Date of last entry: (June 4, 2007 - new material coming soon)

When Something Is Lost

When something is lost, you are never the same.
But, if you refuse to be less, then you must be more.”

Jean Pierre Hallet                          

He was black as his rage. He crouched alone in the far corner of the treatment room, a wounded panther tensed to spring. As I approached him from near a hundred feet away, the particulates of his seething wrath were increasingly obvious - fists clenching, chest heaving synchronizing with his wide flaring nostrils, gnarling jaws visibly altering the outline of his face. Closer in, I could see the vessels of his neck bulging as streams of sweat poured through the corrugated crevices of his ravaged face and soaked his white T-shirt to reveal the incessant rippling of his massively sculptured musculature. Except for his left shoulder, he was physically magnificent.

Incongruously, all about the long rows of tables the physical therapists and patients were stuck in caricatures of concentrated conversation. They stared into each other's eyes struggling to imagine that he didn't exist succumbed to the same denial that instinctively freezes animals suddenly overwhelmingly confronted by their destroyer.

Our eyes had locked the instant I entered, when I knew he knew I was “the man,” the doctor who might magically, finally, restore the impossible. I knew I couldn't. No one could. My task was to convince him of that while somehow saving him, but first we had to prevent the hellish crust from crumpling under us that surely would if I couldn't suppress my laughing because of the only salvation that might work, a crazy percolating that had suddenly bubbled into my head only moments before when I had first heard a stammering sketch of his story.

I had been conversing casually in the crowded hospital corridor, luxuriating in my recent return to specialty training after twelve years in general practice in Wilmington , California , the Port of Los Angeles , a small town whose people trusted their doctor. My patients had permitted me to learn so much from them and glimpse what the human condition must sustain. They had protected me from the pervasive penalties of premature specialization when, for most of those irreplaceable years we had lived next door to my 24-hour office in what had been an all-consuming time. Still, all through the adventures and misadventures I had been irrevocably drawn to the medicine of orthopedics, and now was its time.

And so I was in the corridor conversing when the door of the treatment area had suddenly burst open, the therapist lurching into the crowd wild-eyed, jerking her head back from where she had fled, frantically repeating that he was about to kill. As she staggered through the startled detached around her, I reached out, and she rushed into my arms and eventually was able to compose herself just sufficiently to communicate.

He was a barber from Watts . That was all he wanted to be. But for the previous six months, awake and in his nightmares, every instant had condemned him to the agony of witnessing his left arm flop and taunt his otherwise fully functional hand that could do nothing but helplessly, uselessly dangle.

His girlfriend had caught him straying, and before the crescendo of shots had faded, she had finalized a consummate revenge. He'd only been hit once, but, in all the complexity of his neck, the fateful “. 22” had severed the single nerve root exiting his spinal cord – the Fifth - that, peculiar to him, solely powered his entire left shoulder. From that instant, never again would he be able to raise his left arm to ply his trade – or for anything else.

The medical staff had done all that it could, which wasn't much because there had never been any possibility of restoration. The doctors had explained to him that shattered nerve roots don't heal, that reparative surgery isn't possible. They had offered him assistive devices - splints and pulleys – but they had only intensified his torment.

They were for cripples. He wasn't a cripple!All they had done was try to pacify him and stifle his screams while all that he wanted was his shoulder back.

Finally, his back literally to the wall, he could endure no more.

I had to hold his unblinking stare maintaining the demeanor that he was just one more consultation. Without breaking stride, I crossed the large room among the drab county hospital drapes that divided the room into cubicles, all the while praying that whatever thread still restrained him might hold just a little longer all the while having to consciously force myself to ignore the dangerously insistent percolating and concentrate on the clinical reality. Then there were just the last few yards between us, and each instant would witness whether we would survive long enough for those crazy bubbles to have a chance.

I stopped an arm's length away. His breath was on my face. I smelled his sweat and heard his gnashing teeth. We stood that close, looking at each other. Nothing perceptible changed… Then, for the first time, I released his eyes and lowered my gaze to his neck.

He had to let me touch him! … Touch is the primal communicator, the first sense of even microscopic creatures. If I would have any chance to succeed, we had to touch. I had to absolutely convince him of the truth that nothing then was more important to me than him and that no matter what had happened before, I was there -- I knew -- I understood -- and I cared.

