Monday, July 3, 2017

Robbie Maakestad: On Pneumothorax and Writing Medical Trauma

This past spring semester I taught an introductory literature course at George Mason University. For our final text of the semester my students read Mike Scalise’s The Brand New Catastrophe: A Memoir—a hilarious (albeit harrowing) account of dealing with the hormone-less fallout of emergency surgery to remove a ruptured tumor on the narrator’s pituitary gland. In order to undermine the medical trauma, the juggling of drugs post-surgery, and the deep level at which this event transformed his life, narrator-Scalise consistently cracks jokes.
Yet, this book is more nuanced than an entertaining take on a medical catastrophe. For instance, look how Scalise begins the prologue: “Telling a good catastrophe anecdote means becoming a maestro of sympathy.” Later, he continues, “The trick to keeping [the audience] engaged is to focus on the oddities and ironies that would seem incredible and ridiculous in any context, not just that of your disaster.” And so, throughout his memoir, Scalise takes his own advice. I found myself not so much drawn to the humor and bizarre circumstances that Scalise explores, but rather I gravitated toward his writing about the way medical stories are told, how they are crafted for an audience.
            Throughout the book Scalise tells his pocket version of his pituitary trauma to various effect and with varied purpose: via email blast to friends and family [claiming the surgery as an accomplishment], at a family get-together [complete with slideshow], at a Manhattan party [for the first time his story entertains an audience], and to his boss at his first job [empathizing with her medical condition]. He even spills his story during an interview with a publishing house [an abject failure], and follows this up by inquiring about the quality of their health insurance policy.
As the reader observes this narrator feeling his way into an understanding of how and when his story works (or does not work: see publishing house interview), the reader is able to gauge the way illness narratives function for an audience—a metacognitive analytical experience since readers are in themselves an audience. The very act of reading Brand New Catastrophe becomes a learning experience in that subconsciously Scalise’s readers consider when and how to tell tales of medical trauma while also engaging with an entertaining memoir.
As such, a recurring point of class discussion ended up being the way Scalise consistently wields humor to deflect the reader’s pity. As Scalise begins to craft the narrative of the wracking headache that first sent him to the ER, he breaks back into narratorial explication of how one best relates a story of medical trauma: “Notice how the focus here is not on the vast pain that commandeered my head that night. Pain is a socially competitive thing, and too much emphasis on it can cue people to recall their own bouts with pain, or compare theirs to yours.” And this proves true time and again in Scalise’s narrative; by attaching the reader’s focus to the humor present in his situation, Scalise causes the reader to move beyond their propensity to feel sorry for a narrator wading through difficult circumstances. Perhaps the best medical nonfiction, then, finds a way to deflect the reader’s pity, or to avoid it all together.
            In March of 2009, my left lung collapsed in the middle of an intramural basketball game—a spontaneous pneumothorax—which hospitalized me in middle-of-nowhere Indiana, fifteen minutes away from the college where I was studying. Though unlikely, a pneumothorax is a common-enough diagnosis for tall, thin, white dudes in their late teens. As the chest walls extend with growth, so too do the lungs, which can become unwieldy and weigh too much to be supported by lung tissue alone, causing the organ to fissure, air to escape into the chest, and the organ to shrivel like the popped balloon that it has become. Once a surgeon stabs a tube into the chest cavity, the air escapes, restoring the body’s internal pressure balance, allowing the lung to reinflate. A week or so resting in the hospital is usually standard for the body to patch scar tissue over the fissure, restoring the pneumothorax victim to health. And this is precisely what happened to me.
            Sitting in that podunk hospital, I found that when friends and family visited, they approached tentatively, as if I was fragile. After asking how I was doing, they’d inevitably express their sorrow over my defective lungs, which was the last thing I wanted. Rather, I missed the joie de vivre of college life, of living in a dorm surrounded by friends, of dinners at the dining commons, of going to class. After laying in a hospital bed for days watching America’s Funniest Home Videos marathons, the last thing I wanted was pity. I already pitied myself. When friends visited, I deflected their condolences with attempts at humor: “It’s cool cuz once the chest tube comes out the hole allows for Mr. Potato Head attachments,” etc., etc., ad nauseum. Even when my dad walked into the room immediately post-chest-tube-implant, I closed my eyes and splayed myself dramatically across the bed, playing dead—a joke to downplay our family’s first major medical drama. Without a second though, my dad, thinking I was still “out” (though I had been awake for the entire procedure), snapped a photo with his brand new smartphone so I “could see myself later”—my first attempt at pity deflection memorialized in snapshot.
