child, thinking to myself that I already have a little girl I love at home.

It was while I was evading this little girl that a swarm of wasps descends on the park we are in, scattering the grown ups and children who are at play, or sitting on benches reading newspapers. I’ve recently been dealing with hornets trying to establish nests in the eaves of our home, maybe that’s where this part of the dream originated. I start swatting the wasps away and now am running from them. As will happen in a stampede random groups of people start to run in unplanned tandem with others, which is how I found myself next to the little girl again, and now I can see more clearly her chapped, sun-exposed face, the same skin I had seen on the cheeks of street urchins in Kabul. She is crying, saying that she has an owie, a wasp had stung her little tongue, and one of the older ladies nearby stops her to look. We peer inside her small mouth and see that there is indeed a stinger embedded in the left front corner of her tongue, with a green colored envenomation spreading from it. One of us pulls the stinger out, and the little girl tells us that she has to tell her mommy about her owie, but of course, the dream-me realizes that she is a stray, she has no mommy to tell about her owie, and that’s when everything falls apart.

One of my favorite photos taken from my child’s birth in the hospital is one that represents one of my early attempts at parenting. We’d been told that skin-to-skin contact was best for newborns. My wife was exhausted and needed a break; our child had been born a tiny thing (our perinatologist kept referring, to our bemusement, to our developing fetus as a “dinky kid”), so I tucked her in to my shirt, and there we are in the picture, both of our eyes closed, her nestled against my chest in my shirt. I can’t imagine not loving this child as much as I do, her skin against mine.

I hug the little dream-girl to my chest, feeling her squirm away from me a little the way my own child does when I squeeze her too hard, and right before I awake I think, I can’t not do something, I can’t just let this child go with this owie, without a mommy. All day today, every time I look at my daughter I think about her as a little, motherless child, clever, articulate, injured, with no one who would hold her close, this girl alone, trafficked, used, not an end to herself, growing harder to the world around her, instead of the little baby I held, her skin against my own. I remember thinking about Louis C.K.’s quote that you don’t look in to your neighbor’s bowl to see if you have as much as they do, the only time you look in to your neighbor’s bowl is to make sure that they have enough.

I’ve been to some shitty places in the world and have been in some shady circumstances. There are people who have made some incredibly poor choices in their lives, fucking things up not only for themselves but also for entire tribes of people around them. But everyone began as a baby small enough to hide inside her father’s shirt.

After Newtown

I am a life-long gun enthusiast. Although my father never owned a firearm, some of my fondest childhood memories are of the avuncular Vietnam veterans letting me shoot their AR15s and 1911s at what was then an unregulated firing range in Lytle Creek Canyon at the east end of the San Gabriels. As soon as I was old enough, I started buying my own firearms, and I’ve had guns ever since. The stereotype of the firearm owner may be that of a bug-eyed, slavering fanatic in constant fear of black helicopters, pulling a trigger as rapid-fire as a gun will allow, but that cliché does not match the reality of the vast majority of American sport-shooters and hunters who, like me, have grown up with guns as a part of their daily lives.

I am also an emergency physician; as an ER doctor at the only Level I trauma center in Southern California’s Inland Empire I have treated hundreds of men, women, and children who have suffered gunshot wounds. Having seen it firsthand, I have learned to respect the destructive power of these weapons, including the guns that I myself own. In no uncertain terms guns are far more able to cause grave injuries than knives or other common weapons. Modern soldiers are sent in to combat with guns and not swords for a reason.

As an emergency physician I am on the very front lines of medicine and see how health care needs manifest in a community. Winters bring more cases of pneumonia. Surges in gas prices like the one in 2008 when a gallon topped $5 meant an uncanny decrease in the number of car accidents that summer. And firearms have been used far too frequently in the violence that has afflicted our communities. The recent spate of mass shootings in America has given further urgency to the need to have a discussion about the way we live with our guns.

As a gun owner I have skin in the game when the question of how we will address firearms regulation is raised. I value my right to own my guns and participate in the sport which I have enjoyed my whole life. But the majority of us firearms owners agree that in the wake of the mass shootings in 2012 alone, such as at Oikos University in Oakland, California; the Sikh temple in Oak Creek, Wisconsin; the movie theater in Aurora, Colorado; and Sandy Hook Elementary in Newtown, Connecticut, gun ownership, like any right, is not an unfettered one. Just as the right to free speech does not mean one may yell “fire” in a crowded theater, the right to own firearms does not guarantee one should have the means to commit a mass shooting in one.