The wound was almost invisible. I paused. Then… slowly… I began to raise my hand. In that same instant, he sprang. Not toward me, but away, thank God, spinning in a blur to his left, dropping into a deep, wide-legged crouch completely obstructing me from what I had been reaching for, whirling his face back just enough to keep me in the sidewise fury of his right eye. All I could do was stand passively with my hand outstretched unmoving near where he had been … and wait… and continue my fight to suppress those tickling, sizzling bubbles.

Time...

Dear God, please give me enough time... The longer he allowed me to examine him, the more authority he invested in me -- and I knew I would need all of it.

Again, I dropped my gaze deliberately to his neck. With gentle, unhurried voice I asked him to please turn to allow me to feel the wound… Nothing… Nothing…

Then, hesitantly, barely perceptibly at first, he turned and for a quiet moment I softly palpated the tremulous tissue. Slowly, very slowly, he stood erect for the first time.

I glanced in his chart because I knew he expected that, but at Los Angeles County/USC Medical Center, one of the world's largest and busiest, I knew that what I wanted wouldn't be there. But it gave us the brief time-out that he desperately needed to take my measure and just maybe to accept the battle to begin to return to the rational. Besides, too often, consultants are tempted to ingest the records of others before they have assimilated their own independent conclusions. Ideas are powerful. Attempts to expedite, to ”save time,” are a treacherous snare. Especially in the press of the county load, where shortcutting is easy to hide, it can happen while hardly realizing it. Even just a typographical error, or a simple slip of a pen, has more than once become immutable in its passage through too long a string of unwittingly careless reports that converged into a cascade of chaos for the luckless.

Examine everything . Commence with his neck and then his right arm.

Examining his normal side first was not threatening and prepared him for how I would study his injury. The muscular structures are the actors, repositories of the emotions, capable of almost infinite expression -- both in function and dysfunction. Their nuances may be subtle and transient, so the examination can be like hunting, observing clues however they present themselves.

I n his case, however, the paralysis of his left shoulder was absolute and irrevocable. There was no spectrum of movement to evaluate, no difficult decisions about the possible significance of obscurities. Still, when I did confront him -- and it was inevitable -- he had to be completely convinced that both of us had reached the same irrefutable conclusion. He must have no other alternative -- or I would have no chance at all. Gratefully as I entered the examination I received the grace of clinical focus and was spared for a time of the jeopardy of those premature bubbles.

When we move our own parts, it is called “active” movement; when others move them it is called “passive.” Both need to be examined along with each involved joint and its associated structures for position, tenderness, temperature, contour, flexibility (too much or too little), tone, range, strength…

It was time to begin the examination of his left arm.

I asked him to try to move his shoulder, and he tried. T he intensity of it shook him as his whole torso strained from his effort. I urged, and he labored even harder, as the sweat again beaded and flowed from his forehead, as we searched the fibrotic atrophy for the faintest flicker, but there was nothing -- and we both knew it.

The examination for sensation is completely subjective. For the first time, he had to speak to me. What the patient says is, so a trustworthy examination takes the dedication of two, clear communication, patience and mutual attention. I explained it all to him. He listened.

The test for pain perception is much more than just the report of the stick of a pin. Too often, a device called a Whartenburg Wheel, similar to a dressmaker's pinwheel, is expediently rolled along the skin while the patient is asked if it was “felt” or was it “sharp.” But perception of sharpness and perception of pain have different connotations. In his case, it was his pain appreciation that I needed to elicit and compare to his opposite side -- and whether it was more or less -- and which side was normal. In contrast to the prick of a pin, a sudden series of sticks from a rolling wheel of pins easily summates, destroys precision and causes confusion in an intimidated mind -- another examination wasted by haste. We went carefully through everything I had to do. His eyes grew thoughtful. He took his time. He responded. I finished.

Then, I gave us both a long respite as I carefully studied his thick chart...

When I looked at him again, and our eyes met, the rage was gone. Instead, his long buried fear was seeping through pitifully pleading with me. But there was no time left for me to respond with the sympathy he deserved because my own time had run out. My total involvement to his examination had contained my composure, but now there was nothing to sustain it, nor could there have been. Wish it or not, the super percolated crazy bubbles had finally forced their fissure and erupted into my first few sentences.

