Blake Charlton's Blog, page 3

Aequanimitas

Dearly Beloved You Guys:

I am struggling to keep up this blog. Clearly. In the past, I have declined to post because I have nothing to report, because I'm chugging away at a manuscript deadline or cramming for an exam, because my personal thoughts are quotidian. However for the past three months, the opposite has been true: so much has changed and in such remarkable ways that I never had the time to write it out.

For two months, I was on an in-patient internal medicine service: long and demanding days, very sick patients, many triumphs, a few heartbreaks both professionally and personally. I struggle to write clearly about it because I struggle to think clearly about it. Talk to a hundred doctors about their training and you likely will get a hundred different stories. Maybe more. The only thing physicians might agree upon regarding training is that it changes those who undergo it.

To me it feels as if medical training is changing me almost faster than my ability to perceive. Most notably, I have become largely unperturbed by suffering and death. It's something of a surprise, and not entirely unwelcome. The father of modern internal medicine, Sir William Osler spoke at length about the young physician's need to develop the quality of 'aequanimitas,' of being able to keep one's self mentally and emotionally steady in the face of semi-chaotic situations and highly charged emotions. It is this quality I suppose (and hope) is beginning to affect how I see the world. This isn't to say that I have achieved any great deal of aequanimitas; though having cared for patients with very poor prognoses before, over the past months, I for the first time witnessed death as it happens. For the first time, I made and delivered a terminal diagnosis. So long as I was wearing the white coat, so long I was in front of patients or physicians, I betrayed no sign of strain. But in the bottom of empty hospital stairwells, during 2am car rides home, in personal relationships, the cracks showed. Things fell apart. And yet…those most important were put back together. The service we provided in the hospital felt more important than the transitory distresses. These were the two most challenging months I have yet faced in medical school, but also the most rewarding.

The holidays were a welcome break, a chance to look back at 2011—the year my second novel came out, the year I began to truly develop a sense of what it means to be a clinician. Looking forward to 2012, I anticipate it being a pivotal year. Only surgery and OB-GYN remain of my required rotations. Thereafter, I'll complete a few months of electives, select my future profession, and after a month of being a "sub-intern," will very suddenly be done with medical school. In the time before I start residency, I will have to finish up the third and last novel on my current publishing contract. After turning in that manuscript will come the difficult decision of what I am to write next. Another fantasy? Something about disability? About medicine? All three?

In short, this year I will have to define myself as a physician and redefine myself as an author. But thankfully, things won't be all work and tough decisions. In fact, I'm excited to announce that I'll making three authorial appearances across the country in the coming months. (See the events blog post shortly after this one.) So while San Francisco is more likely to see snow in the coming months than I am likely to blog turning my surgery rotation, I will hope to see you in the spring.

Back to the Wards

The time Stanford graciously allowed me to pause medical clerkships to write and promote Spellbound has gone with the last of the summer. It was wonderful. Book tour was much busier and more fun this year. The time to research, write, and think was a rare luxury. But now, summer's over. School's back in. I start my Internal Medicine rotation tomorrow. I am both a little sad to take the writerly corduroy jacket off and excited to put on the medical white coat back on.

Those of you who have been following for a while know the drill: I won't have much non-hospital time and almost certainly no time to blog. So if you're curious what's happening in my life–both in terms of medicine and writing–click through to my  Facebook page, which I'll try to keep current. Feel free to friend me once over there!

Spellbound Book Tour Video

Last night I came stumbling in from a six city book tour.  Compared to last year, tour was more successful, more fun, and much more hectic. Thank you to everyone who came out to the events. Apologies to those for whom I didn't have as much time as I would have liked. And for everyone who would have liked to show up but couldn't…thanks to Shawn Speakmen of Suvudu fame and fellow Tor author, Peter Orullian filmed my reading in the University Bookstore in Seattle!

Coincidently, the "Megan" I'm addressing early in the video is Megan Lindholm a.k.a. Robin Hobb. Her work was especially important to me and so it was a real honor to be able to read to her.

New Fiction: The Autobiography of a Brain

Introduction

To continue to celebrate Spellbound's launch and book tour (hello from Dallas, btw), I'm publishing another organ-based magic realism story. As with The Heartbreaking Work of a Staggering Liver, this is an experimental bit of fiction that helped me to explore the close relationship I experience existing between literature and medicine. So, without further ado, here's is a short inspired by a brain I dissected during a second year autopsy elective.

Here's a short bit told by a liver I dissected during a second year autopsy elective. The bald medical student is me. The "Man in the Pan" class is the same as in the previous story.  

The names and details of the story are fabricated. No identifying patient information exists in this story. Though the pathological conditions described are real and the narrative was inspired by multiple real-life events, the narrated course of events is purely a work of fiction.

This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.

