Apple a Day

On a recent Saturday morning, I woke up early and took my problems to a bar. The bar was located on Boylston Street at the end of a row of seedy pubs. One night during medical school orientation several years ago, my classmates and I worked our way down that row, presenting ourselves proudly to one unsmiling bouncer after another.

On this particular Saturday, I was headed for a different kind of bar: the Apple Store Genius Bar. There were many clues that, location notwithstanding, this was not going to be a typical Boylston Street experience. For one thing, the "bouncer" was a skinny man wearing a large white lanyard. For another, there were small children zipping around haphazardly at waist level. Most alarmingly, the floors didn't stick to one's shoes to hold one safely in place.

After a short wait, the bouncer led me to a wooden counter at the back of the store and introduced me to a man named Genius Jim.

"What can I help you with?" said Genius Jim, and I told him I had two problems.

The first problem was my phone, which was too slow. Genius Jim asked to take a look. He pressed some buttons, then handed the phone back to me. "You have all these apps running in the background," he said, flicking through several panels of active applications. Many of them were applications I'd downloaded out of curiosity and opened once: Social Girl, a compass, a cocktail recipe generator, an app that turns things you say ("indigestion", "it's tax time") into little songs.

Genius Jim's face was graciously stoic as he made the buttons jiggle and then X'ed them out one by one. I was embarrassed, and not only because he had seen my choice of apps: I'd come all the way to Boylston Street to seek help for a problem I should have been able to solve from home.

"What else?" asked Genius Jim once this was done.

The second problem was my laptop, which had recently started giving me the "kernel panic." This, I've gathered, is the Mac equivalent of the blue screen of death. Now Genius Jim looked concerned. "I'll have to run some tests," he said and asked me to sign a consent form.

After I'd signed, he disappeared with my computer, and I was left to wander around the store and creepily watch small children play. An hour later, I returned to the counter.

"Did you back up?" asked Genius Jim, "Because we need to wipe your drive."

Apparently something had gone awry during the testing process. Now my laptop was suspended in a technological coma, unresponsive to all stimuli.

Another consent form was produced. This time, I had questions. "Do you really have to wipe the drive?" I asked. "Can't you just make it go back to the crappy way it was before?"

No, said Genius Jim.

Seriously? I said.

Seriously, said Genius Jim, looking serious.

I signed the form.

Genius Jim got everything ready. With his finger hovering above the button that would erase three years of work, he asked me one last time: "Are you sure you want to do this?"

Call me sensitive, but it seemed like a loaded question. Kind of like getting your bowel perforated during a colonoscopy, being told that it would take surgery to fix the damage, and then being asked whether you'd like to undergo surgery.

After the deed was done, Genius Jim said, "You shouldn't have any problems now."

I found myself breathing a sigh of relief. At least it was over. At least I could move on.

That's when my laptop -- my blank-faced, factory-setting laptop -- gave Genius Jim and me the kernel panic. This time, it felt less like a blue screen of death than a middle finger.

"That's strange," said Genius Jim.

I checked my watch. It was no longer morning, and next door, the pubs were stirring to life. I wished I'd taken my problems there instead, or even better, simply kept them to myself. But it was too late. I'd sought help, and now there was no turning back.

*

As a medical student, I spend one afternoon a week working in a primary care clinic. Most of the patients I see are young, healthy women. They come in with a cough or simple urinary tract infection; they leave with a cough suppressant or an antibiotic. Once every few weeks, an impressive collection of ear wax walks through the door, and the office happily mobilizes to perform an irrigation. Most afternoons, however, pass without incident.

Primary care doctors have one of the most important jobs in medicine: they are patients' first line of defense. If and when something serious comes along, they are the ones who are supposed to find it and flag it and make sure all the right people get involved.

But things that are serious tend to get mixed in with a lot of other stuff -- stuff that doctors can't do anything about, stuff that they could treat easily over the phone, stuff that other trained professionals could handle equally well. I imagine being a primary care doctor must sometimes feel like sifting through an endless pile of kidney stones in order not to miss a diamond.

