Course 1; 2009; Fall; Book 3; Bloodletting & Miraculous Cures

Author; Vincent Lam

About the Author from (Random House Website)

Vincent Lam was born in 1974 in London, Ont., into a family from the expatriate Chinese community of Vietnam. Four years later, they moved to Ottawa where he was raised on stories told by his father and the works of C.S. Lewis and Roald Dahl, and developed aspirations to become a writer. Acknowledging that he hadn’t seen enough of the world to create great literary works, Lam enrolled in medical school at the University of Toronto, hoping it would provide real-life experience and a wealth of rich material. His plan proved to be a very good one.

It was while working as a doctor aboard an Arctic cruise that Lam had a chance encounter with renowned author Margaret Atwood. She agreed to read his short stories, and later sent him an email announcing “Congratulations. You can write.” Atwood mentored the young author, and was instrumental in bringing Lam to his publisher, Doubleday Canada.

While crafting his debut collection of short stories, Lam worked in the emergency room at Toronto East General Hospital and helped fight the 2003 SARS outbreak. “An emergency physician is often in the centre of a storm of tensions and drama,” he says. “We work in a world that is both medical and personal, where the stakes are high and events are unpredictable. As a doctor, I respond to the world around me, and act within that world. As a writer, I do something fresh and new on the page.”

Lam’s depiction of four medical students who become doctors in Bloodletting & Miraculous Cures was so unique and accomplished that the collection won the 2006 Scotiabank Giller Prize – Canada’s most prestigious literary award. He is the youngest writer, and the only first-time author, to win it.


General

This book is about lives of four characters, three Asian, one Anglo, who become doctors. Their  lives are intertwined. Wonderful character descriptions

The author is an emergency room physician in Toronto. The book is a work of fiction, but is informed by the  author’s knowledge of the workings of medical school, hospital, students, residents, etc.

Comments below (# 1-6) are from Random House Website

1. In this book, it might not seem that medical school is designed to foster individualism. When are there moments in which the doctors, the professionals, reveal their personal self?

2. What events root these stories in a particular time? Do you see references to outside news? What about SARS? Does the intense focus of the stories capture the funneled lives of physicians, especially in the E.R. and obstetrics?

3. What does it mean to be Chinese in "Bloodletting & Miraculous Cures"? Is it even relevant most of the time? The characters are doctors and people with little sense of their immigrant background. However, when are the few times that being Chinese is made explicit?

4. Writer Joyce Carol Oates says, "Tragedy always upholds the human spirit because it is an exploration of human nature in terms of its strengths. One simply cannot know strengths unless suffering, misfortune, and violence are explored quite frankly by the writer." Does this concept help us understand the characters and events in Bloodletting & Miraculous Cures? Discuss how some of the patients, doctors, and survivors emerge from suffering and violence.

5. Much of the book is about initiation. Is it the reader's initiation as well as the doctors' in this no-holds-barred odyssey into the world of medicine?

6. Lam is a highly skilled storyteller. How would you describe his writing style? What are the methods he uses to interweave horrific events with small human moments, balancing despair and love, grimness and humor?

Close Reading and Questions in Specific Stories

1. How to get into Med School; Part One

We are introduced to two characters, Ming and Fitzgerald
--------------------------------------------------------------------------------edit
P2. Ming contrives to meet Fitz, so she can tell him that she is not interested in him romantically

P4. Long sentence bottom of page, a wonderful description of Fitz feelings, concluding with his impression of this “pre-emptive romantic rejection”.

Q. Do you think these are universal themes, attraction, love, rejection, and are they present in all societies and at all ages. .

Q. Why is Ming not interested in Fitz? 2 reasons are given; (a) family would not approve of her hooking up with an Anglo, and (b) needs to focus on getting into Med school

Q These are the reasons she supplies to herself. But could it be simpler, i.e. just not attracted to him, without being able to say why, so she rationalizes it with other reasons?

P7. We see the first intimations of alcohol abuse by Fitz; “relief and ease of first drink”.

Q Use of alcohol; why do people abuse alcohol? Much controversy. Is there such a thing as alcoholism as a primary disease? Are there genetic factors? (Fitz’s father was heavy drinker) My own take; it is always secondary to something else, a form of self-medication, most often used as way of coping with anxiety disorder. Becomes perpetual, self-reinforcing because it works. Particularly effective with Panic disorder. In many cases, if treat PD successfully, alcohol abuse disappears.

P8. Fitz recalls his mother “went away” We later learn she was killed in car crash. Experience of abandonment at an early age will make this a major fear, will make him aware and sensitive to of rejection. He uses alcohol to blot out the fear of abandonment, in this case the feelings that go along with the rejection.

Q. As he drinks he becomes angry. Why does he become angry? Social controls that he can exert most of the time over the feelings are inhibited with alcohol, so the anger comes out. Anger is a secondary emotion, usually the result of hurt or fear. (in this case, hurt) Usually comes in a fraction of a second so people may not be aware of the hurt. Much of psychotherapy is involved in tracking back to the primary emotion, so one can feel it, explore it, and not get angry for no apparent reason

Q P 10. Why do people go into medicine? Ming and Fitz agree; they want to be doctors for the “right reasons”, humanity, service, giving; others do it for money or prestige. The irony is that others see it the same way as they do. Yet they each knew that their motives were improvised, created by them as means of clinging to the idea of “moral correctness”. Smugness of the young; others are FAKE. Yet they also recognize other reasons; Ming, want to make a good living, Fitz; tends to e obsessed with what he is doing, if not medicine could easily be something else.

Reality; become aware as one gets older, that all of these things, pure and selfish, all play a role. When young, all or nothing, later see life less as black and white, and more shades of grey.

P12. Fitz speaks of “improbability and importance of human connection”. Any thoughts?

Does Ming’s idea that they should not see each other, so as to avoid interfering with their work, have merit?