            But this avoidance of the reader’s sympathy raises a question: if the success of medical essays hinges on the deflection of pity, what then is the purpose of writing it in the first place? For if an essayist attempts to fully encapsulate their own medical trauma on the page, is not the essay at some level a request for the reader’s pity? Likely most people have not experienced similar trauma, so exposing the reader to a nonfictive medical experience forces the reader to grapple with that account, to reckon with the experiences of another—a situation in which they cannot help but feel some semblance of pity.
            In her 2003 New Yorker essay, “A Sudden Illness,” Laura Hillenbrand writes of developing Chronic Fatigue Syndrome (CFS), a disease about which little is known, and for which she bounced from doctor to doctor in search of a diagnosis. The essay recounts years that Hillenbrand spent in bed, crippled by the disease, too dizzy to stand up, locked in a stalemate with CFS. Though Scalise argues against leveraging the reader’s capacity for pity, Hillenbrand does the opposite; of the essay’s 7525 words, 5295 (70 percent) detail her wide range of devastating symptoms and the variety of misdiagnoses that doctors ascribed. The essay reads as a veritable tsunami of pain—the chaos of symptomatic overwhelm.
Though at times the reader slogs through the narrator’s listed symptoms, the effect is that the reader begins to understand, if only fractionally, what it is that this narrator herself experienced—a shift from pity to empathy. The recounting of this disease’s resulting isolation and debilitation restricts the reader to Hillenbrand’s metaphorical bed of symptoms: “The realm of possibility began and ended in that room, on that bed. I no longer imagined anything else.” Just as Hillenbrand’s narrator is confined to a piece of furniture in her bedroom, the reader also does not move beyond the overwhelming description of the symptoms until the ending in which Hillenbrand leverages the stridency of pain in an unexpected shift outward, beyond her pain and her struggle with symptoms, to a hope for reprieve—a breath of air beyond the sick chamber—a rolling back of the reader’s pity, replaced by hope for this narrator’s future health.
Two months after my first hospital stay, my lung collapsed a second time, so a friend drove me to a hospital in Indianapolis—one that had actual lung specialists. When a lung deflates too significantly to permanently repair itself or when it collapses multiple times (my case), the surgeon recommends surgery to glue the lung to the ribcage in order to take the weight off of the organ: a procedure known as pleurodesis. To affix the lung, a surgeon slits open the skin to the side of the pectoral muscle, and inserts a de facto tire jack between the ribs to ratchet them apart without breaking the bones. The surgeon then sticks his hand into the orifice to manually manipulate the deflated-football lung until the ruptured tissue is located. The fissured area is sliced out, and the lung gets stapled back together, which enables breathed air to expand the organ, reestablishing the full flow of O2 to the bloodstream. The surgeon scrubs the medical equivalent of steel wool across both the lining on the organ’s exterior and the interior lining of the ribcage, and deposits acidic talc powder upon the freshly abraded surfaces. The lung is pressed against the ribs to trap the acid powder between, which reacts against the bleeding tissue and creates gobs of scar tissue, bonding the organ and bone—a procedure that sounds rather medieval in execution. But, for how inhumane it sounds, my recovery was not as bad as I had been told, and the surgery worked to lessen the self-weight of my lung.
            In his 2003 Georgia Review essay, “Bullet in My Neck,” Gerald Stern dramatizes the moment when two would-be thieves shot up the car he was traveling in at a stoplight in New Jersey. One bullet hit his chin and lodged in his neck, and another grazed his shoulder. Slumped over, Stern floored the gas pedal with one hand, and his driver, Rosalind—a fellow poet—took the wheel and drove them away. Though a fantastic hook to the essay, Stern’s handling of the shooting itself only spans half a paragraph.
Rather, Stern focuses on the shooting’s aftermath. He details their difficulty in finding a hospital as anyone he asked for directions shied away at the sight of all his blood. But they eventually found one; he does not remember how. Though Stern details the medical treatment he received at the hospital as well as his difficult recovery, throughout these passages, Stern continually focuses on the suffering of the other: Rosalind, who was left alone and untreated in the hospital while he was cared for; a frog that his friend abused as a child, which child-Stern put out of its misery; Bruno Schulz, the Polish-Jewish writer and painter, killed by a Nazi officer; and Stern’s own sister’s death from cerebrospinal meningitis. Stern ends his essay:
And I want to remember how small was my brief “suffering” compared to thousands of others’, what cruelty, absurdity, insanity, maliciousness they were forced to experience, how the lamb itself was twisted and pulled in a thousand ways, how it wept for itself at last, just as it wept for others—and continues to do so.