Sitting at the Bar waiting for Genius Jim to fix my computer, it occurred to me that he might feel the same way. What are Geniuses, after all, if not doctors for technology? Instead of white coats, they wear lanyards; instead of coughs and UTIs, they fix bugs and RAM. Like primary care doctors, they always have to be looking out for the big bad thing, even if most of their time gets spent dealing with people who have downloaded one too many compasses onto their iPhones.

For everyone's sake, I had to wonder: wasn't there a better way?

*

When Genius Jim finally got back to me with an update, it wasn't a good one. He was stumped, and he'd consulted two other Geniuses, Genius Paul and Genius Joe, who were also stumped. "If you're willing to leave the laptop here for a few hours, we can run some more tests," said Jim. "Get to the root of the problem."

I said: "OK."

Feeling vulnerable, I went across the street to a cosmetics store and bought an overpriced skin cleanser. Then I went to a cupcake store and looked at some cupcakes. I walked several blocks to the river, where some people were falling in love. The afternoon had stirred up a severe wind -- the kind of wind that anorexic girls could ride like a metro -- but these couples were behaving like nothing was wrong. That's how I knew they were in love.

When it was almost time to head back to Boylston Street, my phone rang.

"It's not ready," someone on the other line said. "I'm taking over for Jim. The testing won't be finished by the time the store closes tonight."

I had no choice but to say: "OK."

The next morning, my phone rang again. "Just wanted to update you on the status of your computer," said yet another voice I didn't recognize. "It now works, but in the process of having more testing done, the logic board may have gotten damaged."

What's that now?

"We were running some tests to overwhelm the system. We think that it may have gotten -- overwhelmed."

He went on to explain in detail what might have transpired. Ultimately, he concluded, it meant my computer would need to be shipped to an outside facility to get fixed. For a few hundred dollars.

A mid-conversation Internet search told me that for a few hundred more, I could get a new laptop.

Had they at least figured out what the original problem was?

No, said Phone Genius, they had not. But I should rest assured: the outside facility would be able to run more tests.

That's when I decided to make my laptop Comfort Measures Only.

"Don't move," I said, which made no sense. "I'm coming in."

*

Looking back, I wonder what could have been done differently (if anything) that might have led to a better outcome. I don't have a good answer, but if I had to venture some lessons learned, they would be:

1. It's best not to wake up before noon on Saturdays

2. One really ought to back up

3. In tech -- and in medicine -- a good triage system is everything

4. In tech, and in medicine, no test is free

5. One ought to back way up, New Hampshire up

6. It's good to have a Genius as your first line of defense

7. It's probably smart to have a second line of defense, too

Sometimes I think of my medical school orientation and recall the sight of a hundred future doctors descending upon Boylston Street. That night, the long city blocks seemed to stretch straight into our future. Not everything appears so straightforward anymore, on Boylston Street or elsewhere. Medical school has shown me the uncertainty of being a doctor; Apple has shown me the uncertainty of being doctored. In the time it's taken to write this blog post, my laptop has kernel panicked twice.

Hi, I've been saying to my laptop, could you please be better now?

Reason doesn't back me up on this, but I'm not complaining. For now, at least, it's still here.

NPO and Be Merry

It is the holiday season, and all through the hospital, patients are being made NPO. This means no eating or drinking allowed.

Mr. T, silver-haired and newly unemployed, is NPO on account of his pancreatitis. "We don't want to upset your pancreas," the team tells him when we pass through on morning rounds. It is nearly breakfast time. We hover around his bed in a half circle like an uncertain a cappella group.

He is sitting on the bed, legs swung over the side and hands on his knees as if he is about to push up and take off. He looks a little disheveled, but not sick. Okay, he says.

"Okay?" says the team.

"Okay," he says again slowly, and nods.

We keep going. Two rooms down is Mr. B, a large man in his seventies, here because he vomited blood the day before. He has a history of stomach ulcers, which concerns us, and eyes like a blind person's -- only he isn't blind, because after the whole team has crowded into the room, he looks at me and bellows, "And who are you?"