* * *

THE AUTOBIOGRAPHY OF A BRAIN

A bath when you are born,

a bath when you die,

how stupid.

That was a haiku Teresa Malinski once read. I like it. It is simple. It is also serious and silly. It comes from silence and falls into silence. I like that about haiku. Perhaps I am biased. It is possible. Consider my situation: I am a brain in a bucket.

 

The bucket is filled with water and formaldehyde. Yesterday, the pathologists used an electric saw to open Teresa Malinski's skull. Out I came. I'm small for a 69 year old brain. Parts of me have shrunk away into nothing.

It is quiet, here, in this bucket.

Outside Teresa's other organs lay in steel pans. They are constantly talking. Also outside of the bucket are three medical students. Also talking. This class is called Man in a Pan. Teresa was a woman. I am glad I am in the bucket.

Perhaps you supposed brains would be chatty organs.

We're not.

 

But the way, that haiku was written two hundred years ago. A Japanese man named Kobayashi Issa wrote it. An American named Robert Hass translated it. Issa means "cup of tea." That is nice. I don't know what Hass means.

But I associate it with avocados.

Hass avocadoes?

In any case, Robert Hass edited a book of translated poems named The Essential Haiku: Versions of Basho, Buson, & Issa. Teresa liked it. She read it in 2005. I remember the book perfectly. It was the last book Teresa ever read.

In late 2000, when Teresa turned 60, she retired from a directorship of a local charity. She and her partner went to Bhutan. She returned with a curiosity about things South and East Asian. She took a Chinese calligraphy class at her YMCA. She read about Taoism and Buddhism. She practiced yoga.

She tried to cultivate the quiet mind.

I was her brain.

Her mind was never very quiet.

That was fine.

When she practiced yoga, her mind was quieter. Then the pains that shot down her leg got too bad. Doctors called it sciatica. One of them thought she should have spine surgery. Another thought she should wait and try physical therapy. She wanted to wait at least until she was 65 and on Medicare.

Teresa tried tai chi and water aerobics, both hurt too much. She gained ten pounds.

 

She moved in with her partner, a retired engineer named James Wilcox. She called him Jimmie. But they started to argue, mostly about small things.  She moved back into her house. They saw each other more when they lived apart.

 

Teresa was born just outside St. Louis, Missouri.

When she was born, I was less than one third the size of the brain I would become. However, I was already complex. My neurons performed their slow dance of connection.

Infant brains need to develop their rear portions. That is where movement and balance are regulated. Babies are not capable of dexterity because that region needs to grow. Fast growth means a higher risk of cancer. Most childhood brain tumors arise lower down in the brain.

I was surprised to learn that.

 

When Teresa was two years old, I had reached four fifths of my mature weight. No tumors. No malformations of my stem or of the blood vessels. Nothing wrong yet. I was proud.

Teresa was proud she could use the toilet.

 

There are many types of cells in a brain. Likely you're familiar with neurons. Perhaps you think brains consist entirely of neurons.

We don't.

Perhaps you believe the thing you call you is an electrochemical storm flying around in neurons.

You're not.

 

Brains are made mostly of glia. They are the cells that hold neurons in place, provide nutrients for them, isolate them from each other, and remove toxins. Glia can alter how the electrochemical signals fly about in neurons. The thing you call you is as much glia as neuron. I think so. You are as much stomach as brain, as much lungs as brain, as much liver as brain. And so on.

The soul isn't a singer.

It is a chorus.

I figured all this out when Teresa attended college at Washington University in Saint Louis. I had reached my full size, in perfect health. So did Teresa. At five foot seven she wasn't tall. She wasn't short. She had short brown hair. Her pale face was usually serious.

Teresa learned to enjoy smoking.

 

After graduation, Teresa got engaged to a young man in her class. She thought she would stay in St. Louis for the rest of her life. But he broke off the engagement. The next year he married a girl who had been in her sorority.

It was 1963.

Of all the American cities Teresa had ever heard about, San Francisco sounded like the most different from St. Louis. She applied for jobs and received an offer as a paralegal.

 

In 1968, Teresa married a tax lawyer, another California immigrant, named Bob Malinski. He was from New York. They lived in the Berkeley Hills and raised two sons. It was a typical, pleasant suburban life. Once their younger son was in college, Teresa and Bob separated. They completed the divorce in 1994. She was 54.

 

Two years later, she met Jimmie Wilcox at a charity dinner. Jimmie asked her to a museum in San Francisco. It was a pleasant date.

But the next morning she was upset. She never thought she'd be dating at 56.

 

Teresa called her oldest son, by then a lawyer in Chicago. She asked if it was okay that she was seeing someone who wasn't his father. The son said that it was so long as she didn't ask him for dating advice.

 

Jimmie would sometimes nag her about her smoking. She wondered if dating him would help her quit.

It didn't. But she smoked less than a pack a week.