P13. She would not have a romantic relationship, “and so she decided she would not be hurt”. Was all her fancy language about no romance because she needed to focus on her work, just a smokescreen for her real fear, i.e. of rejection? So they both had issues around rejection.

P16. Are there differences in different groups, e.g. ethnic groups, regarding academic success? Ming’s father “importance …. of not bringing shame to her parents”. This value is important in the disproportionate academic success of Asian students.

P19. “Delayed gratification of becoming doctors”. This is a key concept for every medical student, intern and residence. The hours are totally taken up with medical studying or working in the hospital and unless one believes in this concept, one can’t go on.

P19. “Once they were admitted the difficult thing would be done”. Partly true, Once in, simply need to get a passing grade every year. Residency is somewhat competitive where there is a pyramid system. The toughest task though is in competing with the pool of students who want to get in, most of whom won’t make it.

P21 What is difference in personal styles between Fitz and Ming? She is concrete, linear, deals with memorizable facts. He is non-linear, more interested in broad concepts, is spontaneous.

P24. They have a style of flirting by saying things directly straight-forwardly, how they feel about each other, but treating as if it’s a joke or as irony, they can get away with it.

P26 Ming carries this secret about her cousin Karl seducing her starting at age 12, and tells Fitz. Why does she do this? Is she testing him?

P27-29 What Is the status of her relationship with Karl? Is Karl a manipulative person? She recognizes that she was coerced, that his power and prestige within the family was used to essentially “rape” her, but she considers herself partly responsible because she enjoyed it. What do you think of that?

Is her anger with Karl responsible for not wanting an intimate relationship with Fitz?



2. "Take All of Murphy

P31-32; Three students Ming, Chen, Sri. This is a wonderful description of the first day of an anatomy lab in which students actually begin dissecting cadaver. What might they be afraid of or apprehensive about?

P33. Much moving and shuffling around. This is authors way of showing how nervuous they are.

P34 The anatomy demonstrator tells the medical students, "This fine cadaver is your first patient. Dignity and decorum are crucial. You must be mindful of this gift you are given, and treat your patient nobly".

Anatomy instrictpr “Dignity and decorum are crucial” Why are these important? Respect for the dead, Their “first patient”. Treat patient nobly.

P34-35 Impatient competition. Ming; “if your goint to take forever”

P36 These bodies are volunteers, not body-snatched or "people from the jails or found dead in fights or ditches" (p. 36) as for earlier generations of anatomy students.

P36. Dean Cortina tells Chen about her experiences with dissection, esp about calling the cadaver a “broad” What is she trying to say? Teaching respect for people. Includes the dead.

P41-42. Cadaver has tattoos, airplanes, air force language, religious quotes. This humanizes cadaver, reminds that this was once a live person.

P45-45; Ming and Sri are continually antagonist to each other, culminating in tension when Ming misplaced a dissected specimen (half the cadavers head). Wonderful character development. Ming is cavalier; Sri is compulsive and up-tight. They are each irritated by each others style. Culminates in nasty fight on P50. This close working arrangement is not unlike a married couple who have to learn how to get along once they realize that there are differences between them.

P49-51. What does story say about alcohol? Alcohol is a drug, or medicine. After final exam they go relax and drink. Sri is feeling generous and buys Ming a drink. She tells him she found head and left it in the wrong bag with the omentum. Sri feels she doesn’t care enough, is annoyed with her, and insists he must get specimen right away. Culminates in nasty fight on P50.

Sri; “alcohol can build and then burn bridges” Exactly what happened. He buys drink, then later social controls removed and she is swearing at him.

P51-53 Religious symbolism. They have seen “Mark 16” written in tattoo on cadaver. Refers to the resurrection. How does it apply here? “ Chen says that a pilot (as Murphy was) would have figured his body wouldn’t be left for anyone, and the resurrection story was comforting. This gives Sri a chance to say that’s wrong, the body is left for them. Why is this important? It gives the gift of the cadaver greater meaning.



3. How to get into Med School; Part Two

P54-55 Ming and Fitz now have a romantic relationship. Summer before she starts Med School. How is Fitz being excluded from her life? Parents banquet, he is not there. At this point is only her parents doing the excluding.

P56-57 They are clearly both in love. Fitz suggests they get married. She suggests “circumstances are not ideal” He asks “are they ever for anyone?” What do you think?

He wants commitment, she is cautious, or is this something else? A desire for everything to be perfect? Fear of her parents reaction? They seem to have different levels of commitment.

How are their different levels of commitment described in story? He wants to live with her, she wants to wait. He wants marriage, she is ambivalent. He is eager for her to tell her parents, she is not ready to do that.

P59. How is Ming beginning to push Fitz away? Telling him in Oct that they need to speak every other day instead of daily. “You need me too much” She identifies him as the needy one, implying that she is not.

P59-66 We see the breakup of a relationship over about 4 months. . Lam is wonderful in his showing of how this happens, Fitz’s desperation, Ming pushing him away, letting him know in stages. There is a level of cruelty in how she is treating him.

P70-72 Fitz has his interview and meets Karl, who is sitting in as a second interviewer. In what way does he blame Karl for his predicament with Ming? He believes that she had learned “to exclude, to be hard” because of Karl

P72 Fitz has fantasy of kneeing Karl in the jaw. Do you think he might have done this? He has a spontaneous personality, not the sort to worry about consequences.

P74 Karl tells Fitz not to count on getting in to Med School. Why does he say this? Karl did not like Fitz saying he was close friend of Ming. Now Karl is using his power to threaten Fitz. But Fitz ends up having the last word.

P77-78. Fitz obsesses over Ming. He goes to her apt, and when she wasn’t there, he lets himself in. He reviews all the attempts to contact her, all that he wrote. This is a wonderful description of unrequited love. Some believe that the only real love that lasts is unrequited love. What do you think?

P78. Fitz fantasizes Ming being glad to see him, and everything comes back, she will never “turn away again”. Is this fantasy unusual? For a man obsessed, he needs to believe this. Lam does a wonderful job of describing a man completely smitten, and how that can lead to magical thinking.

