Friday, October 11, 2019

The First Time I Cried When a Patient Died

Dear Patient,

"No show." Those two little words usually mean someone forgot their appointment, or couldn't find a ride, or changed their phone number and didn't get the reminder call. So I was offended for you when I looked up in the middle of clinic to see that you had been marked as a "no show" for your hospital follow-up with me. I had gone over your chart the night before and walked into clinic happy to start a busy afternoon with a friendly face, only to find out that you had died the day after you were discharged. Because it happened outside of a healthcare setting, there was no documentation in the computerized record that status asthmaticus had sucked the life out of you.

You, who came to me when you felt a lump and needed to know whether it was breast cancer. You, whose roommate kicked you out for fear of getting sick from your chemotherapy and radiation. You, who survived so many complications until you could finally get your bum shoulder fixed. You, who sounded so agreeable on the phone when I reminded you after your pre-op visit that if you could find the money for it, an inhaler would help with your trouble breathing. I thought you needed one, at least while the weather was changing.

When the clinic manager told me you had passed away, I hoped he meant some other patient. Maybe you would have laughed self-deprecatingly when I told you I dropped everything I was holding in order to channel all my energy into standing upright in his office rather than crumpling to the floor. As he stood up to hug me, I don't think he thought I was the kind of resident to cry at a patient's death. Maybe I didn't either, since I had never done it before.

I had seen patients die of cancer and of overwhelming infection. There was the middle-aged man I was sure I had killed with too much Valium for the seizures from the tumors in his brain, whose mother's vitriolic comments after his death surprised even seasoned ICU nurses. I tried to get closure around the woman whose fingers and toes were black and gangrenous from the blood pressure medications needed to keep her heart pumping, whose husband let her go on my one day off. I have done CPR on children we knew were not going to survive, including a baby whose mother tried so hard to get pregnant and then fell asleep with her on the couch. I was able to collect myself after those deaths. But for you I cried.

Was it because of the shock of expecting to see you and then realizing I never would again? The injustice of surviving cancer only to succumb to a treatable chronic condition? The fact that you were only a few years older than me? Or that despite proudly being "[your] doctor," I had not been able to keep this from happening during the peak time for asthma attacks?

When I left clinic at the end of the afternoon, I stopped by the clinic manager's office again. He asked how I was doing, and he remarked that caring for patients is what makes medicine and nursing so hard. He is right, but I also believe that caring for you made being your doctor easy, because it was less of a job and more of a calling. Maybe it is better that I missed the funeral and will always remember how vivacious you were at our last appointment, complaining that the surgeon had not prescribed you enough pain medication.

Upon more sober reflection, I realize some of my tears may have been in anger: that no one called your primary care provider after declaring your time of death. That the chart did not alert me to your status as a "deceased patient" when I was preparing for clinic between a long day at the hospital and a few hours of sleep. And that the electronic medical record does not have a designation for "a patient who cannot keep her appointment because she could not afford a life-saving medication."

Your Doctor

This is What Residency Looks Like LXXV. You can find the previous post about CPR training here.

Thursday, October 3, 2019

Portland: Oregon City

One day we rented a car to get out of Portland. First stop: Oregon City, which was the first capital of the Oregon Territory. Settled by a Mr. John McLaughlin of the Hudson Bay Company, it had the first courthouse west of the Rocky Mountains, which is why it was the end of the Oregon Trail (Dear Husband is sitting on the marker for the end of the trail). Not only did pioneers file their land claims there, but the original founding documents of San Francisco were also filed there. The town is crammed between some bluffs and the Willamette River (accent on the second syllable), eventually growing up and along both banks. 

This land was originally settled by the Clackamas and Kalapuya. They had a myth that two gods created the Willamette Falls by pulling a rope across the river. The drop is only 4 stories, but it is the second-largest waterfall in the United States by volume, behind only Niagara Falls. Because of all that hydraulic energy, the Falls became site of plants for timber, paper, wool, and electricity. Consequently, they are not scenic in the least, being surrounded by (mostly defunct) industrial buildings. There is a campaign to tear down the empty ones and building offices, homes, and a riverwalk instead. They reminded us of the theme of human interaction with nature from our Japanese Garden and Chinese Garden visits, albeit in the direction of making nature look worse rather than better.

 Although we stopped by the End of the Oregon Trail Museum in order to take pictures of the green and general store where pioneers typically ended their journey that had begun in Independence, Missouri, we chose to visit the decidedly less flashy Museum of the Oregon Territories, in an ugly little building from the 1980s across from the Willamette Falls. It was cheaper but offered 2 solid hours of education and diversionf. The exhibits cover the earliest Native tribes, European settlement, natural resources as well as human industries, an old-time pharmacy display, and a rather thorough exhibit on early photography dedicated to both portraiture and documenting downtown Oregon City.

The blue globe is a hand grenade fire extinguisher. Yes, you read that correctly.