 

After the sciatica made Teresa's life more sedentary, she read more. She started gardening. Her hips began hurting. She wondered if it was the weight she had gained.

 

In 2002, her ex-husband called her. He'd had a heart attack, two weeks ago. The doctors put a stent in his heart. It scared him. He apologized for some things he had said during their divorce.

Teresa listened carefully. She tried to be gentle with him.

But he was still an asshole.

 

From the time Teresa left Saint Louis to when she returned from Bhutan, I changed only subtly. Neurons rewired, fired differently. I had lost weight. All brains shrink with age.

Then I began to change very rapidly. No one else knew it.

 

In 2005, Teresa flew to Chicago. She stayed with her eldest son's family for Thanksgiving. Mostly she played with her granddaughter.

On the flight home, Teresa felt at first too hot and then too cold. She coughed.

 

The next morning Teresa felt hot and weak. Jimmie came over toward noon. He noticed that she wasn't using her left hand. She didn't believe him.

Toward dinner on the following day, Teresa's fever broke and the weakness in her left hand was gone.

I could have told her why.

 

Teresa was now on MediCare and considering spine surgery to remove the shooting pains. But the surgeons were equivocal. Some thought it would help. All agreed it could make things much worse.

She decided to wait.

 

Five days later, Jimmie gave Teresa a copy of The Essential Haiku. She was feeling better. But it was raining. She felt lazy. She read the whole book between 10 in the morning and 1 in the afternoon, pausing for lunch.

She read it again after dinner.

 

Teresa had never enjoyed poetry. She felt like she didn't 'get' poetry. There seemed to be secrets to enjoying verse known to professors and particular kinds of people. It seemed to her that most of those particular kinds of people owned black turtle necks.

Teresa didn't own a black turtleneck.

 

The haiku in Hass's book were different kinds of poems. Teresa had never encountered anything like them. These were poems open to her. On her second reading, she read Hass's introduction and discovered there were rules to classical haiku. Rules that were often broken.

A classical haiku should use simple language. It should be understandable. It had to contain an image of the ordinary world. It should reference the season either in the first or third line. This reference might be done by describing snow for winter. Cherry blossoms symbolized spring. And so on.

Most surprisingly the haiku—or at least Hass's translations—did not follow to the five then seven then five syllable rule she had thought mandatory.

Her row veering off,

The peasant woman plants

Toward her crying child.

That poem was also written by Kobayashi Issa. It notes the season in describing planting. Issa's mother died when he was three years old. Issa must have been thinking of his dead mother and his infant self when he wrote this.

That connection made Teresa feel sad. She thought of her sons.

 

Of the three masters in the haiku book, Teresa liked Issa the best. His poems were often about small animals or simple things. Many were silly. Some were angry. All were a little pathetic.

She had a weakness for the pathetic.

The book included a self portrait of Issa. He had drawn himself as a dumpy little monk. He has a bald head and a big nose.

 

These are the poems that moved Teresa most.

Children imitating cormorants

Are even more wonderful

Than cormorants

 

What a strange thing!

to be alive

beneath cherry blossoms.

 

Asked how old he was,

the boy in the new kimono

stretched out all five fingers.

 

I'm going out,

flies, so relax,

make love.

 

Nursing her child

the mother

counts its fleabites.

 

Pissing in the snow

outside my door—

it makes a very straight hole.

 

It once happened

that a child was spared punishment

through earnest solicitation.

 

The toad! It looks like

it could belch

a cloud.

 

Napped half the day;

no one

punished me!

 

In the spring rain

a pretty girl

yawning.

 

This stupid world—

skinny mosquitoes, skinny fleas,

skinny children.

 

The day after Jimmie lent her The Essential Haiku, Teresa read it for the last time. She had a realization. Before she picked up Hass, she had never encountered haiku. She had read only parodies of haiku. Authors who obey the 5-7-5 syllable rule but ignore the other values. It produces nonsense:

Haiku are easy.

But sometimes they don't make sense.

Refrigerator.

Teresa thought these parodies were a shame.

Was there're anything about haiku more or less absurd than a sonnet?

It got her thinking. The only other form of poetry she had encountered as parody was called Deaf Poetry, or Slam Poetry. She knew that that form was associated with black people.

Teresa learned that Robert Hass was a native to Northern California. He had been the national Poet Laureate from 1995 to 1997. She wondered if she could see him read.

 

oh god the bucket lid is opening. gloved hands are lifting me out.

put me back. put me back.

they're staring at me. the three medical students. and spread out on the table are all the organs. yammering. the repetitive heart, the moody liver, the needy bowels, and groaning bones.

it is too loud.

they're talking about what might have killed teresa. they wonder if it was the surgery.

put me back. put me back.

the gloved hands are turning me over. they all point to the places where i'm sunken in. they're looking at my lesions, correlating them to teresa's disabilities.

oh god help me. put me back. please, put me back.

one of them, the bald one, is staring most especially at the lesion that kept teresa from ever reading another book.

