Opinion
A PIECE OF MY MIND Rachel R. Osborn, MD Departments of Medicine and Pediatrics, Yale University School of Medicine, New Haven, Connecticut.
Corresponding Author: Rachel R. Osborn, MD (rachel [email protected]). Section Editor: Roxanne K. Young, Associate Senior Editor.
The Mask She was in her late 60s, but a lifetime of the sun’s abuse added 20 years of wrinkles to her face. I met her on a stifling morning, where I found her attempting to escape from her bed through an open window. A stroke had robbed her of language, so I could not verbally dissuade her from this pursuit. Besides, I never learned Zulu, and she never learned English. However, that same stroke had also taken the right side of her body, making her escape effort as futile as it was tragic. I rested my hand on her contracted arm, unaware that she could not feel it, and smiled behind the thick blue cloth of my mask. She stopped her fervent struggle for the window, though mostly because its inevitable failure had finally exhausted her. I flipped through the flimsy paperwork of her medical chart and asked the nurses, “How is she doing today?” I did not use her name. I could not read the handwriting on the cover of the book that would have told me her name. “She is eating well but is agitated, Doctor. No family has come to visit.” I nodded as I scribbled a short footnote on the final page available in her patient binder. As I left, I pulled a vocabulary sheet from my pocket and stooped near her face. “Salani kahle.” I concentrated on my enunciation. She did not respond. I had come to South Africa to work at an HIV clinic in an area of the country with high rates of antibioticresistant tuberculosis. In my suitcase, sharing a compartment with sneakers and extra toothpaste, I packed 30 special masks to prevent transmission of tuberculosis—a mask for every day I would see patients. On the first day, the mask was suffocating. The steam of my own expelled air smelled faintly of stale coffee. The mask fit tightly, leaving marks on my face long after the mask was removed. At one point I referred to the circular indentation as the “The Scarlet O,” branding my face as that of an American physician. The pliable metal rubbed the bridge of my nose, and the resulting small blister stung. After clinic the first day, I shoved the mask into the garbage and inhaled deeply. I thought of my orientation in the States, months prior to my flight. “Everyone has to wear the masks for all patient encounters. You need to protect yourselves in order to protect the program and all your future patients. Trust me, you don’t want resistant tuberculosis.” The second time I saw her, she writhed in the bed. I assisted the nurses and held her on her right side while they scrubbed her bottom. The pressure sores oozed. She cried, and stared at my forehead. Her left hand reached out and grabbed at my mask, like an infant reaching for her mother’s earring. “I’m sorry.” This time I spoke to her in English.
The mask became more comfortable. Over the coming days and weeks, the blister on my nose thickened into a callous. I stopped compulsively leaning my head out a window, lifting the edge of the mask from my chin to vent my sweat in the fresh air. I no longer rubbed my cheeks repetitively to blend the marks on my face when I finished in clinic for the day. The mask protected me. One young man coughed as I leaned with a light to see within his eyes. Thick saliva splattered on my closed lashes. I wiped it away and approached to look again. I hardly noticed the streak of blood-tinged mucus the front of my mask left in his stubble. The mask concealed me. When I performed my first thoracentesis, my fingers trembled lightly. The patient’s sister stood near the bed, watching the procedure. She could not see me frown and bite my lip so hard a small chapped portion bled. I secretly chewed the wounded area while the pleural fluid trickled into the basin. The mask exposed me. A toddler with an extensive skin infection cowered and sobbed as I approached him while he lay in his mother’s lap. I could not hide behind a smile and a funny face with the mask. His mother averted her eyes, leaving me looking at her temple. The mask revealed another truth to her—in a waiting room filled with torrential disease, her child’s lungs had no shelter. My delicate Western lungs were more “precious.” I was too fragile and important to breathe the same air as her child. The final time I saw her she did not cry, or crawl, or fight. She had an intestinal infection and had not been active enough to drink water. Her eyelids fluttered; her lips clung to each other, bound by thick, crusting saliva. When I pinched her skin, distinct marks remained, like footprints in dry sand waiting for a tide that might never reach them. I attempted to place an IV nearly a dozen times, and the puncture marks did not bleed. Her body was too empty to spare blood or tears. Her chest moved but without the cadence of life. I stood silently near the head of her bed, gripping her limp hand. She stared at my shirt. These moments, likely the last of her life, shared with a foreign physician who must appear like a monster to her delirious mind. At her most vulnerable, I wore an unsubtle shield. I had no medicine to cure her. I had no words to comfort her. I removed my mask. “I feel like I’m going to die if I keep wearing that,” I sighed to my colleague in the room. I smiled and looked down at her. She looked at my teeth. The mask destroyed me. My professional identity relies upon a link with those who sit across from me in the consultation room. In South Africa, I had no shared cul-
