Mudlark Flash No. 112 (2017)

Goals of Care and You’re Welcome
Poems by Daniel Becker

Goals of Care

During a bedside conversation 
about slippery slopes and failure to thrive
we consider every option, 

whatever it takes to get him back 
to the bed where he belongs.  
It may take piano movers.  

I know their piano teacher.
I know their piano teacher’s teacher.
They’re still learning what kind of perfect 

practice can accomplish.
In my medical opinion a harpsicord, no pedals,
would be easier for high mileage knees and ankles.

I’ve never played one, but a college roommate 
played Dance of the Marionettes—
the theme song to Alfred Hitchcock Presents—

on a harpsichord he built from a kit.  
So what? their faces ask.
So there’s a lot more to talk about:

avoidance versus denial, dignity versus gravitas,
gravity versus pressure sores,  
hospital beds versus recliners, 

sponge baths versus slipping and falling in the shower,
indwelling versus in and out catheterization,
hospice versus home health, PT versus OT 

versus lying around hoping for the best,
the clinical utility of faith in a cozy hereafter 
versus nothing—not even a vacuum 

with good Ouija board reception.
The first hospices were for bodies that acted dead 
but in those days you waited a few days 

to be sure not to bury the living
which brings us to the 21st century ICU
and modern versions of perpetuity

and families who choose that
and doctors and nurses who judge that.
We cross ICU off the list.

After pianos, harpsichords, and advance directives
but getting back to Hitchcock:
you never know when he or someone like him

will insist on entering the conversation.
After all, he was famous for his cameos.
At clinic the other day I was explaining vertigo

to the victim of a rear end collision
and the husband, spiraling his finger, asks 
like the movie? Exactly I spiraled back.

Life might imitate art, and we might smile
when the unexpected matches the unexpected,
we might be grateful for the chance to change the subject,

but often, and sadly, after pianos, harpsichords,
advance directives, and elephants in the living room,
there’s durable medical equipment

still waiting for third party approval, waiting forever
if that’s what it takes. Just last week I was talking to 
the shipping clerk at the catheter supply warehouse, 

not really talking, begging. Not really begging,
preaching about doing the right thing on a Friday afternoon,
a holiday three day weekend, 

a long time for a bladder not to empty.
Someone might have mentioned something 
about Dante’s Inferno and poetic justice.  

It is possible to do the right thing 
and it doesn’t help to get all holy
or complain about the music when they put you on hold—

that wasn’t just a flight of fancy, that was Liberace—
or worry too much about reusing a catheter
after giving it the soft boiled egg treatment.

Maybe I’m sharing too much?  
We’re sharing the window seat.
We’re in those yellow anti-MRSA gowns

so we talk about normal bacterial skin flora
and how it changes for the worse
with repeated hospitalization, 

which brings us to the Book of Job 
and whether Job’s boils were the Biblical version 
of the particular community MRSA that festers.  

I’d rather talk about MRSA than bed bugs,
than bed bugs in public housing that if torn down
would make its tenants happy if, a big if,

they had somewhere else to go.
The thing about unfairness is how unrelenting it is, 
like a stiff prostate—the root cause of a stiff bladder 

and recurrent urosepsis, except we call it sepsis of urinary origin 
because of a Medicare loophole.
The thing about human knowledge is

how after the fact it is, like a broken hip
after a ground level fall while trying one step at a time
up the sixteen steps to the bedroom.

Sooner or later these conversations lead to 
who else can help at home: friends, dear friends,
kids, grandkids, strangers rented by the hour, 

and, rather than just sitting there watching someone napping,
which good books to read at the bedside?
Which music to listen to? Something andante,

but not, I gather, Dance of the Marionettes.
So there we are draped in yellow, adjusting the shades 
so the sun stops interrupting, bragging about our kids, 

awarding the grandson of the year award,
trying not to worry too much about what happens next, 
trying to be practical, to make lists, to revise lists,

to face facts, to craft solutions, to test solutions, 
to laugh off a little more than necessary,
and we shouldn’t hug, because of the germs, 

but we do.

You’re Welcome

Meanwhile, after the election, it’s one day at a time 
and somewhere in the Internet someone’s cockatiel sings 
if you’re happy and you know it clap your hands.

Cockatiels don’t clap but they can nod their beaks for emphasis.
Same for parrots, and the chatty one a patient shows off
will interrupt itself to observe out loud 

I can’t believe I just said that.  
Not every bird brain is that honest.
For decades I’ve watched a blind woman and her guide dog

walk to work while I drive by, and today, 
when they’re walking towards me in the hospital lobby,
it’s a good time to go a little out of my way 

to thank her for being out in the world
and going about her business. You’re welcome she says 
then asks about a door she worries she passed.  

We decide which side of the street she needs for her bus, 
I offer my arm and guide her and her guide dog,
now black when it used to be yellow, to the door and the stairs.

Watching them go down the stairs is even better
than watching them go down the sidewalk.
If we meet again we’ll be old friends.

Those stairs lead to the corner of a garden
that’s a nice spot for a seminar when the students
teach me it is too nice outside to be inside.