P81 Lam does a wonderful job of showing Fitz’ jealousy of Chen “Chen the kisser, Chen the interloper”. Then more fantasy, now a bad romance movie

P83. Fitz finds his letters to Ming unopened but in the drawer, If Ming did not open them, why did she keep them rather than just throw them away?

P83-84 Yet another fantasy (Fitz is good at this). This time a fight between Chen and Fitz in which Fitz ends up in jail. Is this sort of fantasy common in person in love? Why does he torture himself this way?

P84-88. Fitz and Ming run into each other. He is surprised at her appearance, etc. The magic is gone. “His memories seem like a mirage”. The “desperate winter was now embarrassing to think about”. Why was it embarrassing? Because of his fantasies, his obsession; he doesn’t like to think of himself that way, does not want to be that vulnerable.

P87. Thinks of her as his “screen idol”, a celebrity. Now has fantasies of revenge for the abandonment.

P88. The end of this story is also the end of the Ming-Fitzgerald romance-drama. Through closed eyes Fitz feels the sun shining through and hears the sprinklers coming life closer and closer to him. “He lay on his back and waited for them to swing around and spatter him with cool water” What is the significance of this? It is a moment of cleansing for Fitz,



4. Code Clock

P89 Two characters, Fitz again (now he is a Medical Student) and Nigel, a Resident.

P89 Why do they use expression “Code Blue” Why not just say, “ resuscitation needed”, or “medical emergency, go to room --- “. So much of medicine is conducted out of sight. Is this good? Does it lead to a lack of honesty or appreciation? Must we pretend and wrap unpleasant truths in illusion?

P 90 Why does one person need to “run the code”? It can be chaotic. There can be differences of opinion as to what to do. One person needs to be in charge or mass chaos.

P91 Nigel asks “How long has it been”. Then Fitz also asks how long. Wants to know when heart stopped. Why? Because if brain not getting blood, brain cells will start to die. If don’t start perfusing with blood soon, the whole exercise becomes pointless because of brain death.

P91 What do you think about nursed response. “Well, I was on break …. Well, was here just a minute before, but Mr. Singh didn’t say anything” How does this describe personal responsibility? (Not a political battle between nurses and doctors, but a reflection of fear of being blamed and wanting to cover one’s ass.)

P92 Fitz shows a great deal of competence and more importantly total self-confidence.

P95 Competition between Fitz and Nigel. Nigel not sure Fitz can do it, wants to take over, Fitz wants to do it himself.

P97. Fitz is tapping the heart. (Pulling any fluid out of pericardial sac). Nigel thinks “this never works”. So why do they do it? Many things are done in medicine without adequate evidenced. Years later, find it was just plain wrong. Points out need for “evidence based medicine”.

P99. Sharon, who disapproves of this code going on so long, is being passive-aggressive, and deliberately doing everything slowly. This is her way of doing the code and not doing the code. It is a kind of statement.

P100. Body was cold when he got there. What is the significance of this? Means much more than 10 minute delay. In turn, means nurses really hadn’t been on top of this, and code was pre-determined to be futile.





5. A Long Migration

In this story we again see Chen, but now it is written in the first person, and describing his family origins. His family was Chinese, and had come from the expatriate Chinese community in Viet Nam. This is the same origin as the author, which may be why he writes of Chen in the first person

The migration in the story’s title is that of Chen’s grandfather, a fascinating man. What do you think of Yeh Yeh’s life style, his money going for gambling, drinking and prostitution? Lam draws a wonderful portrait of this man, who clearly lives for himself. He is a Chinese man who has lived in Viet Nam, Hong Kong, and Australia, with a large extended family living all over. He has been married four times, and has lived fully. Chen, a med student, is learning the perils of taking care of a member of ones family, as Chen ministers to his grandfather. What are the pitfalls in doctors taking care of members of immediate family? Emotional involvement clouds judgment, may lead to cutting corners, desire to impress family members. . Chen wants to be thought of as a doctor, but doesn’t yet have the knowledge. His family thinks of him as a doctor. One of the things that is introduced in this story is the intersection of medicine narrative and spirituality. In the story we hear of the proposed baptism of Yeh Yeh

P109 Yeh Yeh considers the pros and cons of a deathbed conversion. Among doctors, there is a tendency to a greater prevalence of secular thought. Why?



6. Winston

There are three main charactiers in this story, Sri, Winston, and Dr. Miniadis. In the story we again meet Sri, now a resident physician.

The second main character is Winston. Lam provides a perfect description of paranoid schizophrenia in Winston. He is showing us, not telling us, precisely what schizophrenia looks and sounds like. The story is told in the first person and tells exactly what Winston is experiencing. Suspicion, convoluted explanations of everything, racing mind, ruminations, delusions,

The third character, Dr. Miniadis is a tour de force, a loony-perverse representative of the "sane." Are you reminded of the French film "King of Hearts" or "One Flew over the Cuckoo's Nest"?

Dr. Miniadis says to Sri, "This is the dilemma, to build a rapport, to allow the legitimacy of experience, but never to speak of what is NOT real as if it were" (p. 126). Is the Halloween party a real Saturnalian blowout? Or does Winston imagine it all?

P118 Winston wonders if he should go to doctor because “some people say that doctors dispense poison” what’s that about? Common among some minorities, e.g. blacks, Gets started either as urban myth or because someone has had a bad personal experience and doesn’t trust doctors. Trust, candor, very important.

P119. Winston sitting in waiting room thinking that receptionist “can see everything about him”. “and the whispering” Delusion, and paranoia are indicative of psychosis probably paranoid schizophrenia

Suspicious of doctor “too young, too friendly, “why should these things make him suspicious? No reason, more delusions and paranoia.

Winston’s response is hyperrational, intellectual, and also paranoid “on verge of being destroyed” Another characteristic of schizophrenia.