They put me back.

 

It strikes me now how ridiculous this whole affair is: A bath when you're born, a bath when you die.

 

Five days after she read The Essential Haiku, something happened to Teresa. While watching television, she had trouble focusing on the screen. She changed her glasses and realized that she couldn't see out of her left eye. She went to the mirror. She watched herself wave her right hand in front of her left eye. She saw nothing.

She called Jimmie. He didn't pick up. She left a message and thought about calling one of her sons. She didn't want to be a bother.

Then vision began coming back to her left eye.

But the time Jimmie called back an hour later, she felt normal.

She wanted a cigarette.

 

The next week she woke up and wondered if she were hung over. She and Jimmie had watched a movie and shared some wine. After he had left, she had another glass.

Now her head hurt. Sunlight was pouring into her window. She wanted to go to the bathroom. But when she tried to stand, her right arm felt like it was anchored to her bed. She looked down at it. It did not seem real. It felt a rope that was stretching down from her to some sea of white cotton sheets.

She wanted to call Jimmie. But when she looked at her phone, she couldn't remember his number.

She looked from her arm to the phone on her bedside. From the phone to her arm.

Time did not seem to pass. Time seemed to have gone away.

Abruptly, she remembered her cell phone. Jimmie was the first number programmed into the phone. With her left hand she opened it.

All of the names seemed to have been written in Russian. She stared for a long time. She was frightened.

Then she remembered that Jimmie was first on her contacts list. She selected the entry at the top and pressed call.

His sleepy voice answered. She tried to say, "Jimmie, I think I'm having a stroke."

She only said. "Ji… Ji…" She tried again. "Ji…Ji…Ji…"

 

In the emergency department, the physicians examined her and then sent her to a large tubular machine they called a non-con CT. The noise it made around her head bothered me. However, I was preoccupied. Part of me had died the night before. Trying to cope with the dead tissue, I was swelling.

 

The physicians admitted Teresa to the hospital. The left middle portion of her brain had died. That was the portion of me that handled most of Teresa's ability to speak, write, and read.

Reacting to the injury, I continued to swell. Teresa lost consciousness.

 

Teresa was not aware of her visitors. Later she would hear their stories. Jimmie, her ex-husband, her sons, two old coworkers.

Teresa didn't like the stories. She couldn't eat on her own. She lost bowel control.

An MRI of her brain indicated that she had sustained several smaller strokes before the latest and largest. The fever she had had after Thanksgiving had taxed me and so "unmasked" a small stroke in her right hemisphere. That's what caused her right handed weakness. The narrowing of the blood vessels in her head had caused the stroke. It had also caused her brief episode of one sided eye-blindness.

 

During her second week in the hospital, one of the nurses heard an abnormal heart sound coming from Teresa's chest. The doctors ordered an echocardiograph, and discovered that her aortic valve, which normally had three leaflets, had only two. They did not know what role, if any, this had played in her strokes.

 

When Teresa went home, Jimmie moved in with her. She had to learn everything all over again. Eating, using the bathroom, speaking.

Every morning, before she grew tired, Jimmie would patiently talk her through the day. Defining most every word for her.

It took a long time.

 

I often thought about the haiku Teresa had read.

 

After two months, Jimmie hired a nurse to help take care of her. The nurse suggested they buy an English-as-a-second language program for her computer.

It didn't work. The letters on the screen made no sense to Teresa. No matter how long she stared at the letters, she could not make sense of them.

 

On a follow up doctor visit, a neurologist explained that she might have a condition called 'alexia,' or 'word blindness.' Another phrase for it was 'acquired dyslexia.' The part of her mind that had recognized the sight of letters and words had died. He suggested that she try tracing the letters with her hands.

 

This worked, to a degree. That part of me that understood what letters looked like was dead. But other parts of me remembered how words were written. When Teresa traced the letters with her hands, I could deduce what letter she was trying to write.

We could read, very slowly.

 

The year went on. Teresa remembered how to walk. Her speech became fluid again. She could move about her house. She was upset to see how messy Jimmie had made it. But she didn't say anything. She could leave the house on her own. She bought small things at the convenience store. The temptation was to buy cigarettes. But the neurologists had said that smoking increased the risk of a second stroke.

Eventually she broke down. She never let Jimmie see the cigarettes.

 

She didn't want to try driving. Jimmie insisted.  She never drove far. She couldn't read any of the signs.

 

Eight months after her stroke, Teresa had recovered enough to begin arguing with Jimmie about housekeeping.

Jimmie moved back into his house. It made her a little sad to see that he was relieved to go back. She took him out to a fancy dinner in San Francisco.

 

Things were almost back to normal.