A medical student, the doctors reassure him. Anyways, any blood?

"No blood!" He thinks we are fools. "I had some raw bacon yesterday, and that's why I threw up."

The attending physician signals for me to check the basin next to the patient's breakfast tray. Inside, bits of food float in a merlot-colored broth.

He shouldn't be eating, someone murmurs.

"Mr. B," says the attending, "we're going to ask you not to eat until we figure out why you're bleeding."

"What can't I eat?"

"You can't eat anything. NPO."

This angers him. "Says who?"

Says me, says the attending.

"Are you a doctor?" the patient demands.

Yes, says the attending, we're all doctors.

"She's not!" says the patient, shooting a finger in my direction. We have to give him credit: all raw bacon aside, the man is quick.

*

We go back around the next day.

"Mr. T," we ask our patient with pancreatitis first, "how are you feeling? How is the pain?"

"I ate cake," he tells us.

Alright. We ask him not to do that anymore, and he nods. It is not an unreasonable request.

Mr. B, meanwhile, has been advanced from NPO to a liquid diet, so we expect him to be in a better mood. Instead, we find the opposite. "This is not food!" says Mr. B from an armchair, jabbing his tray. On it are two ginger ales, something resembling gruel, and several cartons of Jell-O.

"Have you tried this?" he asks the attending. He lifts a spoonful of gruel. "You all should have to try this stuff if you make other people eat it."

Sympathy clears, I think to myself -- either a reasonable or highly unreasonable request.

"This is killing me," the patient announces.

I am learning the distinction between what is important to doctors and what matters to people. I once met a pregnant woman with Marfan syndrome -- a tissue disorder that can cause damage to the heart -- who had an aorta that was massively dilated. She could easily die from the pregnancy, her doctor warned her. The patient dismissed this to ask: was it possible, when she accidentally rolled onto her stomach in her sleep a few nights ago, that she might have crushed the baby a little?

Another woman who had cancer growing in her neck flagged me down half an hour before a surgery to remove the cancerous mass. The surgeon who would be operating on her was famous, and she was a fan of his writing. She was thinking about making a joke before the operation, she told me, but wasn't sure how he would take it. She practiced the joke and waited for my reaction. The line across her neck, marking where the surgeon would make an incision with his scalpel, was curved like a smile.

*

The day goes on, and Mr. B is taken for an endoscopy. It turns out he has bleeding ulcers after all.

Mr. T is spotted lurking by the service elevators, IV pole in tow, waiting to catch a ride down to the cafeteria.

*

In the Emergency Department, an old man with advanced stomach cancer and dementia has pulled out his feeding tube. The tube goes straight into his gut, because he can't eat the normal way anymore. The patient is restless. "I need an ambulance," he says over and over again in Spanish.

You're already in the hospital, we tell him. What do you need an ambulance for?

"To go home," he says.

This holiday season, patients all through the hospital are far from home, far from the comforts of food and drink, far in many cases from good health.

We think of doctors as doers, slicing out problems with their scalpels or melting them away with their medicines. They give the orders that are supposed to set betterment in motion -- NPO, they peck out on a keyboard, and suddenly the world changes.

But maybe the world lives by slightly different rules, rules that account for not only getting better but also getting there in a certain way.

"Guess what Mr. T ate today?" my teammate reports. "A cheeseburger."

In a perfect world, patients would do exactly what their doctors said, and doctors would prescribe cheeseburgers. Short of that, the best thing for patient and doctor alike may be to have a cup of gruel and get to know each other -- not as one person trying to save another one's life, but just as two people living.

It's a Placenta

Jack Handey, the father of wisdom, once said, "To become a knife thrower in the circus, they probably don't let you start off throwing at a live woman. They start you out with a little girl."

I've gained a new appreciation for these words over the last month. This is because I've finally started working in the hospital, a place that -- much like the circus -- seems to defy human limits on a regular basis.

My first hospital assignment was to the Labor & Delivery floor. L&D is where childbirth, arguably the greatest show on earth, takes place. It is also where the show Boston Med takes place. Unfortunately, I had never seen Boston Med, and everything I knew about childbirth had to do with food babies. So I guess you could say I was ill prepared for what lay ahead.