P120 more delusions. Don’t even sip. Put down that glass” inner voice, give me a sign (magical thinking)

P121 Patient has an answer for everything. Delayed response to poison? That is “the ethos of poison”

P122 Loud voices; Adrienne and Claude. Are these voices he is hearing, that are not really there? i.e. auditory hallucinations

P122-123 Stream of internal conversation, keeping him from sleeping, hyperalert.

P124; we learn more about Winston, and about his delusions that Adrienne is in love with him and about to leave her husband.

P125 Sound of hoof beats usually means horses, not zebras except rarely. A common saying in Med School that expresses the idea that one must give priority to the common things that give rise to a symptom, and not think too hard about the very rare things.

P125-126 What do you think of Dr Miniadis? She is focused on the educational value of this experience, and gives him no help in dealing with the actual clinical problem. Basically, he is on his own.

P127-128 Racing thoughts, insomnia. Manic?

P134-138 Sri talking with Winston. Trying to get him to be admitted. Dealing with extreme suspicion. Sri not sure of himself. Is suspicion of psych admission common? Still has stigma of being labeled crazy.

P136 Admitting patients against their will. Should this be permitted? Under what circumstances?

P137 Winston is afraid of being “watched”, especially in bathroom when he urinated. Sri tells him he was not watched din the bathroom, but that the exam rooms are monitored with cameras. Was this wise? Telling this to someone who is paranoid will reinforce their delusions.

P149 Voices getting worse, Now Winston’s mother is part of it. The entire thing has a surreal like quality, as in a dream. Winston has fantasies in his waking life that are similar to dream that non-psychotic people have. Do the surreal qualities of dreaming resemble psychotic mental illness?

P152 Why do you think that Dr. Miniadis asks Sri about the purple bird? What do you think about his response? Dr Miniadis presents a puzzle with the purple bird. It is intended to be a metaphor for a very unlikely event. But what is interesting is Sri’s dealing with it. He takes it very literally, does not get it, concrete thinking, looking for explanation, unable to think abstractly. He needs to make sense of everything, even things that are absurd. She is trying to show him how his search for explanations misses the essential point, i.e. this is very very unlikely He has no clue what she is trying to ask him.

P154 Winston getting worse. Auditory hallucinations. Hears his mother

P158 Sri goes to home. Adrienne comes to door, asks Sri what’s wrong with Winston. Sri invokes doctor-patient confidentiality. Is there any point at which this confidentiality should be breached? How about with a minor? But what if 15 year old girl tells doctor about sexual activity, and asks him or her not to tell parents. What then? Or says she is pregnant, ahs arranged for abortion, don’t tell my mom. What then? .Breach this only with great care. Minors, persons who are threat to others. What about threat to self via suicide? Does doctor have duty to tell someone? What about patient taking meds that may impair him but doesn’t want employer to know? Do you tell employer? What about if he is airline pilot? What about if he is a pilot, he is taking meds, is definitely not impaired, but med theoretically, in a small number of patients can cause impairment. Does one have duty to inform employer? Tarasoff case. Patient tells doctor he is so angry with his ex-girlfriend that he many kill her. Does he have duty to warn?

Psychosis is a mental disturbance in which the patient loses contact with reality We certainloy see this with Winston. But what about Dr. Miniadis? Is there something unreal about her? Consider, Sri is seeing a psychotic patient, she is wearing her earphones, listening to Smetana, and beaming manically at her student-doctor. She tells him "Drink it in! Take full advantage of this educational opportunity" (p. 125). Is this reality? Is there some disconnect here?



7. Eli

This is a terrifying story on many levels

The line on P 168, "Benevolence and cruelty are separated only by a veneer of whim which, in medicine, we understand" How is this exemplified in this story.. Fitz starts out with benevolence of his doctor persona, and ends with an acti of cruelty. .

P164. Fitz again. Working in hospital ER.

P165. Room where they put screamers is called quiet room. Why? Two meanings. First is euphemism, used ironically. Second, it is room where they hope to quiet patients down.

The emergency room has never been more vivid: Wonderful description of the chaos. "The crying of the child, the belligerence of drunkenness, the thin whine of a failed suicide. The noise and presence fills the waiting room, a condensation of the city's private screaming made public"

P166. Lam is making the point that the police, rather than have boundaries, park where they want, use staff washroom, etc. Sense of entitlement because they are public servants, keeping us all safe, and so have extra privileges. In this description, Lam is showing his wonderful powers of observation re police behavior. I remember when I was an intern, and working in ER, I had the same impression of police. What are your impressions of their behavior here?

P167 Playing a game. Police say prisoner fell and sustained injury. Fitz knows he didn’t fall, but police inflicted injury. Fitz knows that they know that he knows. “Benevolence and cruelty are separated by only a veneer of whim”, referring to how police treat prisoners. How does this apply to medicine? Who gets sick and who doesn’t is matter largely of luck, (? if religious, can call it whim of God) What does this say about the power of police? Prisoner very much at mercy of their whim; if police officer had fight with their wife that morning, might affect this.

P170 Fitz thinking to himself; Cops responsible for his legal ailments, he is responsible only for medical problems. Is t this division of responsibility accurate? No, he has responsibility to report any misconduct he uncovers, especially if patient dies. “Police records show everything explained to you” But of course everything wasn’t explained. What are ethical issues? Do no harm. Is he harming patient by not reporting his suspicions? Yes, (a) harm to this patient, (b) harm to society by giving police idea that they can get away with it. Be fair (justice) If police caused injury, certainly unjust.

Why does Fitz consider referring him to Psychiatrist? Not for good reason, but to protect himself. Last doctor to see him is one responsible.

P171 We see a surreal duet of doctor and patient, both shouting at once, neither, of course, listening. This passage is a microcosm of the story as a whole. Wonderful example of miscommunication, as they have parallel conversations. Fitz trying to elicit psych symptoms (hallucinations, delusions), while Eli trying to relate what happened to him. Neither is listening to the other.