 

But Teresa never regained the ability to read quickly or for pleasure. She listened to NPR. She watched more television.

 

She never read another book. The Essential Haiku was the last one.

It was a good one to end on.

 

And that nearly ends my autobiography. Eventually, I removed the cells that had died. In those places, I became smooth.

 

Teresa's life was everyday life despite her disability. It made her sad that she could not read the emails her granddaughter sent her. Mundane tasks were harder. It took her hours to sort the junk from the bills in her daily mail. She struggled to deal with anything that pushed her to online interactions.

But her disabilities were only disabilities. She was grateful for the extra time.

 

Jimmie was diagnosed with pancreatic cancer. It didn't seem fair. He had never smoked a cigarette in his life.

It was Teresa's turn to take care of him, as much as she could.

He died seven months later.

 

In 2008, Teresa was visiting her youngest son's family in the North Bay. Teresa felt light headed when she walked up the stairs. Once her chest hurt.

She was afraid it was her abnormal valve in her heart. The doctors had warned her this might happen.

 

A month later she received an echocardiograph. The two-leafed aortic valve was calcifying and growing smaller. Her heart couldn't push enough blood out of the stiff valve when she was exercising. They scheduled a "bicuspid aortic valve repair."

 

The procedure went well. Her younger son visited her the day after. She seemed fine.

That night she ran a slight fever, and the next morning the nurse noted that Teresa was having trouble speaking. Worried that she had another stroke, they took another CT scan of her head. She hadn't.

 

They drew blood to culture for a possible infection and started her on intravenous antibiotics. She began sweating profusely. Her heart rate accelerated and her blood pressure dropped.  They transferred her to the critical care unit.

 

That evening she died.

 

I heard the pathologists say that the blood cultures grew out bacteria. The theory is that Teresa died of septic shock. They performed the autopsy to confirm this. They also want to make sure that nothing went wrong with the surgery.

The pathologists have the answer already. It was sepsis. Now the medical students are trying to figure out the same. I just hope they don't pull me out of this bucket again.

 

It's peaceful in here.

 

A bath when you are born, a bath when you die—it's a little stupid.

But, then, there was everything that happened in between.

New Fiction: The Heartbroken Work of a Staggering Liver

Introduction

In my mind, medicine and narration are intertwined. I understand nearly everything–from how a medication might work, to the course of an untreated disease–as a story. Perhaps that's why I see literature and medicine as being woven of the same cloth. I know I understand a particular area of clinical medicine well when I can tell stories within that area. Once upon a time, in the fourth decade of life, there was a heart who had collected too much cholesterol along his coronary arteries… What is physiology but the protagonist, pathology but the antagonist? Organs are characters; drugs and interventions plot twists. Of course, the most important characters are the patients, nurses, and physicians. The most important plots are their lives. But every so often, I like to use the speculative fiction muscles, tell stories from the perspectives that have no voice.

Here's a short bit told by a liver I dissected during a second year autopsy elective. The bald medical student is, perhaps obviously, myself. The blonds are a classmate I briefly dated and her new beau.

The names and details of the story are fabricated. No identifying patient information exists in this story. Though the pathological conditions described are real and the narrative was inspired by multiple real-life events, the narrated course of events is purely a work of fiction.

This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.

* * *

THE HEARTBROKEN WORK OF A STAGGERING LIVER

There is just no easy, delicate, or otherwise endearing way to say that I am a dead man's liver lying on cold autopsy tray. Doesn't mean I'm not beautiful in death, even with white grotesques grown into me, even with my staggering size. Look at me. I am dark red like a gem. I've sleek lines as if pleasingly designed. Firm, heavy. Slide your fingers across me. Velvety. I'm velvety for all my raw substance. For so long I've been silent while the brain talks, still while the heart beats. But I've got words like blood, like bile percolating through me.

The pathologists call this class Man in a Pan. But the man is gone, and I'm dead but not yet gone. Tomorrow I will be cremated with the rest of the body. I don't mind. Better to burn than soak in embalming chemicals I can't metabolize. An ironic purgatory that would be. Like keeping the lungs in air they couldn't move, the heart in blood it couldn't propel.

So I count myself lucky, and I lie on this table. Three medical students—dressed in thin white polyester gowns and purple gloves—pore over us with grave expressions, as if we are holy scripture. They don't have a clue. Not about the how the man who died or who that man was.

So who was he? I wish I could say. I knew him intimately, knew him not at all. I metabolized the nutrients from every bite of food he swallowed, deactivated every drop of ethanol he drank, pulled the iron from his damaged red blood cells and made it into bile, assembled for him countless complex enzymes. But other than that…I know almost nothing.  Other organs would know more, but I was always too busy cleaning and building, building and cleaning.