This became apparent within minutes of my first day. Morning rounds, a time for the doctors to discuss all the pregnant women on the floor, had just started when news arrived of an imminent delivery. A few moments later, I found myself in an operating room. There was a woman on a table. People and metal carts were scattered all around. The woman pushed twice, and before I could even adjust my gloves, we were plus one.

If there had been time to swell with feeling, I would have. But a nurse appeared in front of me holding a cylindrical plastic container, the kind that soup gets served in if for some reason you're ordering a lot of soup to go (where are you going with that soup though?). "You're gloved," she said. "I need you to pick up the placenta and put it here."

So while the team from Pediatrics huddled in the far corner of the room fussing over the baby, and the team from L&D huddled around the operating table fussing over the mother, I stood in the back trying to fold up the placenta like a newspaper so that it would fit inside the container.

People often ask me how many babies I got to deliver during my time on L&D. Almost no one wants to know how many cups of ice chips I delivered, and even fewer inquire after the number of placentas. This is unfortunate, as the latter two are both non-zero numbers. But tales of ice chips won't get anyone's pulse racing these days. And it isn't always easy to casually broach the topic of placentas in conversation. Say the word and people instinctively grimace, or stop eating whatever they're eating, or change the subject to something less gruesome, like Pap smears.

I can't blame them. The placenta is basically a giant human wheel that awkwardly follows a baby into the world because it has nowhere else to go. Once out, it looks hapless. It doesn't move around or act adorably infuriated. Its Apgar score at forever minutes is still zero.

But perhaps because this is my first month in the hospital, I've found myself drawn to the placenta more than any other part of the childbirth process. The placenta is my version of Jack Handey's little girl, a safe place to start out before trying my hand at anything with a shot of graduating high school someday.

And there are other reasons to relate to the placenta. In a way, it captures the life and times of a medical student: we're usually following, and when we're not following, we're lurking. At rounds, we lurk in the back row and listen as acronyms fly through the air like badminton birdies. In the OR, we lurk behind the scrub techs and watch pink bowels jiggle on large overhead monitors, one of the many benefits of modern camera-assisted surgery. And on the L&D floor, when a pregnant madam gets close to the moment of truth, it often feels like we are part of an entire troupe of lurkers -- us, the midwives, the nurses, the uncomfortable boyfriend with smart phone in hand -- fixated from the safety of darkness on the illuminated empty space between her legs.

Someday, of course, we hope to be the ones in the light, the ones who lead the action. For now, we watch and follow and pray that the cord connecting us to everyone ahead of us doesn't break.

On the evening of my last day on the L&D floor, I scrubbed into one final delivery, a cesarean section. The young woman on the table had given birth before, but never by c-section, and she was nervous about how this baby was going to make the journey from her belly to her arms.

The husband appeared in the OR looking tall and goofy in a jumpsuit that one of the nurses had instructed him to wear. We proceeded with the operation. The baby was a girl, large and healthy -- "She is big," reported the husband to his wife, who couldn't see; "She is not small" -- and we began the process of closing the mother back up. Per standard protocol, the uterus was lifted out of the body and wiped down with a wet rag like the hood ornament of a fancy car. I looked over to see how the husband was taking this, but he was busy snapping photos of the baby girl with a disposable camera.

After the operation was over and we began cleaning up, the husband turned his camera on the woman, who was still lying on the operating table. She groaned in protest and held up her arms to shield her face.

"No, don't hide," said her husband as he reloaded between pictures. He was documenting everything: the johnny, the narrow table, the metal basins, the scrub cart now piled high with bloody towels. I remembered my first day in the OR and wondered if he, too, was overwhelmed with emotion and searching for a way to take it all in.

"We need these to show our kids someday," he said, "so they won't want to give birth. We don't want to be grandparents anytime soon."

He may not have been the father of wisdom, but there in the company of both a woman and a little girl, it seemed a wise father had been born.