P172 Up to this point, police have the upper hand. Now Fitz turns the tables as he relates what he knows, and acts dumb “must be mental illness, psychosis”

P176 Eli needs to be restrained. Medical and ethical issues. What about restraining old people in nursing homes so they don’t fall out of bed? Often done more for staff convenience than for patients benefit. I.e. don’t want them to get out of bed and wander around. Pros prevent them from falling out of bed, prevents falls, pulling out IV lines, catheters, Cons; higher morbidity and mortality, longer hospitalization, loss of autonomy, greater immobility with its complications afterward, higher incidence of infections and pressure sores. What are ethics of restraining? Loss of autonomy. (patient choice) and doing harm

P177-178 While being stiched up, Eli suddenly lunges and bites Fitz. He is very upset (worried re HIV, Hepatis B, etc). After this, Fitz’s attitude changes. He swears at patient, uses staples (which will leave scar and are more painful to put in) instead of sutures What aobut this change? Are you surprised? This is Lam’s way of honestly showing that doctors are human, not robots and cant always be “professional” “Anger needs to lay blame” What is anger? Always a secondary emotion, in response to fear, frustration, etc. Always due to an unrealized expectation (he did not expect to get bit, he thought Eli being held down, etc)

P179 Trouble finding a vein to draw blood. What does that mean? IV drug users have veins that are hardened and inaccessible. Scarred, referred to as “tracks”

P181 Again, Fitz is showing his anger toward Eli. If he apologizes, he will be nice. Eli uses profanity, so Fitz tells him that now he is leaving police, He baits him (I didn’t hear you)

This is a menacing story. Look at the words on P 181. "The evil of blood is like a malevolent thought. Once it touches, the very suspicion of its presence causes it to grow, to distort motive and action, and to propagate its own dark, spreading reach"

P183. Fitz plays a little trick on both Eli and police by deliberately leaving a scissors within Eli’s reach, knowing he will take it and try to stab police, and they will retaliate with more violence.

What do you think about Fitz’s acts of revenge against both patient and officers? There apparently is enough moral reprehensibility to go around

P183-185 Fitz is collaborating with police in covering up any evidence of police brutality. He is so angry with Eli that it is OK for cops to act as judge and executioner.

P186 How do you react to the last line, "I didn't look to see the faces of the officers in that car"

How do we feel about Fitzgerald's complicity with the police? (". . . the game: You do your thing and we'll do ours…cops and robbers and doctors" p. 167).

Entire story shows hostile game between Fitz and Eli. Most ethicists would say Fitz is behaving badly. Yes, but, he is a human being with human emotions.

Do we see all three sides— Eli (patient), police, Fitz (doctor)—reaching a lowest common denominator in their behavior? Lam is putting them all on the same moral level in this story.

8. Afterwards

Wonderful little story about the aftermath of death, family tragedy, secrets. We again meet Sri, working in the ER, where a man who has undergone a cardiac arrest is brought in. Turns out he arrested while in the middle of an episode or oral sex in a brothel masquerading as a hair salon.

A very effective device Lam uses is the silent response, revealing the thoughts of doctors as they deal with patients. In this story we are privy to Sri's internal dialogue

This is a Rashomon story, told from multiple points of view. Whose points of view are used in the story? Sri, Cynthia, widow of dead man, her son, paramedic.

.P187-190; Man brought in unconscious. Cardiac arrest. No vital signs for at least 25 minutes. Try to resuscitate, unsuccessful. Patient has V Fib. What is that? This is an excellent description of an attempt at CPR. Lam describes details, like Zoltans posture, etc.

P188 “too late to make a difference” What does that mean? Too long, will not be successful. So why do they try anyway? Routine, habit, this is the way they have always done it, needs to show they did everything, etc. Why is Sri calm? Nothing can go wrong at this point. He doesn’t have to worry about making mistakes.

P190 Patient referred to as the V Fib. Common designation. The stroke in Bed 4, the pneumonia in Room 2, etc. Dehumanizing. Know patient by the name of their disease, not the name of the patient.

Philosophical musing by Sri. When is patient really dead? When Sri pronounces it? After family told? (Family thinks he’s alive until they are told)

Sri dreads talk with family. Do you think this happens? What must it be like for doctor who has never met the family to tell them their husband, father, is dead. He goes through a routine, while mulling whether he should just tell them he is dead.

P191 “I always feel I might be lying” Why would he lie about this? (Pain and discomfort). Since really don’t know, why not make family feel reassured that he did not suffer.

The vee-fib victim, Mr. Wilhelm, was a sedentary, smoking diabetic. "Sri always felt relief to learn that a deceased person's end was predicted by his life. It made it a happens-to-someone-else event, a bound–to-happen circumstance. There was less to explain, or understand". Does this attitude correlate with what else you know about Sri? Likes things to be concrete, rational, no loose ends, everything fits and makes sense.

P192 Son is Sri’s age. That is the sort of detail that an intern or resident would notice, because this is what makes them relate more directly to the family

P193. Fairly typical for family to focus on those details that they need to know about but which doctors never think about. Where is his car parked? Will they tow it? Etc.

Family is suspicious of story that he died in hair salon. They set out to learn more.

P198-206 Story shifts to point of view of prostitute, in which we see events through her eyes, get a sense of her emotional reactions, what this job means to her.

P205 Prostitute and widow feel “an almost identical mixture of hate and pity for the other”. Each hates the other, and can understand what the other is experiencing. Empathy is mutual. Lam is convincing; even though he tells us this, we can sense it, see it.

P206-208 Story shifts back to the ER.A paramedic, Zoltan, finds himself unable to have sex with his wife after being involved in the events of the story. This shows (a) the events depicted in the story have repercussions that go beyond the prostitute and the dead man’s family, and (b) Sri acts to prevent a repeat set of behaviors by Zoltan similar to the dead man (i.e. having to go to prostitute).