Before today I've witnessed light only once. Twenty two years ago, the skin near my lower boarder opened. Gloved hands entered and cut out my gall bladder. The stones inside the bladder crunched like gravel when the surgeon rubbed it between thumb and forefinger.

This morning, they cut me out of my abdomen. Nothing gruesome about it. That surprised me. As she worked, the pathologist told a technician about hurriedly undressing and then redressing her six year old son so he wouldn't miss a school play. As she peeled back my body's skin and unfolded ribs that had been broken by CPR, I decided I was undergoing something similar to that impatient undressing. Hurry up now, little guy. We have to get this fat off of you or we're going to be late. Here we go. Off with that fascia.

Later, other pathologists came into the room. They began talking over my case:  Mr. Roberto Gaspar—a 74 year old Hispanic male retired biology teacher—arrived in the emergency department yesterday evening with mild chest pain and bouts of dizziness. Three hours prior, he fainted and hit his head on the carpeted floor. Nothing broken or even bruised, but it scared him. For the past two months he endured increasing fatigue, abdominal pain, trouble moving his bowels, dark stools. Five years ago, he'd survived a minor heart attack.

Sitting up on the ED gurney with grimacing expression, Mr. Gaspar appeared pale and distressed. He stammered when speaking. Both his hands trembled. His heart was beating fast.

A blood test revealed elevated enzymes released by damaged heart cells, but the levels weren't high enough to indicate a heart attack in the past two weeks. His EKG was abnormal, so the physician admitted him to the ICU and gave him medication that stabilized his irregular heartbeats. Mr. Gaspar tested positive for blood in his stool. More samples were sent for tests, but before they came back his heart entered a deadly rhythm. A code was called, CPR began. One rib broken. They shocked him. He regained normal cardiac rhythm; gasped in pain for long minutes; tried to tell the nurses that he didn't want to be shocked again but found it difficult, nearly impossible to speak. Ten minutes later he entered another arrhythmia. A second code. More CPR. Two ribs broken. Shocked him again. They pronounced him dead shortly after 11PM.

His daughter and her husband arrived at the hospital an hour later, unaware that he had passed away when they were driving over from Oakland.

Death within 24 hours of admission to a hospital requires an autopsy. So here the pathologists were. After discussing the story above, they focused on maters pathophysiological—causes of arrhythmia, death, blood in the stool…but nothing about what he had been like, what he had looked like, whom he had loved or hated. Pathophysiology.

But then—in a lull of technical discussion—a pathologist wondered if he had been Portuguese. Gaspar was apparently a common enough Portuguese name. The pathologist in question was of Portuguese decent, had a cousin living near the Little Portugal neighborhood of San Jose. And did the other doctors know the Portuguese had been living in Northern California for centuries? It was true. They left the volcanic islands of the Azores aboard whaling ships, living for a time in New England, before trading Atlantic waves for Pacific blue and settling around San Francisco. Perhaps Mr. Gaspar was descended from one of these settlers. Perhaps Mr. Gaspar and the pathologist in question were related to each other. Pause.

And that was it for the historical trivia and the conjecture about Mr. Gaspar. For the rest of the morning and afternoon, there were nothing but recitations of the past medical history, past surgical history, findings that confirmed or refuted past diagnoses. The doctors waited on some microscopic examination. The results came back. They had a diagnosis. They moved on to the next cadaver, the next case.

A technician wheeled me and the other organs upstairs into a smaller lab. There were windows on the far wall, brilliant California daylight shining in. It dazzled me. I've never witnessed daylight. It was like…like…an intoxicant I was not obliged to metabolize. Even now it makes me both giddy…and more acutely sad know that tomorrow I will become ash.

There is another problem with the sunshine: one of the med students leaning over me is bald and the daylight shines unpleasantly off of his scalp. He's a stocky fellow, black goatee, head like a cue ball. Looks like he was headed for a convention for boxing referees, got lost, ended up in medical school. I don't like the way he keeps grimacing at me as if trying to ignore the other two med students. They're more pleasing. Tall, fair. They examine the organs, stand closely together, brush against each other as if by accident. They're secretly taken with each other. It's endearing. It makes me wonder about Mr. Gaspar. He had a daughter, but did he have a wife? Or perhaps an ill-fated romance? Perhaps after years of estrangement, his daughter found him. Perhaps he called his daughter from the ICU and she came driving over the bay to be with him.

You might be surprised to discover a liver with a romantic streak. I've been in this external world for hours only and already I've heard the phrases "listen to your heart" and "get it off your chest." Perhaps it is the heart you think is romantic and poetic. Please, no. Don't listen to the heart. He's got nothing but tda-d'da to say, over and over again. Tda-d'da tda-d'da tda-d'da tda-d'da. The only time he said something different, we died.

The only hearts worth listening to are the broken ones.

