I leaned over a bed in the ER and stared into the opioid epidemic. The patient was a late sixties Vietnam veteran who looked up at me from sunken eyes, his body shaking on the small bed. He was going through withdrawals after trying to quit prescription Dilaudid that he was supplementing with Heroin. Fighting back tears, he told me he was prescribed narcotics for neuropathy in his right leg. My mind, already struggling against ever strengthening biases and heuristics, didn’t have to work hard to see that this man was in pain. Distinguishing real versus feigned suffering is an instinctual judgement call whether we like it or not. Pain is complex and it forces us to ask philosophical questions for which we don’t have answers. Whether we have fibromyalgia or necrotizing fasciitis, pain is all in our heads. It doesn’t exist without our brains and it only matters to us because of the neural connections running between the primary somatosensory cortex and the amygdala. Even though this brain tissue is as biological as our fingers, we cannot help but ascribe agency to it. To do differently would be to alter the very idea of what it means to be human and how we see ourselves in the universe.
The man in the bed in front of me was suffering. It’s so fucking hard, so fucking hard he stuttered again and again. He was brought to the ER by the sheriff who had heard from a friend that he might harm himself. When and where to ascribe blame is always complicated, but this patient was unfortunately a perfect example of someone whose brain had hijacked their life. Narcotic abuse, like any other drug abuse, is an complex problem that challenges our ideas of free will. If we control our own actions, why would we do something that makes us suffer? What do you do when patients demand narcotics, when patients appear to be in real pain, and when you have that power at your fingertips? I deleted and stopped listening to the podcast “Reply All” after their episode on Opiod Abuse. It frightened me to hear people so convincingly simplify a staggeringly complex issue in order to make it more palatable and give it more zing.
Pounding up the final ascent of my last hill repeat I wondered why the hell I was doing hill repeats. I was up on the Birkie trail with my family after Christmas. After finishing eight meaningless repeats I skated off deeper into the woods. Tall pines graced the sides of the trail as I skated alone through the trees. The trails around Telemark snake through a rugged undulating forrest and every so often you can turn a corner and find yourself in a magical grove of old-growth trees. It’s enchanting to look up at the towering pines sheltering carpets of soft white snow. Floating through the trees stirs the same feeling as when you look at someone you love and she smiles back at you. That jump in your chest that tells you the world is an endless maze of possibilities ready to be conquered. I stayed on the trails till the sun went down.
On Monday afternoon I met “John,” an obese white male in his late 60s. He had shaggy gray hair, a shaggy gray beard, and red suspenders just barely holding onto a massive belly contained within a stained white t-shirt. He was in the clinic to have a cyst removed. The cyst removal was important, but so was his “oh by the way.” My hand was on the doorknob ready to escort him to our procedure room when he started to talk about his depression. In a flat voice he began to me tell his story. I was transfixed, placed momentarily in a world I’ve never known and would never want to.
You’re from another state but have been living in Ely for ten years now. Never making friends besides those of us you see in clinic, you believe that someone once diagnosed you as a hermit. You don’t get out much, maybe to the grocery store twice a week. You live off disability and spend your days in your small apartment watching tv, sitting, staring, watching the world go by without you. You had a dog that a friend gave you. He wasn’t house trained but he loved you. You both loved it when he sat on your lap and you scratched behind his ears. He made you happier than you’d been in years, but your apartment complex took him away because made messes inside. You don’t want another dog because you’re afraid he’d get taken away too. Sometimes you get confused about things.
I eventually had to take him into the procedure room to incise and drain his cyst with the help of another doctor. The cyst was scarred over the top and diffuse under the tissue after it had been squeezed multiple times. We had to use two different scalpels to cut through it. I’m not sure that I’ll ever get used to that smell. Every day since, he’s come in for wound care at 11 am. Usually the nurses take care of wound management, but in the interest of learning functional skills and not being an asshole who makes people do things I can do just as easily, I asked if I could take over. Every day, one of the nurses lets me know when he’s roomed and I then proceed to unpack, irrigate, pack and dress his wound. We talk as I carefully shove centimeter after centimeter of packing tape into the hole in his back. He gets by with his life and I selfishly get to peel back deeper layers of a wounded humanity. Whereas he makes me confront my own biases about dog owners and white male suffering, I also can’t help but marvel at the adaptability of the human spirit.
On New Years Eve I watched Jesse Diggins race on TV in a bar in Northern Wisconsin. She was amazing, racing fearlessly against the top skiers in the world. It shouldn’t have, but it made me proud to be in a bar where a group of people watched women perform feats of unthinkable athletic achievement. I bombed back to Ely the next morning to coach middle school skiers. I co-coach with one of the doctors in the clinic. When Dr. Bianco and I told the skiers they could head back in, I noticed that there were 3 girls who seemed like they wanted to stay out longer. So I volunteered to take them on one more loop and teach them V2 alternate, a simple technique we hadn’t worked on yet. As we took off our skis in front of the chalet, the girls turned to me for what I took to be a final word on the day. After telling each one of them what I thought they rocked at and what I wanted them to work on next time, I mentioned that I thought that each of them could grow up to be as strong as Jesse Diggins. Seeing the smiles on their faces reinforced just how powerful it is for young women to have role models like her.
I’ve had my own trouble with smiling recently. Yesterday I lost my composure with a patient for the first time in medical school. Twice actually in one day. The first time was early Friday morning when I was seeing a patient for stomach pain. As he told me about his one-day bout of ten to fifteen loose non-bloody stools, it seemed to be a pretty clear case of a limited diarrheal illness. I was comfortable with my diagnoses and therefore caught of guard when he finished in a thick Minnesota accent, “I decided to come in yet because last night I was talking to my friend on the phone and I farted and shit myself.” I lost it. Not being able to get ahold of my laughing, the next thing I knew I was telling him that I was only laughing because I had recently done the same (which isn’t inconceivable but not true either). I felt terrible but it was all I could do to keep a straight face through the rest of the visit.
The second visit was different. I spent a half hour or so talking with a seventy year old man about his insomnia. The trouble sleeping turned out to be secondary to a depression and anxiety brought on by a multitude of stressors. He told me that he’d called his son the other day, and that his son must have thought he was crazy. Why? I asked. Because I told him I was just callin to visit. But you know it felt good to talk to him eh. His eyes watered and mine welled up. I put my hand on his shoulder and told him that I was sure that his son would like to hear that. I told him how much it means to me to be able to talk to my dad.
I’m coming up on four months now in Ely and I’m still snorting at farts, gagging at cysts, and tearing up in exam rooms. Yesterday wasn’t a win for professionalism but who am I kidding? I’m loving it up here but can’t help counting down the days until I get to fly to NYC to stand next to one of my best friends as he gets married. Almost as importantly however, I’m counting down the days until I get to reunite with the other two members of the greatest dancing trio of all time.