The gun lobby has, with some success, been assiduous in its efforts to frame this question as a matter of the right to own firearms versus the abrogation of that right, which while raising tempers and inciting the passion of gun owners neatly sidesteps the real issue: the need for gun safety. Whenever the national conversation has returned to the question of gun safety, the National Rifle Association and its fellow lobbyists have instead blamed video games, indolent law enforcement, poor access to mental health services, etc., conscripting an army of straw men to divert the discussion to the false dilemma of gun liberties versus gun bans. Instead of taking this opportunity to engage in the gun safety debate, thereby helping shape this discussion, the gun lobby has instead chosen this answer: more guns, and more bullets.

Claiming that the only choice that can be made is either absolute prohibition or unrestricted access to firearms forces a false dilemma. The truth, of course, is that it will take an all-of-the-above approach – enforcement of existing laws, greater access to mental health care, an examination of our culture of violence, and yes, regulation, to prevent even more victims of gun shot wounds from entering my ER, and more national tragedies like the one in Newtown. The question we face as Americans, and as gun owners, is what we will choose in our communities: will we honor the lives of those twenty children by enacting common-sense, reasonable regulations, or will their deaths be remembered as sacrifices to the Moloch of the gun lobby’s relentless demands for unrestrained access to firearms?

Medicine and the Bodhi Tree

Once in a while, somebody will tell me that I have such a nice bedside manner, and for a long time I’d receive that kind of approval with a wince. I was mortified by the praise people gave me, and honestly, more than a little gratified too, because it really felt good to have nice things said about me, but mortified because that night, the one I’m writing about now, that night was a night of abject, miserable failure.

I was on another overnight shift as a senior resident, this time at the university hospital we worked the other part of the year. It was probably a Monday, since the beginning and end of the week tend to be the busiest, although nowadays it seems like every day is busier than the last, and the emergency department was in normal condition, that is to say totally FUBAR’d – ambulance gurneys lined the hallways holding patients in street-clothes, in house-robes, drunks in restraints, the paramedics who had brought them chatting with each other while waiting to be told what bed to take their charge to, the firemen’s yellow jackets smelling faintly of smoke.

Since I was the senior resident on duty, I had the responsibility of the entire department, with nurses pulling at me from all sides, medication needs, test results, consultant problems, new patients. Every time I’d leave the desk to go to a patient’s bed, to the x-ray room, to the bathroom, a crowd of RNs would swarm behind me – picture a deer followed by a pack of wolves, a pack of wolves wearing scrubs and holding clipboards.  One nurse told me that there was a new patient in Bed 1, an 18 year old girl who had chest pain and a high heart rate. Yet another patient.

Every time another nurse popped up with a question or request I’d frantically fire off the first thing that came to mind while I moved on to deal with the next one. I asked the nurse for Bed 1 to get an EKG and told him I’d be there shortly – I was relieved that he seemed satisfied with having something to do, which would hopefully buy me enough time to attend to yet another high priority. But just minutes later he handed me the patient’s EKG, which showed a heart rate of 135 – that really was fast. Not too fast, but faster than it should have been.

I finally made it to the patient’s bedside – the nurse had told me that she’d been complaining of crampy chest pain while out line dancing.  What an odd detail to add, that she had been line dancing, apropos of nothing. The girl was sitting up in the gurney, her eyes squeezed shut against the pain. She was pretty? I don’t remember. She seemed young. Dressed to go out. Perhaps I should stick with the details I received in her autopsy, later: “this is the nude body of a well-developed, well-nourished young adult female appearing consistent with the stated age of 18 years. The length is 165 cm, the weight is 62 kg. The hair is black, the eyes are brown, and the complexion is fair. The body is not embalmed. Across the right medial ankle is a small tattoo of a heart. The finger nails are painted red.” I was able to get out, “I’m Dr. Kim, do you have chest pain?” She replied, “my chest hurts,” when she had a seizure.

On t.v., when actors have seizures their eyes kinda roll back and their limbs start sort of flopping around, and that’s how you know that it’s supposed to be a seizure. In real life, though, it’s the most uncanny, unnerving thing, it’s inhuman – her eyes were still open, but they looked like they’d lost the animus behind them, the rational personality who had until then been a girl out with her friends just disappeared, and all that was left was a machine, an automaton in the shape of a human being but without human thought or feeling. Her head twisted to the left, her eyes open, staring at nothing. Her mouth twisted and foamed. Her limbs involuntarily contracted, shook in a way that is impossible to do consciously, a marionette with its strings twisted, and then dropped down when she fell back in to the gurney, unresponsive, gurgling noises coming from her throat. Putting the head of the bed down, I pled for the nurse to get an attending physician, quick – I figured they might want to know that I was intubating someone – that is, putting someone on a ventilator.

Dustin, who was chief resident when I was an intern, and was now an attending, materialized at the bedside.

