Ring Reflection

I held my wedding ring in my palm, feeling the weight of it. I put it on and took it off – making sure it didn’t get stuck and testing the feel of it. It was still months until I’d be able to wear it but, I liked having the opportunity to test it out. It had our favorite mountain range on it; an unassuming range that most overlook. Yet, we’d had many true adventures on that range. By happenchance his favorite mountain was on one end of the range and mine was on the opposite, with a slog of a ridge between them.

Someone asked us recently if we were serious hikers and we laughed. Serious? We’re day hikers who find trails whenever time and the fatigue of busy lives allows. Serious? We like showers, feasts, and fireplaces after miles climbed. Serious? We always seem to be bellowing Star Wars and Mighty Python quotes (between giggles) when those scarce other hikers unexpectedly find us on the trail.

My ring felt light and heavy at the same time. A simple band with so many stories behind it. I didn’t want or have an engagement ring, so the wedding ring was the first tangible reality that we were “getting hitched.” Engagement rings are not for me; though I realize for many they are a joyous aspect of their engagement. A thing I’ve enjoyed about not having an engagement ring is my interactions with people who don’t know me – what does it take for me to tell them I’m engaged? As a medical student I interact with numerous people every day, yet only some of them inspire me to share any part of my story with them. It’s an exercise in exploring exactly how humans create trust and connection during encounters the length of medical office visits. You might be amazed by the number of physicians with whom I worked for weeks yet did not tell I was engaged. Not for fear, but simply for lack of connection or reason to share that tidbit of myself.

I looked at the range as it unfolded as I turned my ring carefully. Ranges represent a journey. My fiancé and I had been on many journeys but, overall, we were on life’s journey together. Our path had thus far been calm yet still varied by ups and downs and mud patches. School had been the overarching limitation, much like a heavy pack, of our life as a couple. I’d been in school our entire relationship, and he’d been in school for most of it. We were friends for years before we started dating. In those years, we weren’t in school and had had a more leisurely approach to hiking and feasting, without the pressure of tests and hard study schedules.

We had in common a love of healthcare, yet our approaches were quite different. To be honest our brains perfectly illustrate the difference between the nursing and physician approach to patients and health. He was the matter of fact, nurturing, and patient human you’d want at your bedside hours upon hours when you’re sick. I was the curious one, driven by a desire to understand and then solve problems. I was not the one you’d want to answer your call bell as you tried to live your life in a hospital. However, I was the one you wanted examining your labs and exploring your history to discover how we might wrestle your health to a stable place. Healthcare is a culture and a lifestyle. It is terrible and amazing at the same time. These days it is more of a tragedy than a comedy, yet there remains in those of us soon to enter the field as newly trained members of the team a sense of hope. Hope that we can help. That, somehow, despite the broken system and so many brands of red tape in our way, we can improve (and maybe even save) lives. Hope is powerful.

I put on my ring, again. I looked at it. It seemed to fit. It felt weird. I was excited. I was hopeful. I looked forward to discovering how the days would unfold after I started wearing it. Like all adventures there was fear in my heart as I stood on the threshold preparing to take the first step. But, also like all adventures, I knew that the first step had to be taken. While never a nomad I’ve always been a wanderer, which inherently means I have stepped from many thresholds. Every first step was filled with anticipation and worry about what would unfold. And, yet, I have never regretted where the road took me. I often reflect on the harsh and beautiful meanders I’ve undertaken. I’ve never wished for a different journey.

I guess there’s something significant about the fact that rings are circles which have no end. A symbol of eternity. I’m a staunch believer that nothing lasts forever. I also believe that the basis of life is change. These beliefs make me curious about what it’ll look like to take some wedding vows and say that this jubilant soul I’ve decided to marry is my forever adventure partner.

My ring felt heavy, but not too heavy. I looked at the mountains depicted there. I wondered what mountains we’d climb in the years to come. What valleys we’d rest in. What ranges we’d prance along taking unruly numbers of selfies because we could. Serious hikers? Perhaps not. We’re just two people who share a deep love of the wild places and exploring them together.

Pride and the Human Experience

The patient was muscular and wore coordinated clothing, both uncommon for someone admitted to the hospital. One of my tasks was to deduce his age from observation; the moment I saw him I knew it’d be hard. He was one of those mystical people who appear much younger than their age.

There are a series of questions we always try to ask our patients in the hospital. They seem silly, but you’d be surprised how often patients can’t answer all of them. “What’s your full name? Where are we? Why are you here? What’s the date?”

