April 21, 2016

Thursday // Nature : The Crow's Nest

Last week I wrote about finding nature (specifically, waterfalls) in your environment, as a cove for reflection, processing and decompression in your routine life.  This week, I'm remembering a moment when I was in an environment far away and completely different from my own, and how it was again nature in the form of a waterfall that gave me perspective and comfort.  It was during my last year of medical school, when I spent a month at a hospital in Kampala, Uganda.

Sipi Falls, Uganda. February 2012.

On Friday, the attending physician, Ugandan medical students and I spend almost two hours with a 15 year old boy, who looks more like 11, who came in with a several month history of a swollen abdomen.  As a group of ten, we spend a long time reviewing his history and physical exam in detail while he lies there and let several pairs of hands examine him at once and lets this group of strangers talk around him about him in language he can't understand.  This slow, comprehensive, detailed discussion includes the thought processes behind each question we ask, each exam we want to do and each exam finding we find, making it intellectually interesting.  Asked if he has swelling other parts of his body, to see if this is related to his heart or liver, or was it confined to his stomach?  Does he have a cough that would suggest tuberculosis, and if not, are his other symptoms consistent with tuberculosis outside of his lungs?  How do we determine how big his liver is without getting any imaging tests?  Is the mass on his left side a spleen or something else?  Does the fact that he doesn't seem to have undergone puberty due to malnutrition or another disease process?  

As each one of us touches his chest and stomach and legs and neck, he lies patiently without any expression.  When I pat him on the shoulder and say hi, he smiles and thereafter gets embarrassed any time I examine him.  Through a deliberate investigation, we find that he has enlarged lymph nodes in his neck, a big spleen and a big liver, fluid in his stomach, and something in his chest area that's causing his lungs to rub up against his rib cage.  We talk about these details individually, throwing out reasons for each one, and then as a whole, and during the process I get immersed in the medicine of it, really appreciative of the thought and understanding that it entails, slowly as things are explored and explained.  

Then when it comes to asking what should be done, I think--we've made all these guesses as to what's inside of him based on our external exam, so we need to see what's inside.  I think--what do I think is inside?  All this talk and test and thought comes together and the tangible sense of it hits--it's cancer, and of course it's at the most advanced stage that we define.  And while this is what we've been working towards the entire time, most of that time had felt like an intellectual exercise, but now I think it really is cancer and I pat him on the shoulder again and he smiles again and we look at the images of his inside where the cancer lives in about three different organs and I feel myself pathetically cry internally so I leave to cry outwardly but privately.  And I think it's strange that with all that we've seen, with the reality he has a slightly better chance than a lot of patients I've seen here, that this response happens now.  I think it's his fragility and the way he looked so still, still until his smile moved us.  Or maybe it's the accumulation of stress and fatigue from seeing so many patients like this and worse, then briefly withdrawing from it into the safety of medicine, and then being sharply drawn back into reality.  

There isn't much time to process, since we're off soon after on a five hour drive to Sipi Falls, a trio of waterfalls in northern Uganda.  The drive could be time to decompress, but the extreme heat makes it more numbing than anything else.  But near the end, when I start to feel feverish and paranoid about having malaria, we're climbing higher and higher up into a range that contains Mt. Elgon, a famous peak in Uganda, and it's all open and green and lush, and the air's cooler and cleaner.  

We make our way to a place called the Crow's Nest to sleep, and it's a teeny tiny place atop a hill where you can see two of the waterfalls across the way, very thin spouts.  We have to climb up to our little shacks, and it's windy and cool, entirely different weather from the city of Kampala.  I take a shower, which is a trickle of freezing cold water, and you can hear the wind hurdling outside, and there are enough cracks in the room to feel it while I'm showering, and I haven't been this cold since coming here and living in dusty heat--I get goosebumps and the water feels like ice.  In a masochistic way it feels good, especially after the numbing heat, and I find the whole situation ridiculous and enjoyable.

The wind is absolutely crazy--it feels like hurricane, and it's completely dark--there's no electricity, just some kerosene lamps that make the steps up and down to our shacks hard to navigate.  The wind is so so so loud, and it blows out my roommate's lamp, twice.  We're the only people staying here, and the people who run the place are used to the dark and wind, and we're in the mountains surrounded by green and very little development, and I feel far away from everything.  It really does feel like a nest, and I get attached to the wind, which is one element of weather I normally don't like.  It's not cold or warm air; it just moves and howls, and it makes me feel like I'm in a cove of my own, but a wide, open one where I can breathe.  Our shack overlooks a little wooden frame with a view of everything and while absorbing it alone I cry a little again, on the opposite end of crying as before (and I think, maybe it's my baseline or the accumulation of this experience or hormones or all of them, because even though I cry really easily in situations with other people I rarely cry on my own like this, much less twice in a day).  Anyway, even though I'm not bawling and I'm by myself I feel a little embarrassed by this and as I'm writing I'm thinking about leaving it out, but it feels good to not feel everything so internally, to have an external expression.  It's really beautiful, this view and this space, and the mountains here are so different from other mountains I've seen, and I think how nice it is to be able to feel new things.  And the wind pounds everything all the while I'm standing there.

if you look closely you can see Sipi Falls in the hazy dusk light

I think about how badly I felt before and how good I feel now.

Later at night when it's time to sleep, I'm brushing my teeth over that wooden frame and spitting out the foam onto the rocks and laughing with my roommate about that scenario, and as I lean over I notice the sky--probably the second most dense sky I've seen in my entire life, more stars than black.  I sit on the wooden frame for a long time with the wind and this sky that I know my boyfriend back home would have been absolutely ridiculously crazy about, and for the first time since I've been here I'm actually breathing in the air that I imagine breathing during my nightly calming exercise.  To find some relief from the dust and the dense compactness of the illness that we see, at night I do an exercise where I imagine breathing out the particled air from the day and breathing in something fresh.

 The wind's making so much noise and motion, but there's so much air that the wind only makes the amount of space more tangible.  And I feel alone and connected, and heavy with how amazing it is, and then as this makes me realize that being in this crow's nest is one of the best moments of my life, I feel calm and think this must be balance...no extreme of pain/tiredness/strain, no extreme of beauty/amazement/wonder either.  I imagine it wouldn't have been this way without either of those extremes, so I think maybe it's good to try and take what you can from both ends of things. 


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