Before we intubated, the girl had another seizure. We let it pass, and then put her on the vent. Things spiraled. Her blood pressure started dropping precipitously. The patient’s friends and father arrived, and it turned out that her mother had died the year before from a brain aneurysm – the patient was the only family member her father had left. Dustin and I had a rapid-fire discussion about what the patient could be suffering from, while ordering IV fluids and medicines, our arms crossed, faces tight. “What do you think it is?” “Bolus one liter, start a second line and start another bolus in that one.” “All I got was chest pain while line dancing, tachycardia, then this.” “Is her sat dropping? Can someone fix the pulse ox?” “Pneumothorax? Doesn’t seem the type. Chest x-ray’s cooking.” “Can someone please start the fluids? Call blood bank – O neg.” “Tamponade?  No history. MI? Unlikely. Aorta? She doesn’t look Marfanoid. No history.”

We placed large intravenous catheters and resuscitated the patient – she went into cardiac arrest several times, and we kept bringing her heart back, the number of techs and nurses in the room growing, frantically performing CPR, calling out orders, voices strained. It’s always hard when someone’s dying, tougher still when she’s so young, and even more difficult still when she’s the only child of a widowed father standing in the hallway, standing quietly, alone, head down, arms crossed.

During one of the episodes of arrest we discovered that she was, curiously, bleeding inside of her chest. It’s often common procedure in these resuscitations to “needle the chest,” that is, place large catheters in the chest wall to relieve pressure that builds up inside the thorax. I sloshed maroon-colored iodine solution just under her collarbones and slid the needles in place, first on the left side, then on the right – what the fuck? Blood started fountaining out of the right needle, a freshet pulsing out of the catheter with every chest compression. I placed two chest tubes to drain the blood. The presence of that amount of bleeding inside the chest can actually prevent proper circulation, and part of the treatment is to drain the fluid off. The blood drained… and drained… and drained. The girl had already received several transfusions, and we started transfusing back the blood coming out of her chest, and it was clear that she was bleeding to death.

We called the chest surgeons who we learned were in the middle of a thirteen-hour heart transplant and therefore unable to take this patient to the OR – she was too unstable to be taken anywhere anyway, and anything resuscitative would have to be done in the emergency department. The girl kept going into cardiac arrest, had done so five or six times already, and opening her chest in the ER to stop the bleeding was probably futile, but come on – she was 18. Her father alone… You could feel a raw, anxious energy in the room, everyone felt helpless but we had to do something, everything, anything. But without someone to take her to the OR afterwards, there’d be no point to trying to stabilize her in the ER. Dustin called the trauma attending, Dr. O – as a trauma surgeon he’d be the only other doc in the hospital who would routinely know what to do with a cracked chest. An older Irish man, with a thick accent, he was infamous for being so compulsive that he’d often round until midnight, unheard of for a surgeon, but someone totally committed, so committed that he agreed to come in for this patient, appearing at the bedside when I had the knife poised above the girl’s skin.

We cracked opened her chest, first the right side, then extending the incision to the left, opening the chest to access the organs. Scalpel on skin, curvilinear incision, straight through yellow fat, down to muscle. Scissors in thorax, gloved finger guiding, zip through the intercostals. Weighty stainless steel rib retractors, wedged in placed, cranked open. So strange – for a young, otherwise healthy woman, the body would be a secret, the breasts an intimacy hidden from the view of strangers like us, but in the moment, there was nothing particular about her chest, just that we had to open it. It’s funny – I don’t remember much of what her face looked like, but I remember in intimate detail her thoracic cavity, the surfaces glistening with pleura, the individual articulated spinous bodies, her spongy, pink lungs, and everywhere, everywhere, blood, a rising tide of blood that we would suction away only to have it fill right back, ebb and flow. It was like something had exploded in there.

Her heart was flat. Imagine, if you would, the heart roughly like a water balloon, one that actually pumps blood around the body, so it expands, contracts, expands, contracts, but it’s always got something in it, a water balloon made of muscle. Her heart, however, was an empty balloon, nothing in it, all of the blood that was supposed to be filling it seeping in to her chest cavity instead. Her heart was a flat meat balloon. Blood, or at least what was now pinkish tinged fluid having been diluted with all of the fluid we had tried to replace it with, kept welling up from somewhere, more blood than anyone in the room had ever seen come out of a chest, blood from nothing that we could clamp off and prevent her death, and we were at a loss, Dr. O turned to me and stripping off his gloves said, “well, Tae,” in his thick Irish accent, “I tink we’ve dun all we can,” and we called it, my arms were up to the elbows in her thorax, blood was everywhere, and it was done. Later, we’d learn from the autopsy that she’d died from a thoracic aortic dissection, the same thing that later killed John Ritter, rare, unusual, a unicorn of a diagnosis, especially for someone so young.