Let me tell you something about livers. We're organs of the ragged and the new: master artisans of enzymes, garbage men of the bloodstream. New treasures and old trash, that's our love. Consider this fact: livers are the only irreplaceable organs. Can't breathe? The ventilator can take over. Heart acting sluggish? Not a problem if we catch it early; it's only a pump. Kidneys not filtering? The eggheads invented a hemodialysis for you. No stomach or bowel? They'll push the pre-digested metabolites right into your veins. No brain? Not really necessary for a living body. (And, really, you should have known that last fact. This morning, one of the pathologists spoke at length about an entire American city where people without brains may live and work for years. But, likely, you've already heard of Washington DC.) But if your liver should fail…. Well, there's no machine to take our place. You get a transplanted liver or you die. Simple as that. We're the essentially human component.

If organs could became people, we would become what a pathologist this morning called a "hipster." It seems there are a lot of them in San Francisco. Although, I think we would be less sarcastic. But, yes, brilliant and deliberately run down. Beatnik, bohemian. That's us.

I don't think any of my med students are hipsters. The blonds seemed too done up; she's wearing rouge, he hair product. And Cue-ball, well, him in skinny jeans. Ha. Right.

I'm starting to worry for my med students. They keep looking back to me, remarking on my peculiarities. But the cause of death lies elsewhere. I'd tell them, if I could. Looking on with arms folded is the pathology professor. He's waiting, smiling. He knows that I am his decoy. But a striking decoy. I have a bit of swagger and strange beauty in my dysfunction. Hipster, remember.

I'm half again as large as a healthy liver. On cross-section, I am bright bloody red inscribed with tan reticular lines. As a younger organ, I was respectably brown.

Now my underside has been partially sliced; my one-centimeter flaps lay pressed together like pages. The students flip through me as if I were a book. Each time they stop on the pages of my pale grotesques, my three metastases of colorectal carcinoma. Each is a tight, knobby knot of white. Something frightening in their geometry makes me think of hunger and blindness. My largest tumor has a black rotting center. The cancer outgrew its own blood supply.  The pathologists described this dark center as 'necrotic.' I think that's a very evocative word. It almost hurts to think of that cracking -khr- sound in the center of the word, sharp as the cancer in the center of me. Necrotic, necrosis, necrotic…

It's the grotesques that hypnotize the med students. Fascination with the abominations. They try to keep their faces calm, but you can see the tightness underneath. They can't hear the cancers muttering in their guttural nightmare language about hunger and immortality. The driving wish of cancer is to live forever. That's why cancer refuses to stop growing when the body hands it tiny chemical suicide commands. That's why cancer tears through the body. It kills in an attempt to live forever. Ironic, no? The med students have found the original lesion in the colon. They know portal veins drain blood from the intestines to me, carrying nutrients leached from food…and malignant cells loosed from tumors.

Across the room, the pathology professor clears his throat. He walks to the table side and asks for their diagnosis. What killed the patient?

The students stare at me. No one speaks for a longtime. They look at each other, knowing that they haven't a clue about what's going on. Whoever opens their mouth first is going to reveal their collective ignorance. Seems like a familiar situation to them. It's a contest of who can stand the silence the longest. Cue-ball is going to lose. I can tell; his scalp is flushing pink. It's a pleasant shade, actually. Reminds me of the smooth sheen of the diaphragm muscle that lay above me for so long.

The professor asks again for the cause of death. Cue-ball cracks and starts talking about the cancer in the colon that must have bled into the stool and then metastasized. He gestures toward me, as if my pale grotesques weren't obvious to anyone within a hundred feet. "And the cancer must have…" Cue-ball says before looking at the heart, who is free of cancer, and then at the blonds. They don't know how cancer killed the patient. But all of them look sure that cancer caused the death…that's what metastatic cancer does, after all. Isn't it?

The professor smiles. Trap sprung. He directs their attention to the heart. The pathologists have cut open each chamber so as to make him a collection of flaps, like some complicated garment. The poor organ. He's still muttering tda-d'da gotta get back to tda-d'da tda-d'da tda-d'da. Gotta get back. Tda-d'da. The pitiful, confused bastard.

The professor wants an analysis of the heart. What's wrong?

Silence.

Time for professorial leading questions. Didn't the patient die of an arrhythmia? Yes, he did. Isn't the heart a little too large, a little dilated? Yes, it is. And wasn't the liver too large and bright red with blood? Indeed, I am. How are those connected?

He-blond gets it. "Right-sided heart failure?" he answers and asks at the same time. The professor nods. The right side of the heart wasn't moving blood out of the liver, out of me, fast enough so I became congested with blood.

The students nod.

So what about the arrhythmia?

The students stop nodding.