“There is no way on this earth you will ever get back the use of your shoulder. When something is lost… you have limited choices: you can run… and try to hide… but you can't… and it will only be noticed… more… and you'll make yourself into a miserable… and foolish… failure. Or you can… use it!… Find a way to… take advantage of it! Make it unique… to you!”

His brow furrowed further from the intensity of his listening. But, for very good reason, he was becoming increasingly alarmed at what his incredulous eyes were beginning to behold. The all-consuming metamorphosis of what was happening to me was shocking him beyond his comprehension as he now saw me contorting, doubling over, my arms crossed vainly attempting to splint my sides as I writhed in the agonized airless beginnings of hysterical laughter, fighting frantically for just sufficient air to survive, totally reduced from my previous stature to a slapstick caricature of a vaudeville comic in a gasping struggle for intelligibility. Collapsed almost to the floor, trying to ignore the pain in my belly, grotesquely twisted to keep his now wild, dumfounded eyes, I persisted in my frenzy for just enough inhaling to get some words out.

With my first gasp, I was exploding with laughter from the sheer fun of it, hoping I'd live through it as I labored with all my will to reach him with what, from the first, was the only potentially effective therapy I could conceive, which, in the end, was perfect.

For the most obvious of reasons, it was too much for him. Having no idea how to respond appropriately (because there was none but he had to do something ) suddenly he dropped forward, bent low, wide-legged, his face tilted crazily close over me, mere inches from mine, mutating expressions along the gamut from nonsensical quizzical to bizarrely ridiculous.

His mouth gaped wider and wider, his eyes bulged even larger, eyebrows arched almost to his hairline. He clawed the air for the total loss what to do with himself -- or with me, as a matter of fact -- as he wildly searched my face for the faintest hint of ridicule. But there wasn't any. And I couldn't fault him at all for what was happening to him because, in fact, I depended on it.

At last, I was able to catch just enough breath to reach to him with pure wondrous once-only-in-a-lifetime congruence when the stakes were everything. The phrases attached themselves to each other in forced clumps as he clung to his last thread and listened! And it was then that I knew we would win !

“Instead of pushing your chair… and your life… into the back of your shop… put it right in the middle of the floor!…You can't get along without using… something…– to get your arm up… So really get it up!… Chrome the pulleys!… Make the ropes ring bells… and whistles!… Make them fly birds around!… Do anything that makes it… fun!… that everyone can see and hear and makes them laugh!… You could name your shop… ‘ The Hang-up!...' You are the only man in the entire world who could legitimately advertise himself in the Yellow Pages as… ‘The Best Hung Barber in Town!'”

The mind is most mutable in crisis. That is where he was and where he needed to be. Only then could my words have maximal impact. And that is where they began to make sense to him.

Slowly… he stood erect… and thus began his most magical transformation as his face kaleidoscoped through the most amazing array of expressions, as the deep crevices of his long torment thawed and melted and flowed away in the streams of his sweat, washing away all the residues of his terrible ordeal with them. He threw back his head and roared.

When he looked at me again, he was ecstatic. He grabbed me up to him, and we hugged each other and rocked almost falling as his laughter boomed with mine. Then, without a word, with glorious smile, his white teeth flashing, his strong right arm swinging, he marched out triumphantly straight and tall. He was whole again -- as he had not imagined he ever again would be.

Incredulously, all about, it was as if nothing had happened. I don't know if any other person in that room had paid active attention. No one ever approached me, not even the physical therapist who had feared for her life. In all its guises, denial is so powerful a dominator of thought. The particular species that infected the clinic that day is called, N egative Knowing that “protects” the too tame from knowing what they do not want to -- b ecause knowing would wrench them from their illusion of safety and even thrust them into naked terror. But first one has to know that reality at a deep level to choose not to allow it into consciousness. Negative knowing always extracts its price. It is always there -- waiting.

In the end, it had been our time, his and mine. His chart faded into the files, and eventually I forgot his name. But every now and then I would think about driving into Watts and looking for The Hang Up.

PHG