We also made a point of experiencing the United States’ only municipal elevator. It was originally built in 1912 of wood and required a 35-foot catwalk to get to the bluff across the railroad tracks. It was powered by water and took 3-5 minutes. There were a couple of scandals involved in its construction, including that Mrs. Clark didn’t want to sell the city access on her land, so they sued and won; the city also had to stack the water board in order to get access to the water system. As predicted, it dropped the water pressure. In 1954, they rebuilt the elevator with steel and a tunnel under the railroad tracks. Now powered by electricity, the trip takes just 15 seconds each way. It’s completely free, and when we told the operator we were tourists, he gave us pamphlets and “I rode the Oregon City municipal elevator” stickers.


The building has a space-age feel, but it got a facelift just over a decade ago, with an old-timey map of the town on the floor tiles and lots and lots of holographic photographs on the walls that change depending on which angle you view them from. There were also helpful decals on the windows describing the views of Oregon City’s tiny but vibrant downtown and Mt. St. Helens and Mt. Hood in the distance. We used a coupon at Mesa Fresca for Peruvian/Mexican lunch before hitting the road. Destination: Multnomah Falls!

Wednesday, October 2, 2019

Portland: Washington Park

In part to adjust to Pacific Time, and in part because I wanted to see Portland instead of the inside of yet more buildings (the cabin fever of conferencing in a hotel set in early), I planned most of our activities to be outdoors. There are a number of parks in and around the city for walking/hiking, among them Washington Park on the west side, where the zoo, Hoyt Arboretum, a children's museum, Japanese Garden, and the famous International Rose Test Garden are located. There was hardly anything blooming this time of year in the City of Roses.

First we hiked up a residential hill in search of “Portland’s favorite tree,” a redwood that won the honor in a in the last popular election of the kind, in 1987. I had noticed a pin in Google Maps, but the GPS was slightly off that day, so we sort of cast about for several minutes until Dear Husband finally noticed the small metal plaque buried at the base of the trunk that declared this particular tall tree (and not the tall ones 50 feet away) as the supreme tree in a city that has many lining its streets and filling its green spaces. I didn’t get a good picture of its towering greatness, but this snarky blogger did.

Then it was on up the hill even further—DH: Pittsburgh, I thought you prepared me with hill training!—to Washington Park. Right there at the entrance is the Lewis and Clark column, donated by the good people of the states of Oregon, Idado, Montana, and Washington in 1903. It enjoys pride of place at the formal entrance to the park, but as monuments go, it’s one of the less ostentatious I’ve ever seen. 

Down the slope a little ways stands Sacagawea’s statue. She carries her baby, Jean-Baptiste, on her back and points west (away from the Lewis and Clark column, incidentally). Alice Cooper sculpted it on commission by the Committee of Portland Women for the Lewis & Clark Centennial Exhibition that was held in Portland in 1905. (This was earlier than I suspected--I assumed she hadn't been added until the 1990s.)

We continued deeper in the park to find the Oregon Holocaust Memorial, which may be one of the best (read: most accurate) I have ever seen. A brick path leads from a “European” streetlamp toward an arc of granite. It is strewn with discarded items in bronze: a suitcase, a violin, eyeglasses, a teddy bear, a baby shoe. On the memorial wall is a large chunk of text expertly describing how the Nazis dragged Europe into chaos and destruction. Then come a series of quotations from victims, including the one that seemed to tie the memorial together: "If you got off of the train with your little bag the Nazis knew you had something personal, something special inside. That bag was the last thing they took before they took your life." On the back side are the names of murdered relations of Oregonian Jews. This visit was especially poignant as we were there on Rosh Hashanah.

Last stop on our monument tour was “The Coming of the White Man,” by Hermon Atkins MacNeil (1904). Two Native men, one older, one younger, stand on a pedestal amongst the trees facing east, toward the Columbia River. It was the most difficult statue to find, as there was no signage, although a parking lot had been conveniently provided for anyone arriving by motor vehicle (we were on foot). We were not entirely sure what the point is: Chief Multnomah appears resolute, while the younger man is agitated (to violence? Is the object in his hand part of a torch or a dagger?) or maybe just surprised. The title does not name the figures we see, but rather the historical figures they saw: the white man/men not represented in metal. In this way the statue and its title appear to erase the Native American presence all over again, although they are standing right in front of us. Why did the designer decide to “honor” Native Peoples by depicting a Native reaction to Lewis and Clark, rather than as members of nations and cultures that existed independently of Europeans (and continue to exist)?

Did you miss the post about the Japanese Garden (I've added a new photo since it went live)? Have you ever seen a Chinese Garden?

Tuesday, October 1, 2019

Portland: Chinese Garden

Second day, second garden: Tuesday we visited the Lan Su Chinese Garden, whose name combines characters from the Mandarin for Portland and for its sister city, Suzhou. It means "Garden of the Awakening Orchids." We arrived early in order to be able to buy our tickets and join the free Kung Fu class that was held on the patio. (Every day they offer a different discipline to try; I suppose if you had a membership you could attend each week.) We spent a chilly hour learning how to move from our pelvises and how to roll a ball of qi with a woman visiting from California and another guy. The instructor, Andrea, is part of the Flying Tortoise studio.

