Tuesday, August 1, 2017

Leaves in a Stream

Let me be plain:
We are leaves in a stream
Caught up together
In this eddy, this pool
This tide, this time
Our deaths not just inevitable
But begun as soon as we dropped
To the river below from our great tree
That was watered by the rains
That came from the vast sea
To which we rush
Together, alone, together, alone

Saturday, June 3, 2017



“Hey. Come here.” It is Thanksgiving week, and my wife and I are in the guest room of her sister’s home in Short Hills, New Jersey. Our three-year-old child is downstairs, playing with her cousins.

My wife is topless. She pivots to bring her left breast closer to me. “Can you look at this? What do you think it is?” Her voice is ambivalently worried. As a medical doctor it’s not uncommon to have family, friends, even acquaintances show me their bodily oddities, but this is my wife.

She shows me her left nipple. At about 2 o’clock, near the nipple’s base, is a dark black growth, about 3 or 4 millimeters in size. “It just showed up this morning,” she tells me.

“Does it hurt? Is there a discharge?”

“No. No. I just noticed it this morning.”

There’s a saying in medicine, the doctor who treats himself has a fool for a patient, meaning, of course, that one cannot be adequately objective in practicing medicine on oneself, and by extension, of course, one’s friends and family. Meaning that whenever someone falls ill, it’s going to be one extreme or another, it’s always cancer or it’s never cancer, you minimize something because in the back of your mind you naturally don’t want something horrible to happen to your loved one, or you assume the worst because the alarm bells immediately trigger that you must do something to protect the one you love. A few years ago, my brother-in-law, then in his late 30s, who as a neurosurgeon would spend hours upon hours at work, that is to say that he is no shrinking violet, if not an unstoppable force, commented during our holiday visit that his chest hurt every now and again, rubbing at it distractedly. I replied that that seemed weird but then changed subjects; we later found out that he had critical coronary artery disease and he soon required bypass surgery. If I had been at work and a patient had come to me with a complaint of chest pain, I would have at the very least taken a thorough history and physical exam, which was what Jim’s doctor actually did discovering his illness, but I didn’t, because we’d been drinking beer and talking about family stuff, not sitting in an exam room, each of us in a respective role as doctor and patient.

“I think it might be a skin tag,” my wife tells me. It might be, she had a few before this thing appeared. I’m an emergency physician – I deal with acute diseases. Cancer is deadly, but it takes its toll over months and years, a slow moving, inexorable train of medical inertia, not the seconds to minutes acuity of emergency medical conditions. The kind of breast cancer I see is the woman who’s waited for months to even years with a growing, fungating breast mass, now erupting from the skin and oozing discharge, the patient, who was in denial, now at death’s door and finally convinced by someone close to them to go see the doctor, with no idea as to whom to go to, appear in my ER. I wrack my memory for everything I learned about breast cancer as a medical student. “No discharge?” I ask. “No.” “Any lumps?” My wife and I spend a few seconds examining her breast for masses, and finding none I return to my med school memories. We’d learned about masses, discharges, but none of my teachers had ever mentioned what a blackened, lentil-sized growth on a stalk on the nipple meant, or how that would change the way you think about the next imagined thirty years of your life.

Keeping in mind the whole you-shouldn’t-treat-your-own-family-members-due-to-bias thing, I told her that we really needed to make an appointment for her with her primary care doctor first thing when we returned from our trip. She agreed, clothed herself and we walked downstairs to join the pell-mell romp of child-cousins that was ongoing.

The week passed in the cheerful kind of winey haze that characterizes joyful family gatherings as opposed to the self-medicating, baleful kind of alcoholic fog I’d grown up with. My wife’s family genuinely enjoys each other’s company and over the years I’d grown increasingly grateful to have joined them. I’m not an orphan or anything, but holidays growing up were thick with the tension of having to choose between two estranged parents, and the fact that most of my friends had equally despair-filled family lives meant there was no home of safe harbor, just endless ping-ponging about on the freeways during the season that hosted the few rare, clear, cool days in Southern California.

My wife had covered her lesion with a band-aid, and every morning that week, around her shower, we’d have a status-check, maybe a little soreness, perhaps a change in size or color, could be because she was worrying at it, kind of a discharge, sort of an odor. She read on the internet that if it was a skin tag she could try infarcting it off by tying a thread in a tight knot around its base, so one morning she tied a length of mint dental floss around it which kept coming loose, requiring an occasional adjustment during the day.