This patient made great eye contact. He sat on the edge of his bed with his spine perfectly straight. He used his hands when he spoke. He said his name purposefully. He stated our location without pause.

“Why are you here?” I asked.

“I’m here to evaluate the hospital systems. I have a solution for your computers,” the patient said.

I looked at his wife who was sitting in a chair a surprisingly far distance from the hospital bed. She grimaced. “He’s been fixated on the idea of attending a business conference recently. I can’t seem to get him out of it.”

The neurology exam unfolded (an exam looking at nerve, brain, and muscular function). On the nerve and muscle function part the patient did well. He was nibble and coordinated. He was very strong. Especially for his age. However, his cognitive score was significantly below the normal level – low enough that despite our newness to testing cognitive function the other students and I were confident that he had scored low enough to count for a diagnosis of a memory disorder. How long had his memory been declining?

As I and the other medical students interviewed the patient, his wife interjected ever-so-politely when he denied he had any health concerns. She’d taken over multiple tasks to manage their household, slowly. Now she managed all the finances and everything else too. She mentioned that the patient would fly into a rage for almost no reason which was unlike the man she’d been married to for many years. He’d always been a calm man. He’d always been a connector and a successful man. He’d always been so well organized.

His memory and brain function were poor enough that the man could not complete all his activities of daily living (things like paying bills, buying groceries, among other things). This memory loss and brain function decline had been going on for over 6 months. In other words, the patient met the textbook definition of dementia.

~

The other medical students and I told the physician we were working with what we’d learned about the patient. The physician requested only the information that would change his management of the patient. So, in the end, we shared very little about what we’d learned about the patient. What makes medicine interesting (to me) is the story; however, diagnoses and treatment mostly depend on the distilled details of signs, symptoms, tests, and timeline.

~

The physician examined the patient. “What would you do if your house was on fire?” the physician asked.

“I’d go outside,” the patient said.

“Then what?” the physician asked.

“I’d communicate with people I know,” the patient said.

“Like who?” the physician asked.

“Well, I know some firefighters. They’re friends of mine. I’d probably talk to them,” the patient said. The room was silent for a few seconds. The physician watched the patient, but I watched the wife. Most of us would call 9-1-1 if our house was on fire. I hope.

~

When we left the room the physician said, “You didn’t tell me how bad he was!”

“You only asked for the information that would change your management of his condition,” I said.

As we discussed the patient in greater detail, the patient’s wife came out into the hall to show us a picture of her husband when he was still working. In the picture, he was dressed sharply and similarly to the physician I was working with. We all nodded and smiled. She looked at the picture with love, but her body was tense.

~

The vision of the wife holding up the picture of her husband stuck with me. I hoped she knew it was going to get harder. It was possible that her husband would have angry outbursts more frequently. It was certain that his memory and ability to function would decline. And it was unlikely that even that picture of him as a younger, healthy man would propel her through the remaining years of her husband’s decline if she didn’t have help. Dementia takes a toll on the loved ones of the person who is slowly losing their brain. There is no magic pill or procedure to fix the brain when it breaks in the way that causes dementia. Dementia is a progressive disease with a fatal end where, along the way, the person who began the illness is not the person who dies from it. Dementia reduces our ability to function and, also, transforms our personality.

Despite the frustration of memory loss, one thing that this patient illustrated and continues to strike me about people with dementia, is that they keep their pride much longer than many other aspects of their original personality. The vision of this patient sitting tall and answering our questions confidently floated in my mind next to the picture of him when he was younger. Why is pride something the brain clings to even as other functions are lost?

The patient’s wife noted that his outbursts most often occurred in moments when he realized he was forgetting things. In the beginning stages of dementia, many people are aware that their memory is going. I thought about how this patient’s wife must struggle to strike a balance between supporting the autonomy of her husband while also knowing he could not grasp the intricacies of complex concepts and decisions like he once could. When she looked at him, she seemed reflective. Perhaps she was recalling the grand times they’d had together. She also looked tired likely because their life together was more difficult at the time she brought him to the hospital than it had been previously.

The longer I stay in healthcare the more I come to realize that illness, while very personal to the person experiencing it, is not only an individual journey. For patients lucky enough to have friends and family at their side, their disease impacts their family and friends in profound ways. For patients alone in the world, their illness impacts those who care for them whether it be their primary care provider or their care team when they land in the hospital. And much like pride which clings on even as the brain becomes weak, the odd realization that illness is often a social experience lingers in my mind as a dark side of the human experience.