We covered her up. You may think it’s a cliché, but we really do use a white sheet. I remember Dustin talking to her father in the hallway, the man quietly listening to the news. Dustin found me at the desk, “hey man, here’s the key to my office. There’s some caffeine in the fridge, take some time for yourself.” Okay – wow, that was some traumatizing shit, that’s a good idea. I sat in his office by myself – okay, I’m processing things, that was kind of horrifying, but I’m okay… no, really, I think I’m okay. I’m sitting in Dustin’s comfortably padded office chair, staring at the white door. I can hear housekeeping vacuuming the floor down the hallway. There is a fake potted plant in the corner. There are pictures of Dustin on various trips abroad lining the shelves. My right hand, wrapped around a can of soda, is starting to feel cold and numb. All that comes to mind is the stack of fresh charts piling up in the rack, patients waiting to be seen.

I forced myself to sit there for a full five minutes, checking my internal state to make sure – no, I’m okay. I’m alright. I quickly dictated a note, and then got back out into the ER, spending the rest of the night taking care of the patients who’d waited while we treated the girl.

Things never slowed down that night. Trotting back and forth, I kept spying in on room 1, where the girl’s father was sitting by her bedside, quiet, back turned to the door. He sat there the rest of the night. With all of the hubbub gone, I could finally see him. Brown hair, medium length. Jeans, denim shirt. His face was sad, thoughtful. I moved on to the next patient.

I have difficulty gauging how long to make eye contact when I talk to people. Fact. I’ve realized that I’m either always glancing away, or that I’m suddenly staring straight in to the other person’s eyes, and it’s only when I start noticing their discomfort that I catch on. There’s more: between, I think, 1984 or so and 1992, I could name every single car sold in the U.S. by make and model, name their fuel type, engines available, displacement of said engines, number of valves on the drivetrain, overhead cams or pushrods, interior options available, colors, pricing, and eventually I went on to do the same with motorcycles. It’s not that I’m Rainman or something, and every so often someone really does tell me I have good bedside manner, but people imagine Marcus Welby and what they get instead is me. It’s little wonder that I’m good at the sciences and that I sometimes make people cry when I talk with them because feelings… fuck it, let’s just say it’s because I can list exactly why Betamax was a better standard than VHS.

I couldn’t muster up the courage to talk to him; I couldn’t walk up and, oh, I don’t know, say something, anything. What do you say? Man, sucks that your entire fucking family’s dead, tough times, bro? I kept silent, secretly peeking into the room, the girl’s father still and quiet, that night still and quiet in my memory.

It’s been a few years now and since first writing it down I’ve struggled over how to end this story; maybe I didn’t have the maturity or the ability to articulate what I experienced. I’ve tried a number of different ways to conclude it with some kind of meaning. In one way I guess you can think of it as a cautionary tale. Now, I’m not Buddhist and can’t pretend to know anything about Buddhism, but I’ve heard a story of the Buddha that seems to fit somewhat. In an attempt to teach his disciples to understand the ephemeral nature of life and its boundaries, the Buddha instructed them to meditate on the decaying corpses in the local cemeteries. But in contemplating the inevitability of their own deaths, these students of Gautama slid into despondency and began to take their own lives in their efforts to reach enlightenment, and when the Buddha returned he was aghast to discover that most of his congregants had committed suicide, and then taught them instead to meditate on the cyclicality of their breaths. Like those disciples of Buddha, in learning the truths of medicine and then the limits of that practice, health care professionals can come to despair during their attempt to attain medical enlightenment. And you do dwell on the deaths, the patients you lose, for a long time. But I don’t think that’s what I came to take from this loss.

I told you that night was one of failure, but not because we couldn’t save the girl’s life. We did everything possible. I don’t regret the thoracotomy, I don’t regret the gore. What I regret is that I didn’t – I couldn’t – say anything to the poor man who’d lost his wife and daughter. I didn’t have the courage to walk up to him and let myself feel something while he contemplated the decaying corpse of his daughter.

I can imagine it now, the way it could have been, you know, if I’d been in a movie about how to be a good doctor or something – I’d pull a chair up next to him, put a hand on his shoulder, look him in the eye even if it’s for too short or too long, and then let him talk. Or let me talk. Or just have sat in silence. Instead, I left him to sit there alone, the rest of the night, while I ran around with other patients and stuffed my feelings down, out of sight, out of mind.

Compassion means not only feeling for others, but permitting oneself to feel. The irony is that compassion is easier to have for those who are like you, but of course even though compassion begins with oneself, its ends, compassion’s purposes, are always for the other, the one who is not you. Like I said, for a while you face nothing but death, but later, you start to see the lives around you, the lives of the patients saved, the lives of the survivors of those who don’t make it, the patients whose lives were never in danger but maybe just needed some handholding. And that was my lesson, which I have learned, and learned well, that what I can do, always do, is breathe in co-suffering, to laugh and weep, with compassion, with the ones who are here and the ones who survive those whom we have lost, and although it has only been a few years, I am becoming in medicine a bodhisattva, that is, one who will someday attain enlightenment.