Whenever my wife and I have an argument there’s a small, child-shaped part of my psyche that worries that the discordant feelings between us presage an inevitable breakup and divorce. In the early years of our union that fear was much larger, shrinking over time with reflection, attention, and naturally just plain old time, but given that in the experience I had of my parents fights meant a messy divorce, I hope I can be forgiven of that anxiety, whereas my wife would always look at me like I was crazy when I’d express that fear to her in the midst of a knock-down drag-out. So a part of my natural instinct is to worry about the direst possible conclusion when confronted by any adversity in our marriage. Over the days since my wife had shown me the black lump on her areola, a small part of my lizard-era-of-evolution-survival-brain kept sounding the alarm that she was going to die, that my present happiness had indeed been meant solely set me up for an even deeper despair than I’d been in before I met my wife

The stuff we fight about is the usual mélange of forgettable topics that married couples argue over: her not cleaning the inside of the microwave standing in for the difference in ways we keep house, I spend too much on my hobbies without thinking about the budget we need to have in order to support my aging mother, she drinks too much when there’s wine at our friends’ gatherings, she can’t believe I’m going to use a pocket knife to cut the skin tag off her nipple.

It’s now been a week and a half since the blackened spot of doom has appeared on my wife’s breast. Her appointment with a doctor is still a month away, but the comforting security of that promised encounter has inebriated the rational me that recognizes that treating one’s own family is foolhardy and fraught with bias, sedating the monkey-brain that had been screaming doom, doom, doom, enough such that one evening on the way home from an event I decide that a skin tag is all it must be so of course it has to be removed. Tonight. Anyway, the tying-a-string-around-it thing hasn’t been working, the ligature keeps loosening which mitigates its effectiveness, and now the lesion has a funny odor which of course means it’s not cancer, right? so it’s okay to just cut the fucking thing off and be done with it, over, out, right?

To my poor, afflicted wife, this ordeal had been of the most personal in nature; breasts are, perhaps even more so than hair, the primary external signifiers of womanhood in most cultures; one’s menarche may be when you think of yourself as coming of age and joining the great sisterhood of traveling pads, but the blossoming of one’s titties is what others can see and marks you as a woman, or a mother, or an object, the plot of the movie Osama (which, by the by, was written and directed by a dude) notwithstanding, hey, you sonofabitch my eyes are up here, asshole. But getting back to my wife, the fact that her breast was what was sick made this episode in our lives a totally different deal than anything else that had struck her before, entangling core parts of her identity.

I figure the best, quickest, cleanest, and least painful way to do this is by using a scalpel, which I have in the medical bug-out bag I keep; the stalk of the lesion is thin, something I could cut through with one decisive, swift motion. I’d need a pair of forceps, or pick-ups, surgical jargon for tweezers, and as it happens, my wife’s eyebrow tweezers were available and precise enough for the job. I pull the car in to our garage and run upstairs to retrieve the scalpel in my med kit.

Only the problem is, I can’t find a scalpel. I rummage through my med kit, turn it over to empty out the contents through which I paw, to confirm that I have indeed neglected to include that most fundamental of all tools, a scalpel, which is, after all, a knife, which is, after all, a sharpened stick, which is, of course, the first tool that made us humans human. But no matter, I have a contingency plan, so I run back downstairs and begin to gather supplies, alcohol wipes (I have plenty of those), matches (for sterilization), band-aids (to staunch what I hope would be a very minimal amount of bleeding) and the tweezers. The tweezers, which also turn out to be missing.

We just had them, the tweezers. But allofasudden, they’re missing, just like the scalpel that was supposed to be their partners in, if not exactly crime, and maybe not unethical but just foolish because of the cognitive biases involved, procedure, let’s just leave it at that. I run out in to the night with a flashlight trained on to the ground, finally bespying the pink eyebrow tweezers on the ground near our parked car. Sure, the instrument I’ll be using in what’s essentially a kitchen surgical procedure has been on the ground, but hey, I have alcohol wipes and matches, it’ll be totes sterilized when we start.

So we’re always trying to be better people in our marriage, but some things about ourselves may never change, may never be changeable, and it’s a matter of compensating, by both parties, for the sake of our continued relationship. My wife is an anxious person, and that fact leads to tensions over anticipated scenarios that never materialize but cause unnecessary turbulence in our day to day lives; for example, having people over for a simple dinner becomes an ordeal because she fears that the recipe will come out wrong even though we live within walking distance, mere steps, from at least a dozen restaurants. I, on the other hand, never seem to be listening, focused so intently on my own internal checklist of tasks that even though I have been told, over and over again, that it’s really, really important to her that I not schedule a complex and attention-diverting pickup of bulky trash items for her to end up doing herself the night before her critical work-meeting, I overlook her priority in favor of my own sudden need to clear out something that’s been cluttering the garage literally for years. And like I said at the top of the paragraph, some of these things about us may never change to the eternal distress of the other, but we are held together by our commitment to each other, as well as our shared history, and the fact that I am about to lop off a piece of her flesh.