Rather than allowing his own pain and suffering to take a central role in the essay, Stern uses these as a vehicle by which he can examine suffering itself beyond his own experience, as a human experience. Rather than leveraging the reader’s pity as Hillenbrand does, Stern shows that it is also possible to redirect, affectively guiding the reader’s sympathy elsewhere.
Though pleurodesis solves the problem of collapsing lungs for ninety percent of people who suffer a pneumothorax and opt for surgery, I fall into the unfortunate remaining tenth percentile. Normally, if a lung collapses after pleurodesis, the scar tissue that affixes it to the chest wall holds the organ up and open, still able to breathe, which allows the lung to heal itself. Yet, in my case, two years after I’d had pleurodesis, my lung collapsed so significantly that the organ ripped away from the scar tissue and fully collapsed.
This surprised the surgeons, who relayed a more permanent option than retrying pleurodesis: a pluerectomy. The procedure would be precisely the same as pleurodesis, but this time the surgeon would rip out the pleural lining surrounding the lung so that the lung could adhere directly to the ribcage itself—an even stronger bond than previously, albeit one whose recovery would be ten times as painful given the nerve endings that would be exposed with the removal of the pleura. I opted for this procedure, rather than risking a repeat failure of pleurodesis—what I hoped would be the right decision.
That night while waiting for an operating room to open up the next morning, I had trouble sleeping, so I did some research on the procedure and found that the surgery was only about sixty-five years old—first performed in the 1950s. While that is many years during which a medical procedure can be refined, even more than that, I found comfort in thinking that I was alive within the slim fraction of human history during which this surgery has existed. Previous to 1950, a pneumothorax would have permanently invalided me if not been my death sentence.
            In her seminal 2014 essay in The Believer, “The Empathy Exams,” Leslie Jamison details her experiences as a medical actor, as well as her decision to get an abortion—blowing both open to explore the human capacity for empathy. Here, Jamison explores the crux of handling pity as pertains to her decision to get an abortion: “I wanted someone else to feel it with me, and I also wanted it entirely for myself.” This evidences the inherent contradiction of writing the medical trauma essay: though the writer desires to avoid overwhelming the reader with descriptions of pain and suffering (evoking pity), at some level the essayist must share their pain with the reader, in order to capture the reality of what they experienced (evoking empathy). The issue then becomes landing in the middle of the continuum of sharing too much pain and sharing too little. 
            But this leads to the question: why put the medical trauma on the page in the first place; what is gained by sharing it with the world? Again, Jamison has the answer. In her essay “Grand Unified Theory of Female Pain,” published by VQR in 2014, Jamison writes:
What’s fertile in a wound? Why dwell in one? Wounds promise authenticity and profundity; beauty and singularity, desirability. They summon sympathy. They bleed light to write by. They yield scars full of stories and slights that become rallying cries. They break open the fuming fruits of damaged engines and dust these engines with color.
Essaying medical trauma, then, presents an opportunity to mitigate the experience itself, to attach to a meaning beyond the pain and trauma, just as Gerald Stern found himself able to do. Later in the essay, Jamison returns to the explication of wounds:
Wound implies en media res: the cause of injury is past but the healing isn’t done; we are seeing this situation in the present tense of its immediate aftermath. Wounds suggest sex and aperture: a wound marks the threshold between interior and exterior; it marks where a body has been penetrated. Wounds suggest that the skin has been opened—that privacy has been violated in the making of the wound, a rift in the skin, and by the act of peering into it.
This logic holds true when broadened to the writing of medical trauma, for what is trauma but a physical or mental wound? When writers peer within the traumatic circumstances surrounding medical emergencies or treatment, they name it, giving voice to the wound. By spreading wide the skin of the medical trauma and poking around to find what’s raw, writers reveal the heart of the wound. For in the telling, some element of healing takes place.
Three years and a move to the east coast later, the pluerectomy still held my left lung in place, but for the first time, my right lung collapsed. I was eating a bagel sandwich when I felt the familiar gurgle of air escaping. Three days later, the hospital released me to meet with a specialist since my lung had stabilized. In an hour-long consultation, my new surgeon prodded for my complete lung history—each and every collapse or gurgle of air escaping, no matter how minor. The tally: nine lung collapses, this most recent being the tenth. Once he had established a complete timeline, he thought for a moment and said, “Well, if I didn’t know you or your past, I’d recommend waiting to see if the lung stays stable and remains inflated. But given the circumstances, I’d be willing to do surgery if that’s what you’d prefer.” When I asked what he would do in my situation, he chuckled. “If I were you, I would push straight for a pluerectomy.” As I left his office, I breathed shallowly, a pluerectomy scheduled for the next morning.