The paramedics lied regarding where they picked up dead man. Said it was hair salon, knowing full well that it was brothel. What about ethics of this? Is telling lies OK? Some say never do this. What do you think?



9 An Insistent Tide

This is a wonderful story, with much suspense, of a pregnant woman who has a major delivery complication. We again meet Ming, now as an Ob/Gyn. There are two characters in the story, Ming and Janice, a woman at term who gives birth but has a prolapsed cord.

What does the title refer to? The ocean tide recurs in the story three times, first as she goes into labor while asleep and her membranes rupture, with fluid soaking her which she mistakes for the ocean. Secondly while in labor at the hospital, after she uses laughing gas (nitrous oxide), and finally while she is having surgery without anesthesia. So the ocean tide recurs.

Lam’s descriptions again are wonderful, very accurate;

P213. “streaking her abdomen with stretch marks of glistening purple skin”.

P 224; and other places, describes the miracle of pregnancy.

P 219-220 Build up of tension. At first, Ming realizes the cord has come down ahead of the head, and tells Janice. Janice does not realize this is not good news. Over the course of 1-2 pages, Janice is finally made to realize this is a true emergency and potential disaster. Lam takes us through the sudden change from normal delivery to a very serous complication, with a sense of the urgency of the situation.

Ming does a C Section on Janice. There has been much talk about unnecessary C Sections and whether they are used too often for either convenience, or to prevent malpractice actions. Is this one of those times? What makes it necessary here?

What about the no-show anesthesiologist? What do you suppose may have happened to him? Going out for dinner? Asleep? Just taking a break and refusing to answer? Most of the possible scenarios involve Irresponsible behavior which almost cost the life of the baby.

What do you think about Ming operating without anesthesia? Lam makes the point that this is how it was done for many years, back to time of Caesar. Ming uses a combination of three things. IV morphine, inhaled laughing gas, and topical lidocaine to anesthetize skin. This combination cannot match the strength of a real anesthetic.

10 Night Flight



Fitz again. We have seen much development of Fitz since earlier stories

#1 prior to Med School), relationship with Ming.

#3 year when Ming away and he is trying to maintain connection; we see the breakup of relationship

#4 As med school handling a code

#7 ER doc with Eli

Now he is a flight doc. What sort of doctor takes this job? The sort of person who doesn't have or want the ability to run a practice, attract patients, be on call for his patients (requiring a high level of responsibility) Is this job for anyone? How does Fitz fill the pattern? Generally a certain kind of job. Not for someone wanting to build a stable practice, but more for someone whose life is in flux, volatile, with few attachments. Also, the requirements are fairly well-known and unambiguous. In actual practice, higher level of responsibility and more room for getting things wrong.

Do you think that Fitz’ life may have taken a different turn if his relationship with Ming had endured? More stable, happier? Shows the role of chance, of fate, of circumstances.

P235. Fitz is relying on alcohol. Why does he drink? To self-medicate his anxiety. So he won’t have to think about the voids in his life, and the pointlessness of day to day existence with not much to be happy about or to look forward to.

P238 This is a very good description of events prior to an actual stroke. Instead of author telling us of these events, he shows us by way of handwritten note from patient’s wife. Nice device, since it keeps action flowing without a didactic interruption, and reveals something about ht kind of person wife is

What is a stroke? Medical term CVA, cerebrovascular accident, loss of brain cells due to obstruction of blood flow to brain, either form clot blocking supply or a bleed from a vessel. Can be of varying degrees of severity, and have varying clinical picture, depending on area of clot, how much brain tissue lies beyond site of obstruction, etc.

P239 At hospital, everyone must pretend like “they know more than everyone else”, and “no one can mind their own business”. Lam is making reference to game playing that most doctors engage in. Again, contrast with being a flight doc vs. working in a hospital.

P244. Lam is letting us know that patient is not doing well. He does this in a way that doesn’t require any medical knowledge. Very low BP, fever, non-reactive pupils, are all bad signs, and the menace comes through. Withdrawal from painful stimuli reminds us that the patient is really a patient and is still alive. . .

What is coning? AS result of swelling in area of brain that is dead or dying, the pressure is pushing the brain toward the one opening at the bottom of the skull. This however will not permit the entire brain to pass, so the brain stem (bottom) gets squeezed. This is where vital functions (heart beat, breathing, etc) are controlled, so that if this is lost, it means death.

P245. What is the level of medical care in this area of Guatemala? Primitive. How do we know? One neurosurgeon 300 miles away, CT machine not working.

Fitz asks questions about diagnostic tests to find cause of fever. Blood and urine cultures? They do not answer, but finesse by stating what they have acceoted as the cause, i.e. increased pressure in the brain. Does this matter? Yes, if due to infection, can be treated. High fever will result in more rapid death of brain cells. Reason for not answering; probably do not have facilities for testing these things. Fitz is speaking like a doctor back in Canada with modern labs, etc.

P246. The wife tells Fitz “The insurance co0mpay did not want to fly him. Said there was no point”. What do you think about this comment from insurance company? May be true, but highly inconsiderate to patient. Bureaucrat adding it all up coldly, thinking of costs and potential benefits, and ignoring impact on patient’s family. This is often the nature of modern medicine. Faceless bureaucrats making decisions based only on costs.

P250. More callous Insurance company behavior. No point in CT scan. Brain dead. Pull the plug, etc.

What are the elements of the story that add to the tension? 1. Critically ill man in primitive area of the world, want to get him to area of better medical care, 2. Fire coming closer 3. No one knows about fire, afraid if he tells them they won’t attend to patient, 4. Airport closure imminent. All these factors come together in just a few pages.

P252 Fitz shows his decent side as he wants to warn Dr Manolas about the fire.