jama.com
JAMA January 15, 2014 Volume 311, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/30/2015
245
Opinion A Piece of My Mind
ture or language with my patients. Human expression, my last, best asset in the battle to connect with those I served, was nearly useless under that thick blue dome. Under the mask, I confronted the unromantic realities of practicing medicine abroad. I offer skills and knowledge, but both must be weighed against my newly handicapped ability for human connection. The mask saved me. It reminded me of some of the best parts of medicine by depriving me of them for six weeks. I returned to the States with renewed gratitude.
The mask destroyed me. By removing it that day I revealed more of my selfishness than my selflessness. With her, while she died, I had this ridiculously egocentric belief that my smile is what she wanted to see in her final moments. In truth, I took it off because I couldn’t stand the way I felt wearing it. It was I who thirsted for a connection, even an imagined one, to help me process the relentless deluge of human tragedy. Mostly, though, the mask saved me. I came home without tuberculosis.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.
Agape is disinterested love. … Agape does not begin by discriminating between worthy and unworthy people, or any qualities people possess. It begins by loving others for their sakes. … Therefore, agape makes no distinction between friend and enemy; it is directed toward both. Martin Luther King Jr (1929-1968)
246
JAMA January 15, 2014 Volume 311, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/30/2015
jama.com
A PIECE OF MY MIND Rachel R. Osborn, MD Departments of Medicine and Pediatrics, Yale University School of Medicine, New Haven, Connecticut.
Corresponding Author: Rachel R. Osborn, MD (rachel [email protected]). Section Editor: Roxanne K. Young, Associate Senior Editor.
The Mask She was in her late 60s, but a lifetime of the sun’s abuse added 20 years of wrinkles to her face. I met her on a stifling morning, where I found her attempting to escape from her bed through an open window. A stroke had robbed her of language, so I could not verbally dissuade her from this pursuit. Besides, I never learned Zulu, and she never learned English. However, that same stroke had also taken the right side of her body, making her escape effort as futile as it was tragic. I rested my hand on her contracted arm, unaware that she could not feel it, and smiled behind the thick blue cloth of my mask. She stopped her fervent struggle for the window, though mostly because its inevitable failure had finally exhausted her. I flipped through the flimsy paperwork of her medical chart and asked the nurses, “How is she doing today?” I did not use her name. I could not read the handwriting on the cover of the book that would have told me her name. “She is eating well but is agitated, Doctor. No family has come to visit.” I nodded as I scribbled a short footnote on the final page available in her patient binder. As I left, I pulled a vocabulary sheet from my pocket and stooped near her face. “Salani kahle.” I concentrated on my enunciation. She did not respond. I had come to South Africa to work at an HIV clinic in an area of the country with high rates of antibioticresistant tuberculosis. In my suitcase, sharing a compartment with sneakers and extra toothpaste, I packed 30 special masks to prevent transmission of tuberculosis—a mask for every day I would see patients. On the first day, the mask was suffocating. The steam of my own expelled air smelled faintly of stale coffee. The mask fit tightly, leaving marks on my face long after the mask was removed. At one point I referred to the circular indentation as the “The Scarlet O,” branding my face as that of an American physician. The pliable metal rubbed the bridge of my nose, and the resulting small blister stung. After clinic the first day, I shoved the mask into the garbage and inhaled deeply. I thought of my orientation in the States, months prior to my flight. “Everyone has to wear the masks for all patient encounters. You need to protect yourselves in order to protect the program and all your future patients. Trust me, you don’t want resistant tuberculosis.” The second time I saw her, she writhed in the bed. I assisted the nurses and held her on her right side while they scrubbed her bottom. The pressure sores oozed. She cried, and stared at my forehead. Her left hand reached out and grabbed at my mask, like an infant reaching for her mother’s earring. “I’m sorry.” This time I spoke to her in English.