The plan is those students will grow up to teach their students
to be curious about all the little things—
Pee Wee the Chihuahua for example—

that explain where and when to bend or break the rules.
A student and I go to visit an old man in the rest home,
an old man at the stage of life when boiling water for instant coffee 

sets the kitchen on fire. He offers us a Coca Cola,
proof he is a gracious Southern gentleman.  
It is Ramadan, the student is fasting,

and after trying briefly to explain that, I realize 
we aren’t thirsty now but we’d love a Coke for later on.  
Later on I explain a little inaccuracy saves tons of explanation. 

The student explains the lunar calendar
and why Ramadan is July one year, August the next.
Five days after the election there’s a super moon

rising over the Atlantic while the sun sets in the Sound,
America the beautiful, from sea to shining sea,
and this is the annual fishing trip that is not about catching fish.

Once the moon releases the horizon it is not so super,
but still magic, as are waves receding from wet sand
and shadows of shore birds allowing a fisherman

to follow a cast pulled south by the current.
Some Novembers the birds are endless, not because
there are more than you can count all flying south,

but because they circle the island.  
They make it look easy.
What else can we be grateful for?  

A dolphin (or two or three) always comes in handy.  
And the grandmother from Mexico with chest pain?
Dios mio chest pain, day after the election chest pain?

Day by day she worries herself to death.
We worry about her blood pressure.
Her grandson’s voice is on my answering machine.

His English beats my Spanish. At his end a dog begins to bark.
Not often enough I get to write a letter to an airline
that proclaims the need for a canine traveling companion.

Through the endless campaign, revelation after revelation,
we learned candidates’ positions on race and gender and strangers 
but not species, not cats versus dogs, aquariums versus terrariums,

warm blood versus cold.
When patients check their blood pressure at home
it’s a good idea to let the cat settle in your lap

and purr for a few minutes before inflating the cuff.
Advice like that is never in the practice guidelines.
The world’s largest therapy dog makes a living as a cane 

and after leading its owner into clinic will take a load off 
by leaning on me. Talk about largesse.  
What else does it take to be happy? After food and shelter

and companionship, not much, assuming the human brain—
if not too PTSD’d—
can encapsulate the daily risk of apocalypse in all its lurid flavors.  

Humans can live with elephants in the living room
as long as they don’t stink. 
How much worry over money is in the dark matter 

that bends gravity and shapes ambition?
How much privilege can we keep? How much should we return?
Is it debt or trespass that needs the most forgiving?

Or pride? Who taught me to apologize so convincingly
that half of my audience, a nurse’s aide,
asks me to teach her boyfriend how.

The object of my remorse has a broken neck
and commands the world by voice alone.  
On a good day she’s as happy as most.

While there isn’t much that she can move, 
she can shrug bad days off, move a joystick with her elbow, 
change the TV channel, make her caregivers care

about paying close attention, select letters on a screen, 
write thank you notes that count her blessings, 
write damning letters to insurance adjustors 

who request documentation year after year 
that she still can’t feed or dress or clean herself.
Ten days after the election and our family 

is as American as Thanksgiving, as American 
as Ellis Island, as American as grandparents  
who owned the five and dime in a small Southern town—

the Jew Store is what the locals called it,
crackers is what my father called the locals—
as American as eloping to an island off the coast 

and reciting vows while overlooking a scenic bluff 
where early settlers massacred the natives,
drove them off the cliff and into the sea, that shining sea.

Love is not love which alters when altercation finds.
Not only lovers but humans as a species find it both convenient 
and necessary to overlook discomforting facts.

The neuroscientists and the social scientists and Darwin all agree
that a little denial saves tons of explanation.  
Can’t we talk about something more pleasant?  

my body language screams
while clearing the table and banishing myself to the scullery.
Our basketball team is headed for a great season.

Credit card points and airline miles
can actually buy tickets to paradise in February.
We get to spoil our kids during the holidays.

We entertain their friends. We sprawl in comfort. 
The living room has more laps to plotz 
than the lap cat ever dreamed.

The luxury of time allows new wine to breathe.
ID bracelets adorn the stems of our wine glasses.
My glass has a dolphin. If we don’t think too hard

we can sit still and almost be content.  
If we don’t think too hard we can fall asleep and stay asleep
until we wake up from nightmares

and take stock of what hurts most and where.
Those trigger points, that muscle rust?
What feels good is to rub it to smithereens.

What feels good is to do Black Friday shopping on-line.
The UPS driver brings dog treats for the dogs.
They drool when brown trucks roll up the driveway.

We once had a puppy named Pavlov
who taught us what puppies were made of.
He gave and he gave, 

we wiped up and forgave,
he trained us as fast as he could’ve.
Those were the days. Once upon a time 

we would never believe our country could get here from there.  
Now what? Sunday afternoon after the Spanish mass
medical students, whose Spanish is better than mine,

volunteer to check blood pressures.    
The families leaving church are like all happy families
with or without untreated hypertension.  

They smile and thank the students. You’re welcome 
the students smile back. De nada.  
De nada doesn’t sound like much.  

We’re not really hearing the blood pressure, 
we hear the arterial echo of blood 
that squeezes to a stop and then begins to flow.

Daniel Becker practices and teaches internal medicine at the University of Virginia School of Medicine.

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