“What the fuck is that?!” she exclaims when I pull out my pocketknife. I’ve started carrying an EDC knife, a little Spyderco Dragonfly with a 2 inch blade that so far I’ve found most handy in cutting paper for crafts that keep our daughter occupied when we’re out at dinner. It has a serrated edge, which I chose in the event that I’d need to cut through fabrics such as seat belts, but it’s a tiny thing, really… although when she puts it like that, what-the-fuck-is-that, particularly in the context of cutting her own flesh, I can sort of see why the jagged edge of this pocket knife might look a little – hmm, let’s say, menacing? “I thought you were going to use scissors or something!”

“No,” I reply, “scissors would crush and damage too much tissue, a clean cut with a knife is better. What - did you already finish that beer?!” My wife is sitting on a little stepstool in our kitchen, a bag of ice inside the cup of her bra to provide anesthesia. She has already chugged a can of beer that she opened while I was collecting my tools. Our 3 year old is on the couch watching videos on the iPad, surprisingly not reacting to any of the screaming ongoing in the kitchen.

“You’re going to use a fucking switchblade?!” she replies.

“It’s a pocketknife, and it’s the sharpest blade I have right now, I’m sorry. But like I said, scissors would crush too much tissue, it’s better to use a sharp knife.”

“Okay,” she says, a wounded look on her face, “okay. Let’s just get it over with.”

I wipe things down with the alcohol pads, I run a lit match over the things that need to be sterile with flame. My wife has opened a second can of beer.

“Ow! Fuck! Is it over?”

“No, I’m sorry, that was just the string.” I’ve only cut through the Gordian knot of dental floss that she’d tied around the base of the lesion, and I toss the ineffective ligature aside. “Okay, you ready?”

“Okay, okay, just do it already!”

I attempt to grasp the thing with the tweezers, but it’s surprisingly… squishy is the medical term, I guess, and difficult to get a hold of. I finally gain traction and make the first attempt at amputation.

“Ow! Fuck! Is it over yet?”

“No, I’m sorry.” The first cut draws blood but goes nowhere.

“Fuck! Stop! You’re not doing it right!” There’s blood now, on her breast, on her fingers, on my knife’s blade.

“Stop moving. Jesus.” I’m sweating now. A light perspiration, but sweat nonetheless.

“Ow! Fuck! You’re not doing it right! Just fucking use some scissors!” I ignore her protests and keep sawing at the stalk of the lesion, now full on pouring sweat, the tweezers slipping off the lesion, then re-gripping it, slipping off, then re-gripping, knife sawing at the base of the thing, my wife screaming in tears, our child still oddly unmoved on the couch, thank god for the diversion of videos.

“Okay! It’s done!” The tweezers have popped off her nipple with the lesion clamped between its teeth. There is blood on the blade of the knife, but all that’s left on her breast is a tiny spot of red that’s easily controlled with a small band-aid.

When I was twelve, my mother tried to shoot my philandering father. We children were in the back seat of the car that my mom had insisted dad drive to the apartment of his mistress, and we were in the parking lot of a Denny’s in Hollywood when my parents started struggling in the front seat. There was a blinding flash, no sound, except after a few seconds a high-pitched ringing in our ears as our hearing recovered from the discharge of the handgun in the confines of the car, the gun that my mother had probably meant to use in a murder-suicide. While he tried to restrain my squirming mother, my father handed me, his oldest child, the gun, and I bolted out of the car with the weapon, figuring out how to unlatch the cylinder of the revolver and dumping the remaining cartridges and firearm in a bush, which my father later had me retrieve instead of leaving as a crime scene. I remember later that evening, at home, my father sitting in a chair in our living room, chain-smoking cigarettes and contemplating the revolver he held in his hand, the instrument that could have resulted in his death.

My parents’ slow motion divorce continued on its inevitable arc, we saw less and less of our father as the years passed. But the violence of their marriage, an example of which was that evening in a Denny’s parking lot, was somehow entirely unlike, even diametrically opposed, to my wife and me sitting in our kitchen with a bloodied pocketknife and nipple, both panting with breaths stinking of alcohol.

“I’m sorry I yelled at you,” she says, collapsing on to the floor, another can of beer in her hand.

“No, honey, no, you did great, that was crazy, you did great,” I reply.

“Where is it, can I see it?”

“No, I already threw it away; you don’t need to see that shit.”

We sit next to each other on the floor of our kitchen, spent. Our daughter continues to watch videos on the couch. That’s what a marriage is – a marriage is made of moments like these, two people becoming relatives by sometimes spilling actual blood.