The mask became more comfortable. Over the coming days and weeks, the blister on my nose thickened into a callous. I stopped compulsively leaning my head out a window, lifting the edge of the mask from my chin to vent my sweat in the fresh air. I no longer rubbed my cheeks repetitively to blend the marks on my face when I finished in clinic for the day. The mask protected me. One young man coughed as I leaned with a light to see within his eyes. Thick saliva splattered on my closed lashes. I wiped it away and approached to look again. I hardly noticed the streak of blood-tinged mucus the front of my mask left in his stubble. The mask concealed me. When I performed my first thoracentesis, my fingers trembled lightly. The patient’s sister stood near the bed, watching the procedure. She could not see me frown and bite my lip so hard a small chapped portion bled. I secretly chewed the wounded area while the pleural fluid trickled into the basin. The mask exposed me. A toddler with an extensive skin infection cowered and sobbed as I approached him while he lay in his mother’s lap. I could not hide behind a smile and a funny face with the mask. His mother averted her eyes, leaving me looking at her temple. The mask revealed another truth to her—in a waiting room filled with torrential disease, her child’s lungs had no shelter. My delicate Western lungs were more “precious.” I was too fragile and important to breathe the same air as her child. The final time I saw her she did not cry, or crawl, or fight. She had an intestinal infection and had not been active enough to drink water. Her eyelids fluttered; her lips clung to each other, bound by thick, crusting saliva. When I pinched her skin, distinct marks remained, like footprints in dry sand waiting for a tide that might never reach them. I attempted to place an IV nearly a dozen times, and the puncture marks did not bleed. Her body was too empty to spare blood or tears. Her chest moved but without the cadence of life. I stood silently near the head of her bed, gripping her limp hand. She stared at my shirt. These moments, likely the last of her life, shared with a foreign physician who must appear like a monster to her delirious mind. At her most vulnerable, I wore an unsubtle shield. I had no medicine to cure her. I had no words to comfort her. I removed my mask. “I feel like I’m going to die if I keep wearing that,” I sighed to my colleague in the room. I smiled and looked down at her. She looked at my teeth. The mask destroyed me. My professional identity relies upon a link with those who sit across from me in the consultation room. In South Africa, I had no shared cul-
jama.com
JAMA January 15, 2014 Volume 311, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/30/2015
245
Opinion A Piece of My Mind
ture or language with my patients. Human expression, my last, best asset in the battle to connect with those I served, was nearly useless under that thick blue dome. Under the mask, I confronted the unromantic realities of practicing medicine abroad. I offer skills and knowledge, but both must be weighed against my newly handicapped ability for human connection. The mask saved me. It reminded me of some of the best parts of medicine by depriving me of them for six weeks. I returned to the States with renewed gratitude.
The mask destroyed me. By removing it that day I revealed more of my selfishness than my selflessness. With her, while she died, I had this ridiculously egocentric belief that my smile is what she wanted to see in her final moments. In truth, I took it off because I couldn’t stand the way I felt wearing it. It was I who thirsted for a connection, even an imagined one, to help me process the relentless deluge of human tragedy. Mostly, though, the mask saved me. I came home without tuberculosis.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.
Agape is disinterested love. … Agape does not begin by discriminating between worthy and unworthy people, or any qualities people possess. It begins by loving others for their sakes. … Therefore, agape makes no distinction between friend and enemy; it is directed toward both. Martin Luther King Jr (1929-1968)
246
JAMA January 15, 2014 Volume 311, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/30/2015
jama.com
