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.

On Paris Time

THE CHARLES

Terminal 2E of Paris's Charles de Gaulle airport is, at the moment, advertising Mexico.

"Millions of monarch butterflies," reads one billboard; "Also, millions of windmills." At least that's what I assume it says, based on the picture of a butterfly and a windmill. Most of what I remember from high school French involves words for describing family trees.

"Mexico," the sign concludes. "A land of opportunity."

It's been two years since I was last in Paris. Last time, work brought me to the city. This time, I am here to do anything but work. I am here in the faith that France, like Mexico, has great national treasures to offer -- ideally treasures somewhat more tangible than wind energy, which we all know will eventually be exposed as nature's biggest Ponzi scheme; it's only a matter of time.

On the train from the airport to the city, the graffiti that flies past the windows offers promise of the undiscovered. "Roro," says the underside of a footbridge defiantly. "Sheat." I am not down with this lingo, and it exhilarates me.

THE CITY

No matter how you enter the city, the first few moments upon arriving in Paris always feel a bit grand.

Entering the peripherique by car, as I had the occasion to do two years ago, one claps in delight at the drone of motorcycles and the flashing green crosses of Pharmacies on the street corners.

Entering the dungeon of a metro station, as I had the occasion to do on this trip, it is harder to clap with a suitcase in one hand. Nevertheless, one still manages to register delight. A French candy wrapper on the ground! A used French metro ticket, also on the ground! It is nearly too much.

THE COFFEE

The first destination on my itinerary is a cafe.

Cafes -- both the place and the drink -- might be the monarch butterfly of France. In France, un cafe is an espresso, also sometimes referred to as a "normal coffee." As in, "Would you like your coffee normal, or American?" Waiters always check with me. It is as if they are skeptical that I actually do want my drink served in a thimble, rather than a paper tank larger in volume than my stomach.

To be fair, there were times when I probably would have opted for the tank. French men at the office where I worked in Paris used to watch me prepare my mid-morning coffee as entertainment. "You Americains," they would laugh between drags of their cigarettes, "with your long coffees and the hot dogs."

I'd like to believe that coffee comes in different sizes because it serves entirely different purposes in Paris versus, say, New York. New Yorkers drink coffee for the same reason SUVs guzzle gasoline: because there is no other way to keep moving. In Paris, the utility of coffee is much more limited. Drinking cafes to get wired seems about as practical as eating Skittles to get full.

More than the caffeine, coffee in Paris might be enjoyed mostly for the anticipation of pleasure. How about a coffee? one proposes to another or oneself, and the answer comes back yes, yes a coffee. The wait, the crema, the tiny spoon are all part of a highly quotidian foreplay -- one that can be repeated many times a day, all over the city. It's quick, it's delightful, and nothing ever goes cold.

THE CHICKS

Alternatively, the butterfly of France might be the French woman.

The women in Paris wear beautiful, purposeless outfits. They do inexplicable things like drink regular Coke. They pour it into tall glasses and take delicate sips, proving that Coke doesn't always have to be chugged from a 20-ounce in the corner of the TMEC computer lab.

The women in Paris are attractive, even the ones who aren't. The attraction is largely to their exotic indifference. At 11am on a Monday, walking down Rivoli, I pass a girl in a floor-length gown leaning against a gate, composing a text message. She has an unreadable boredom written on her face.

Later, at a cafe, I try similarly arranging my face, just to see if there is a future to be had in that direction. "Smile," says my young waiter in English, "or you will have to leave." He laughs at his own joke, before asking if I'd like another American coffee.

THE CONFUSED

American writers, I am told, used to frequent cafes in this neighborhood, but then that isn't too surprising. Americans in general have flocked to Paris for generations. There is something about the city that speaks to those with unplaceable angst, or uncertain identity, or too much middle class wealth. Twenty-somethings come to Paris to "find themselves", as the saying goes, but really they come to lose themselves to something worthwhile.

On one of the bridges that cross the Seine -- which the New York Times recently reminded us is a river that divides Paris into left and right banks -- lovers have taken to putting locks on the metal railings, presumably to declare the foreverness of their sentiments. Some have used real padlocks; others, clumsy round combination locks that look like they got lost on the way to the gym.

One often hears of people locking down significant others, locking down jobs. There is something extremely lovely about the idea of locking down public infrastructure. For couples, it might be the ultimate romantic gesture other than jointly filing taxes. And for all visitors, and especially for those who come to Paris looking for an answer to the question of what they are looking for, it represents at least one gesture of certainty. Our time in the city is transient, our appetites come and go -- but a lock stays to mark our movements, until someday French government officials arrive with a saw, as they have already promised to do.

We, the visitors, might be the ultimate monarch butterflies of France. There are millions of us. We are constantly flitting from one pretty thing to the next. And as incredible as it may seem, we are one of the city's main attractions: we come to Paris to see ourselves in Paris.