“A moment of delicate balance” Suspended narrow bridge of time” between the stable earth on the other side of the chasm, refers metaphorically to modern medicine vs. primitive care All the vital functions are laid bare here, whereas the “healthy man keeps secret and neat” … “while going through life occupied with desire and philosophy” A wonderful reminder of the mysterious chasm between dying and living, in which some matters can loom large, and yet disappear when dying.

P254; again tension re the fire

P256 Mr. Amiel has a cardiac arrest. All the difficult stuff is accomplished; now that they are on the way home, he is no longer pumping blood.

P257 Brain and heart are given human characteristics. “the last abuse” “they tell the heart to stop” “The heart says Fine! Leave me be”

They are going through their expected roles, but Lam does not tell us this directly. He has Fitz “wonder if it looks obvious that we are simply playing our roles” Downplays, understates. “Administer the drugs anyway because I said I would try …”

P259 Tension abates, Patient has died. Patient’s wife is OK. They are in air; don’t need to worry about airport closing. Fire is not a wildfire but an intentional fire to process sugar cane.

P261 “Balance of professing humanity without invading privacy”. How does one know how to strike that balance? Part of the art of being a doctor is to know intuitively how to do this, and how to modify to meet the needs of each of different patients.

Mrs. Amiel asks Fitz if he would not have received better care in Toronto. Fitz lies, telling her they did all those things that would have made a difference. What do you think? Should Fitz have said otherwise? For what purpose? Is this a good lie, or are all lies by definition bad?

Lam defines lie. They are “about belief”. We suspend reality because we want to believe the lie. Must be trust both ways for it to hang together.

P266. They play a “what if” game, in which we learn that if Fitz’s wife has an affair, he would prefer not knowing about it. He wants to be able to continue trusting his wife, and knowing about it would prevent that. Do we learn anything about Fitz from this? And how does this not knowing, being ignorant of the truth, relate to the earlier lie that Fitz told, such that Mrs. Amiel is ignorant of the whole truth about her husbands care.

11 Contact Tracing



This story is the story of the SARS outbreak in Toronto. Toronto was one of the hardest hit cities in N America, and it hit the medical community particularly hard. Lam would have been training in residency or an ER doc at time of pandemic, so would have seen much of what he writes about. Further, the pandemic began in China so it would have another meaning also for Lam in particular.

We see Fitz again. WE have seen him previously as a premed student, Med school applicant, lover of Ming, med student handling code, ER Doc, Flight rescue doctor. How we see him as a patient with SARS. And we learn that he lost his job as an ER Doc because he had been drinking, arrived for a shift and was told to leave.

Much of the writing here is done via consultant’s notes. This introduces an interesting distant dispassionate tone to a very serious deadly disease.

SARS what is it? Severe acute respiratory syndrome, a respiratory disease in humans which is caused by the SARS corona virus (SARS-CoV). There has been one near pandemic to date, between the months of November 2002 and July 2003, with 8,096 known infected cases and 774 deaths. Within a matter of weeks in early 2003, SARS spread from the Guangdong province of China to rapidly infect individuals in some 37 countries around the world. Mortality by age group as of 8 May 2003 is below 1% for people aged 24 or younger, and more than 50% for those over 65

Opens with Fitz in isolation. Toronto was the hardest hit city in North America. Fitz was seen in ER by Chen, his previous rival. What are issues of doctor as a patient? Many. Need to avoid the VIP syndrome, with short cuts.

Should he maintain his identity as a doctor? Pros; security blanket, like a “piece of clothing” Cons he feels there is an implication that he should be able to control the illness, there is an obligation attached to the word.

P271-272; Sheer boredom of being a patient. Wants to leave, to go home. Very common feeling in hospital. Not a good place to relax.

P273; excellent clinical description. Severe pneumonia. Cause not yet know. Treated with antibiotics, two kinds of anti-virals, high dose steroids.

Fitz has coarse tremor; his doc is puzzled. The reader knows he has been a heavy drinker, and tremor is likely due to withdrawal.

Is he an alcoholic? What is an alcoholic? Someone whose life (work, relationships) is significantly affected by it) Why does he drink? To self medicate anxiety, existential angst, void.

P274. Chen exposed to him as his doc. Because no special precautions, he is now quarantined. Later, he also gets disease.

P275 Excellent description of desire to drink. “Binges called him like old friends who were impossible to outgrow”

P276; Fitz has dream Ming is patient on flight. She has newborn that she flings at him. Interpretation? Major anger and hostility. Life with her ?baby. Abandonment of him was a theme with Ming, re her leaving him for Chen. . Now she leaves him to go talk to pilots. Inability to keep baby alive, analogous to his failures, including failure to keep their relationship alive.

P278 Cons note; now Chen is the patient. No longer quarantined but full blown illness. Chen has acted as his own doctor. Is this a good idea? Ordinarily not a good idea for doctor to be his own doc. Here there are two circumstances that make it OK. First, the importatn doctor here is the ID doc, who is doing the actual clinical work. and secondly he doesn’t want to expose another person.

P280 A good example of the ambivalence that goes with love. Fitz realizes that at one time, he both would have wanted Ming to get the illness, and at the same time wanted her to be healthy. Do you find that credible?

P281 Nurses assigned to SARS unit by lottery. Ethical issue; Is this best way to decide who will go into harms way? Same way we assign soldiers during a draft. Alternatives; (a) volunteers only; as in peacetime army without draft. However, may not get enough volunteers. SARS pandemic very frightening at the time. (b) Use some kind of arbitrary criteria, such as age, whether or not married, children, whether in college. Problem; people will often change their personal situation to get out of serving. Plus it puts different values on the life of different humans. Volunteers the best way, but if cant get enough, then lottery is the fairest way.

P285 Making something into an issue. Dying Patient requests eggs Benedict, doc writes order. Nurses balk, get consult from dietitian, who recommends low salt low fat diet. The fact that pateint has termianl cancer does not enter into decision making. This happens a lot; typical in a hospital.

We also learn more about Sri, who has since died. He was very patient centered, even making special meals for this dying patient.