            Perhaps my favorite medical trauma essay is Rachel Riederer’s “Patient” from the spring 2010 issue of The Missouri Review, in which she details an accident in which a bus ran over her left leg, crushing her foot. Unlike any other trauma essay I’ve read, this one captures the raw incongruity experienced as a medical trauma unfolds: the questioning, the uncertainty. In the moment where the bus sits atop her leg, the narrator asks an onlooker, “Can you please tell him to move?” In that moment, Riederer reflects, “It is easy to be calm because I cannot really have been run over by a bus.” Though the bus sits on top of her leg, she denies the actuality of her injury—a rhetorical move that repeats itself throughout the essay.
For instance, in the hospital Riederer cannot move her toes when the doctor requests that she do so. She writes, “My toes would have bent. My feet are pretty and obedient. They are slender with high arches. Yes, they are callused on the bottom, but they are nothing like this fat red blob that has had all the foot shape squashed out of it.” By crafting the narrative to include these moments of disbelief, Riederer immerses the reader into the surrealism of the moment, allowing them to feel her shock and her inability to grasp the reality of her crushed foot.
Further, Riederer creates a deluge of drama: doctors deciding whether or not to amputate, nurses debriding her tissue, the decision not to amputate, her detached calf muscle dying a little bit every day, the first glimpse she gets of her own leg post-surgery. All these recreations of the then-narrator experiencing and feeling in the moment add texture to the essay, establishing the vividness of the “then” in order for the reader to best engage with the experience crafted on the page. By immersing the reader in breathlessly vivid scenes, no room for pity remains.
Before I was released from the hospital post-surgery, my surgeon stopped by my room. “Here,” he said, holding out a business card. “I wrote my personal cell number on the back. If anything happens with either lung, give me a call day or night, okay?” At first I found this reassuring—my own on-call lung specialist. But after he left I began to have my doubts; under no circumstance would a specialist hand out their personal cell number unless they thought it absolutely necessary.
Two years out, my lungs remain stationary within my torso—firmly adhered to the chest wall. Though I have been medically cleared for all activities except smoking and scuba diving, and though I have almost no residual side effects except for extreme shortness of breath if I exercise, my lungs cast a constant presence over my life. I am cognizant of every gurgle and groan within my chest, every torsional shift while sitting or laying down, of the stasis of my lungs while my other organs move freely when my body is in motion. It’s not that I am scared or afraid that they’ll collapse again; rather, it’s a finely tuned bodily awareness usually glossed over by the brain. Two years out, I have yet to call my surgeon’s cell, but it’s a number saved into my contacts just in case.
            In the conclusion to Brand New Catastrophe, after so many pages spent telling and retelling the story of his brain tumor in different contexts, of learning when and where and how to tell the tale, Mike Scalise writes, “And it becomes possible… to grow infatuated with something, even as it destroys you.” Here finally Scalise recognizes the way the story of his brain tumor consumed him in the years following surgery, the way that a façade of humor and an engaging retelling spackled over the hole that his medical trauma had worn throughout years spent juggling hormones levels via medication and further treatment.
And is this not precisely what the medical trauma essay must avoid? A spackling over? A façade? At heart an essay digs deep to open something up, to unearth that which is hidden within, to expose the truth tucked beneath the surface. So too must the essayist push beyond the trauma, the medical terminology, the shock, the pain, the uncertainty, and probe the wound in order to suss out greater meaning.

Robbie Maakestad received his MFA in Creative Nonfiction from George Mason University where he was the Editor-in-Chief of Phoebe. He currently reads and edits nonfiction for The Rumpus and has been published or has forthcoming work in The MacGuffin, Free State Review, and Bethesda Magazine, among others. In 2017, Robbie was shortlisted for the Penguin/Travelex Next Great Travel Writer Award. Follow him @RobbieMaakestad.

Source Materials:
Hillenbrand, Laura. “A Sudden Illness.” The New Yorker. 2003.
Jamison, Leslie. “Grand Unified Theory of Female Pain.” VQR. 2014.
Jamison, Leslie. “The Empathy Exams.” The Believer. 2014.
Riederer, Rachel. “Patient.” The Missouri Review. 2010.
Scalise, Mike. The Brand New Catastrophe: A Memoir. 2017.
Stern, Gerald. “Bullet in My Neck.” The Georgia Review. 2003.

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