Storehouse of Tears
The lines are straight and swift between the stars.
The night is not the cradle that they cry,
The criers, undulating the deep-oceaned phrase.
The lines are much too dark and much too sharp.
The mind herein attains simplicity.
There is no moon, on single, silvered leaf.
The body is no body to be seen
But is an eye that studies its black lid.
—From Wallace Stevens, “Stars at Tallapoosa”
The story Mateo told could only be held in my mind if abstracted, if I flattened the mental image like a collapsible gurney and slotted it in among all the others I had seen. It helped me to not acknowledge how long he had been suspended by his seatbelt in the flipped car, to not consider the feeling of helplessness as his family died around him, considering instead only an instant of time, a still.
Or instead, simplifying Mateo himself, I could reduce his dimensionality, the space he occupied—in my own mind compressing flat his human texture into a simple plane. Then I could bind his story together with others like it I had heard or seen—together they became like a stack of old newspapers, all borne together without individual features, fused in a rain of tears. In this way suffering could be summarized as a tractable single object of ten or ten thousand lives. I don’t know why I can’t cry, he began, and when it was all told and bundled, it was not more, or less, than any other ending of a human world.
There is no formal protocol in medical training to protect a doctor’s exposed heart in these particularly devastating moments. Physicians and nurses, warfighters, crisis workers—they all come to learn defenses on their own, in order to live among the extremes of human suffering. It is not just the magnitude of the pain but also its incessance—the unrelenting descent into the abyss, day after day, year after year—that without some safeguard would be unsustainable.
Our natural impulse is to connect deeply and broadly with someone in a state of personal loss, to try sensing inside our own minds a full and complex representation of the other, to fully understand what the tragedy means. But in the extreme context of horrific suffering, it can be helpful to instead narrow our perspective to preserve empathy, finding a point to experience within the broader tapestry of the patient’s life, focusing on one spot of interlocking threads creating local shape and color
It is important to know that the full perspective is available, but feeling fully does not make sense of —and depths of emotion do not seem to help us with precision tasks in the agonal moment, whether performing an artful lumbar puncture of the spinal column or a difficult psychiatric interview to elicit inarticulable feelings. Our perspective widens when it can, sometimes without warning—on the drive home, or among our children with a sudden sob. Until then, out of view but always accessible are the trajectories of the patient’s threads with all the scope of life and its dreams, from their anchors and origins, through the journeys and relationships that came together in that instant of catastrophe and strife.
Each tragedy is still felt intensely, and each suffering human being is held in the heart carefully no matter how many more come over the years—every stunned and bereft father after a car accident, every mother struggling to form words as she hears her child’s brain cancer diagnosis. And care is needed; when the cases accumulated are still few, early in the life or training of a doctor (and sometimes still later), a single experience can storm and overwhelm the inner self, in the part of us that sees and feels representations of human beings, textured images of valued others, positioned carefully like tapestries in the innermost fire-lit halls, the hidden spaces of the self. In the keep, if we were castles.
I should have been better prepared, but there had been no warning that the keep was vulnerable. Until meeting Mateo (in my role as the on-call senior psychiatry resident who was summoned to the emergency room to evaluate him), I had not been hurt badly by my own empathy for years, not since I had been a raw and young medical student. But all had been different back then—my feelings were mostly only feelings in medical school, not feelings about feelings, a safer form they achieved later. And as a medical student I had been more vulnerable: coming of age in the halls of medicine, not yet able to give orders nor to prescribe, and still learning the language of the field though raising a child of my own as a single father in the world beyond.
On that night that hurt me first and deepest, years before meeting Mateo, I was the medical student on pediatrics at our children’s hospital, on a call night that had not been too busy. My first task for the evening—a brief prelude for what was to come later that night—had been admitting and taking the history from a cystic fibrosis family. The patients were three-year-old twins brought in together for respiratory distress. It was hard for the children to breathe.
The family was well known to the service, as we say. There had been many past admissions to the hospital, and the parents were pros at the process—so much so that they answered my questions as soon as I began to ask them, so much so that they were in the process of divorce.
They had found, with the birth of the twins, what seemed to be a hidden flaw in their union. In most cystic fibrosis families, parents have no symptoms themselves, but each carries one copy of a mutant gene. Mammals have two copies of almost every gene, so often if a single gene is damaged, no ill effects are seen; the other copy can allow a healthy life.
Mother and father are healthy carriers in cystic fibrosis, with the load carried not usually known until their child is born with a far heavier burden—both damaged copies of the gene. The math is simple, and I learned that night that the parents, in their own relative youth, had arrived together at a seemingly simple and practical decision to split and remarry, each to seek a noncarrier and the promise of greater health in the family. But in the meantime, before this defiance of the blind forces of population genetics could play out, I had to work through the mucousy tumult of the sick and screaming twins, patiently building my inventory of facts, collecting their medical history above the din, and completing the admission.
By midnight, quiet had finally been restored when we got wind of a late emergency transfer arriving from an outside hospital: a four-year old girl, Andi, with a brainstem finding.
I would carry this one, and what came next, with me for years: a deep gouge, perhaps deeper than I know still. Perhaps it went all the way through. I helped admit Andi to our inpatient service—she was charming and moony in a high ponytail, kneeling on her hospital bed, arranging her dolls around her, eyes just a little crossed up, one turned a bit inward. It had been almost beneath notice as she played catch with her family earlier in the evening, a detail almost lost in the special thrill of staying outside later than usual—just a little double vision in the twilight, and then just a twinge of worry.
I found myself in deep very quickly, even though I was the least important part of a small collection of people brought together by the case, all crammed together in the team workroom of the inpatient unit. I had started the meeting leaning against a wall, and it immediately became impossible to consider sitting down, or even to shift weight from one cramped leg to the other, as the emotional impact of the scene manifested before me. I was frozen in place until we were most of the way to dawn.
A lone gray rectangle of film, the brainstem scan, had been brought by the parents—clutched and hated, their ticket to ride from the outside hospital deep in the valley. They had borne the scan through the evening to the windowless team room, and it was now jammed up on the lightbox, a backlit gray requiem. Andi’s parents, eyes red with latent tears, were across from me—seemingly transposed into a separate space, somehow alone in the crowded room. The doctor of record—the pediatric neuro-oncology attending—was positioned immediately to my left, sitting down and leaning forward. He had been paged and brought in, as late as it was, not to perform a procedure, nor to make a clinical decision—there was nothing to do that night—but to explain the conclusions from our physical exam, and from the reading of the film, to the family.
Words were the only tool for the neurologist that night. He leaned forward for hours, not relaxing back once, without a glance at me or anyone on the team, his words only for two in the crowded room, for mother and father, for two alone, all through the night.
The double vision was not a mystery to us. There was a finding on the scan. A shadow had fallen across her pons.