P293-294 Dolores. Works on SARS unit. No unprotected contact, no symptoms. but the woman running daycare for her kids wanted her to keep them home “other parents complaining, warned their children not to play with Dolores’ children. What is that about? Is that fair? Fear of plague. Historic issue.

P 295 Chen recollects Dr, Gerstein “one in a hundred” mock exercise with patient. What do you think of this? Doctors often need to make analogies to explain to patients such thinks as risk-reward ratios (as was the case here)

P297 Chen and Fitz speak of death with humor. They both trivialize and intellectualize it. (if they find a cure but our deaths help it will have been worthwhile). Need to do this, habit they developed as doctors, but now are referring to their own deaths. Is very different. What do you think?

Death “its ordinary but like a sudden hole in the world” This is OK as a description from POV of survivor, but not from POV of dying one.

Fitz contemplates whether loss of Ming was a factor in shaping his life. He goes back on forth on this. What do you think? I think that every item in our history shapes our life.

Do you think that loss of Ming led to his drinking? My take is that he was chronically anxious, and Ming certainly played into his anxiety. The alcohol was his way of self-medicating his anxiety.

Flu epidemic of 1918 (Spanish flu); 40 million deaths, more than WW1.

P 299-300 good description of quarantine precautions. Quarantines used to be far more common when there was really no treatment for these diseases. With advent of antibiotics, quarantines have become rare.

P 301 .Dolores in line. Is in typical planning mode. How to improve one’s lot. To bring umbrella? Someone might want to stand too close. Hoarding of blue masks, etc.

P304 A very dramatic ending with Chen breaking through glass partition to try to save Fitz, is told in subdued way as part of a news clipping (banal)

12 Before Light

Final chapter; Ming and Chen.

Find that Chen also has his demons, as he describes one shift in the ER overnight.

P311; Sense of entitlement re car. Has found ways to justify liking certain material things .Speeding part of entitlement.

P313; Series of ER vignettes are very typical

82 yr old woman with dizziness. Poor historian, game playing, hard of hearing.

P314 48 year old man with chest pain. ECG squiggles compared to tea leaves, tells fortunes. Great metaphor, since indeed it does tell fortunes, and reading it looks a lot like reading tea leaves.

P316 What do you think of Jill, the nurse complaining about staff. She is oblivious to presence of patient. She goes on and on about patients dying because of poor staff. Chen tries to stop her and she just laughs.

P319 Chen convinces patient with tax story. So much of medicine is talking patients into things by using anecdotes, Vague explanations (your tax dollars at work, etc)

P 320 Woman with hiccups and psoriasis, wants a Derm consult at 2.30 AM. Chen finally loses it, then documents the visit over thoroughly.

P323 Exhausted, falls asleep for 30 mins. Common in ER.

P325 “I seem to hear better now that I have my glasses”. This at first sounds like a joke, but many people report this. Why might this be? Encourages focus?

P330; Utter banality of ER, death. Name of guy in Bay 4?. Not a human. She needs to do “papers”. Or patient brought in referred to as “brady—“. Lost papers, etc, all as if just another bureaucratic mess.

P331; Battle between Chen and Internist who resents being awakened and is determined to make Chen wrong, re inappropriate referral.

P334-336 Chen driving home in AM after his night shift. Get a sense of the exhaustion that he feels. How does Lam impart that? (Show, don’t tell)

-----------------------------------------------------------------------------------------------------

9. p 43 Sri says "You should respect a man's symbols" Why does he say that.

10. Why do you think the Mark 16 segment is part of the "Murphy" story? What other links between religion and medicine do you see in the book?

11. In another story, "An Insistent Tide," why is Janice vacillating between the beach and her baby's delivery? Dreams, laughing gas, extraordinary pain—how are these ideas connected in Lam's experimental prose?

12. Several of Lam's stories are so rich that they could be novels in themselves. Which ones would you put in this category? Perhaps "Night Flight"? "Winston"? "How to Get into Medical School, Part II"? Does Fitzgerald's obsession with Ming take on a clinical life of its own? "For months now, Fitzgerald's mind had alternated between studying and allowing his speculations to spin like wheels stuck in a rutted path of Ming and medicine, digging the tracks deeper and deeper" (p. 67). This story includes the apocalyptic bike accident when Fitzgerald is sure he is about to die. Does the reader feel Fitz is spared for something else?

13. Further in the same story, in his med school interview, ". . . McCarthy asked him what quality he felt was most important in a physician. Trust is most crucial, said Fitzgerald" (p. 73). How is this statement ironic, juxtaposed with the Karl-Fitz event that follows? What is the poetic justice in Fitz's elevator confrontation with Karl? Is this the end of their story? What is the flick of the serpent's tail in Karl's last warning (p. 75)?

14. One of the most provocative stories is "Winston." Is this psycho-mystery resolved at the end? Or does it metamorphose into a new level? Sri says, about Winston, "His thought process is at times tangential" (p. 124). Is the whole story tangential? A kind of circular nonreasoning?

15. Lam's glossary at the end defines psychosis as a mental disturbance in which the patient loses contact with reality. Starting with Dr. Miniadis, What does Sri make of her term of art, "counter-transference"? Earlier, Sri has said, "Some think of illness as a kind of poison" (p. 121). How does this image pervade his visit to Adrienne? Does it suggest Ionesco and Beckett and the Comedy of the Absurd?

16. What shocking actions succeed this quotation? Are we at all sympathetic?

17. In "Afterwards," as in some of the other stories, the line is thin between farce and tragedy. Is this the nature of the human condition? What are some of these moments? The prostitute too otherwise engaged to hear the inspectors enter? Mrs. Wilhelm clutching the old fedora? The debate about the nature of "the parlor"? "There is a back room. For ten years your father hasn't touched me. Said it was his diabetes, that he couldn't do it" (p. 197). Where else has Lam widened his scope, giving us the story behind the story?