We also come to drink wine at noon and make Eiffel Tower jokes in front of the Eiffel Tower. But whatever.

THE CONCLUSION

Two years ago, in a car to the airport, the driver said to me, "Did you hear about Michael Jackson?" At least that's what I think he said, since Michael Jackson had died the night before.

This world, I remember thinking, as the Champs-Elysees flashed past my window. I wondered when I would see it again, and what else would have changed by then.

A lot has changed, but coming back to Paris mostly reminds me of what has stayed the same. I still love coffee. I still stare at bizarrely dressed women in the streets. I still stop on the middle of bridges and try to look lost in thought, when in fact I am just lost.

The hardest part of leaving Paris is knowing that you've barely touched the surface of all that the city has to offer. This was true last time, and it is true again. I still need to find the French equivalent of the windmill. I still need an occasion to describe a family tree. I still need a gym lock. My days of working in Paris were over, I'd thought; as it turns out, there is still much left to be done.

Snow Problem

A snow storm, of all banal things, forced me to cancel a recent trip to New York City, putting a real dent in my plans to spend part of the holidays in New York City.

"I need to go there," I said over the phone to the woman at Delta the night before my scheduled flight, which had been very quietly canceled. "I need to be in that place."

"Delta can't control the weather," said the woman.

"No one told me the flight was canceled," I said. At that point the blizzard was still no more than a bad rumor, like Monica Lewinsky or the real estate bubble, and I wasn't ready to give up.

"Many flights were canceled," said the woman, helpfully. "We didn't know we would have to cancel them until we had to cancel them."

This is why you are called Delta, I thought. You make people want to change -- airlines.

But the next day, I opened up the New York Times online to find a horrifying slideshow of the buried city. It was like the sky had taken a giant white bowel movement, and, not knowing where to aim, simply hit everything.

There was a picture of a bus stalled in the middle of a street; a snow plow driver digging out his snow plow with a shovel; a woman crawling on her hands and knees up a white slope that had once been the steps of a subway station. I refreshed the webpage throughout the rest of the day to see if the woman had moved a little further up the stairs. She had not.

This gave me pause. There are elements of city savvy that anyone who has lived in a city will pick up without too much trouble. Things like: Carry a decoy wallet. Pack a spare umbrella. When wearing flip flops, avoid the gutter. When using mace, don't stand downwind.

But looking at the subway lady, frozen forever on screen and underground, I whispered a prayer of gratitude to Delta for keeping me from New York. Because gutters I can handle. Even grates cannot slow me down. But against snow -- that much snow -- I would not have stood a chance.

And so it was New York City, of all impractical things, that scared me into learning how to ski.

*

Two days later, I found myself dangling above a mountain. I had somehow ended up on a lift with two small children, a brother and sister, both of whom seemed unfazed by my presence between them.

"Snape, Snape," chanted the girl as the lift ascended. "Severus Snape."

"Dumbledore," said her brother.

"Snape. Snape. Se-ver-us Snape."

I looked down at my feet, trapped in their little prisons. It is strange to be far above everything and yet realize you are in too deep.

"Dumbledore!" cried the boy. "Dumble--"

"Snape!" said the girl, cutting him off, and now she was shouting. "Snape, Snape, Severus Snape! Snape, Snape, Severus Snape!"

"Hermione," said the boy softly.

Meanwhile, I was still focused on not dying. Forgive my ignorance, but I am going to venture that ski lifts are a perverse contraption. They are like dry cleaning conveyors for humans. Placing yourself on them is a remarkable act of faith -- yes, right up there with walking around hotel rooms barefoot -- given how many permutations of mishaps they can accommodate, a subset of which involve the word plummeting.

When we reached the top, I wanted to bid my new friends goodbye, but they were gone in a matter of seconds, two M&Ms carving down the slope.

"Snape," I said, wishing they would wait for me.

How quickly the tables turn. Day to day, you can wake up and celebrate being almost an adult, almost self-aware, almost a functioning member of society. But try something new and you begin to wish you had no concept of what you might lose. At that moment, alone at the top, I envied those kids for their nonsensical songs, for their low centers of gravity, for their bodies without selves. I have eaten grapefruits larger than the girl's head.

There was nothing left to do but fall down a mountain, so off I went.

And it was actually alright. There were a few moments when I felt like the woman stuck in the New York subway. But I got up. And I never felt like the bus stuck on the New York street, which made me proud.

So the next time a blizzard and I both decide to visit the city, I'll be ready. Even if I still can't ski, at least I won't be scared of the snow. And if you think about it, no matter how high the powder manages to pile, the only thing that really plummets in New York is stocks. And that, for once, is a comforting thought.