What’s in the Black Bag?

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Clinic, a small Armenian village. She cracks her hands, practically every minute of the day, so much that they have become swollen, the knuckles sore. I believe that she will permanently injure her joints if this continues, and so does her mother. With an interpreter, and her primary doctor standing by, I ask her a few questions–who is worried about this? (mom); why? (bad for my hands). Her solemn gravity matches that of the 11 who came before her. Though initially, in the dissociation which drives this self-destruction, she is unclear on whether or why the habit troubles her, she does come around, and says that her knuckles hurt. She has tried to stop, but cannot.

I am conferring with the generalists at this rural clinic. They want to know: what would I do? She is the last patient of a day when the news has passed through her cold gray town: there is an American doctor–bezheeske; he is seeing patients with the doctors at the polyclinic. And so her mother brought her.

The 4 hours and 12 patients could have been back in Vermont: parents concerned about their children’s tics, or their angry, un-disciplined ways, or their headaches, or reading problems. My medical training put very little in my black bag to address these problems, and yet I have carried it all the way here, as though it was a talisman. Such a scene had some potential to evoke one of my greatest fears: that I would suddenly discover myself to be a naked emperor on parade. imageRemembering the pivotal scene from The Wizard of Oz (“pay no attention to that man behind the curtain!”), my best response to this fear is to be my own Toto, who with a single gesture pulls back the curtain, reveals the charlatan, and impels honesty onto the scene.

“I want you to tell my son to stop hitting his sister, maybe he will listen to you, since he doesn’t listen to me” says one mother. I can see the logic of backing up this mother, but I also doubt the bargain will sustain: the boy hears me, agrees to try harder, until … More important than his accountability to me (“that American doctor will be disappointed with me if …”) are his expectations of himself (“how will I handle my mean sister? Maybe I will do something different …”). As far as I know, when the problem in the clinic boils down to personal habits, the ethics come down to how and whether I can support better self-regulation, the patient’s best expectations of herself. This is how my “inner Toto” insists that I redeem trust: pills and tests only when doing something different isn’t enough.

imageNow, my focus is on her, the girl who is doing her best not to crack her hands during the visit, under her mother’s eyes. She says she wants to be a surgeon. I ask her to demonstrate the maneuver, just once. A low-pitched, crunching sound comes from the core of her hands, and resonates through us, nurses, doctors, translator, mother, like a wave. She looks down, like she has just done something wrong. My translator, a Yerevan medical school graduate, now steps in and deftly executes a time-honored maneuver of medical interviewing: “So, tell us, what are the 4 things the doctor said to do?” On 4 fingers, they recount:

1) Massage–have the masseur wish for you that you will stop cracking your hand joints.
2) Pray-add your hands, your wish to stop hurting them, into your prayers.
3) Re-image–when you are going to sleep, think of yourself as a person who does not crack her hands.
4) Substitute–the moment you have the thought of cracking your hands, think of a different, more gentle, movement to make.

It was the best I could find in my black bag.

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Black Bag Blues

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