Although we were very cold, the time we spent in the class had allowed the sun to rise over the building, improving the light. We followed the circuit of the compound, taking lots and lots of pictures. While Dear Husband favored the Japanese Garden for its spaciousness and greenery (click for post), I liked the Chinese Garden better, because of the constant juxtaposition of architecture and nature.

It is set up as a wealthy family's villa. One architectural technique they use is the “view within a view,” windows or doors that (re)frame dioramas. This not only simulates infinite space but allows for the artful display of conspicuous consumption.

According to the guidebook, there is more than 600 tons of the statuesque rock from Lake Tai in China in the garden (left image). The rock has been eroded under the surface of the lake, creating shapes that catch light and shadow and invite contemplation. Looking from bottom to top is supposed to simulate climbing a mountain.

There were of course a large koi and lily pond, bridges, a waterfall, and a couple of buildings with exhibits about a home altar (above), botanical illustration, women’s work, and the study of a Chinese scholar. We treated ourselves to a satisfying lunch (steamed dumplings for him, noodles with tofu for me, tea and moon cakes for each of us) while someone played a kind of lute. As a rare souvenir to hang when we get home, we bought a crane embroidery from Shouzou.

Below is the scholar's study. I took the second photo through an opening in a wooden screen, and the repeating window effect continues with the window and the decorated porch beyond it. How could you not love all that latticework?

Above left is the "moonlocking pavilion," so named because it seems to capture the moon (reflected in the pond) in its arms. Below you can see how close the rest of the city was.

This was a very filling lunch, I think because the moon cakes may be meant to be shared. You can see half of my red bean cake on top; it has a sort of dark, earthy taste. DH prefered his lotus seed cake, which was lighter and sweeter ("the vanilla of mooncakes").

This is a backlit photo of the two of us on a covered bridge overlooking the koi pond. Afterwards we walked over to Powell's City of Books, where DH patiently waited for me to scan the spine of every book published on Nazi Germany, and many of the books published on World War I. We also ogled the rare books--some of which are very old, some of which are oversized comics, and some of which are worth thousands of dollars--and did some Christmas shopping. Then we took the tram home for a quiet restaurant dinner and a soak in the jacuzzi tub.

Coming soon: posts about Washington Park and Multnomah Falls!

Monday, September 30, 2019

Portland: Japanese Garden

We are in Portland, Oregon, for a "working vacation"--I have a conference at the end of the week, and Dear Husband had never been to the Pacific Northwest either--so we did some sightseeing together.

Top of our list for places to visit in Portland was the Japanese Garden, which is said to be the most authentic of the kind outside of Japan. Professor Takuma Tono (Tokyo Agricultural University) designed it in the late 1950s to incorporate numerous different styles on the site of the old zoo. The Garden opened in 1967 to visitors, and it has been added to and expanded upon as late as 2017.

You enter by ascending a serpentine pathway up the hillside to a "village" of buildings (visitors center, display area, gift shop, cafe). Unfortunately, their next art installation opens at the end of the week. So we had to content ourselves with wandering through the gardens, two 30-40-minute loops, each time with a break to sit quietly in the far corner in front of a burbling waterfall.

After collecting ourselves, we walked back out of Washington Park to the trendy Alphabet District, where we met an old friend for fancy ice cream at Salt & Straw: chocolate-kissed zucchini bread for me, cloudforest chocolate hazelnut cookies and cream (made with coconut cream) for Dear Husband. Sea salt with caramel ribbons is their most popular flavor. Then it was home to snuggle under a blanket on the couch for me, and a nap for DH, until we were hungry enough for dinner at vegan restaurant Blossoming Lotus.

This pavilion is part of the Flat Garden. During busy times it has exhibitions, including bonsai.

At the Lower Pond in the Strolling Pond Garden. (The cranes are statues, the better to ensure every
visitor gets an Instagrammable photo with "wildlife"?)

Outbuilding in the Tea Garden; tea house constructed in Japan and shipped to Portland in pieces behind it. Classical features include rustic stepping stones and lanterns that give the sensation of a long journey out of the cares of the city into relaxation in the countryside.

Flower arranging and dragon statue.

Heavenly Falls, from the side. They were taller than they appear here, and quite loud.
Strolling Pond Gardens such as these were popular on estates during the Edo Period (1603-1867) as demonstrations of wealth and a luxurious lifestyle.

Sand and Stone Garden, from above. These kind of "dry landscape" gardens were developed in the late medieval period (1185-1333) to capture the beauty of blank space. They are for contemplation, not meditation.

View from the bench at our happy place in Portland, the Natural Garden. Apparently this was originally supposed to be a mossy Hillside Garden, but the terrain was too inhospitable, so it was redesigned with plants to evoke all four seasons. Bet it would look great in spring with pink azaleas, or in high autumn with red and orange foliage. As it was, the tiny maple leaves looked like so many stars against the bright sky.