The pathologists sighs, holds up the ragged heart, who is still muttering. Tda-d'da tda-d'da. The professor moves through the folds of muscle until he comes to a patch of pale tissue. A scar it turns out, from Mr. Gaspar's first heart attack five years ago. She-blonde remembers aloud that cardiac scar tissue can cause arrhythmias. For the first time, the professor smiles. He complements her, and then indicates another patch of gray in the heart; this one smaller and almost yellow. It's a newly forming scar from an unnoticed or 'silent' heart attack the patient sustained about twenty days ago. In all probability, the forming scar set off the fatal arrhythmia. But what was the relationship between the cancer, the silent heart attack, and the arrhythmia?

All eyes back to me. Then the blonds look at each other and Cue-ball scowls. The professor clears his throat. Now all the students look at each other. "The colorectal cancer was bleeding for a long time," says Cue-ball. "So he was losing blood in the stool for a long time. Maybe he was anemic." That's nice. I'm glad Cue-ball finally said something worthwhile.

He-blond jumps in. "And if the patient was anemic, that would have caused his heart to race and made it more susceptible to heart attacks and arrhythmias."

The pathologist points to me and casts out his pearl of wisdom.

My grotesques and I are impressive. It is hard not stare. This led the students to commit the cognitive crime of "anchoring" or "focalism." They were trying to explain the whole picture in light of its most striking feature. But Mr. Gaspar had not died of liver failure. They knew that, but my grotesques were so much more interesting than the heart (it is not a surprise) that they had misjudged his pathology. This 'anchoring' was a vital part of the broader 'confirmation bias,' in which a physician searches for evidence to support a favored diagnosis but not evidence that might refute that diagnosis.

The med students nod, impressed. The professor takes a moment to savor a point driven home. Then, with a curt nod, he ends the class. They pull off their gloves and gowns and leave. The professor heads back down to the basement lab.

I am left alone with the other organs. My grotesques mutter about immortality, the intestines groan, the heart stutters out his remembered rhythms. But I'm quiet, thinking about our story and Mr. Gaspar's story. They both stem from the question: How did Roberto Gaspar die?

I think about the students and what they will remember: cognition errors, pathophysiology, a story written by the organs not by the man. How Roberto Gaspar died. But what of his last night? Did he sleep, or toss and turn? Did he wake early and call his daughter and say that he had been thinking of her mother? Was the daughter scared by the strain in his voice, unsettled because she too had been thinking of her mother? Did Roberto go to the church? We are going to be cremated. That's less common for Catholics, so perhaps he wasn't very religious. Doesn't mean he didn't light a candle for the memory of his dead wife. His lost wife?

On his way home, did he wonder how he had gotten so old? His muscles so much weaker than they had been. His heart was scared from the attack five years earlier. Part of his bowels had been removed fifteen years ago when they found a small cancerous lesion. Then there was his painful hip, his sore back, his fatigue. All his lost abilities. Did he think back to his young self and marvel at how he had never once suspected that he would eventually become this disabled? Did his chest hurt before he fainted at home?

This was the story the students would never know; worse, I would never know.  How Roberto Gaspar died.

Inside, I feel something both sharp and hollow. It seems in death we do not know ourselves.  I haven't much longer. Maybe twenty hours. Maybe ten. It's not a pleasant feeling, this sharp hollowness, but it does make this striking world around me more striking, the bright daylight brighter.

New Ficiton: The Heartbroken Work of a Staggering Liver

Introduction

In my mind, medicine and narration are intertwined. I understand nearly everything–from how a medication might work, to the course of an untreated disease–as a story. Perhaps that's why I see literature and medicine as being woven of the same cloth. I know I understand a particular area of clinical medicine well when I can tell stories within that area. Once upon a time, in the fourth decade of life, there was a heart who had collected too much cholesterol along his coronary arteries… What is physiology but the protagonist, pathology but the antagonist? Organs are characters; drugs and interventions plot twists. Of course, the most important characters are the patients, nurses, and physicians. The most important plots are their lives. But every so often, I like to use the speculative fiction muscles, tell stories from the perspectives that have no voice.

Here's a short bit told by a liver I dissected during a second year autopsy elective. The bald medical student is, perhaps obviously, myself. The blonds are a classmate I briefly dated and her new beau.

The names and details of the story are fabricated. No identifying patient information exists in this story. Though the pathological conditions described are real and the narrative was inspired by multiple real-life events, the narrated course of events is purely a work of fiction.

This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.

* * *

THE HEARTBROKEN WORK OF A STAGGERING LIVER

There is just no easy, delicate, or otherwise endearing way to say that I am a dead man's liver lying on cold autopsy tray. Doesn't mean I'm not beautiful in death, even with white grotesques grown into me, even with my staggering size. Look at me. I am dark red like a gem. I've sleek lines as if pleasingly designed. Firm, heavy. Slide your fingers across me. Velvety. I'm velvety for all my raw substance. For so long I've been silent while the brain talks, still while the heart beats. But I've got words like blood, like bile percolating through me.

The pathologists call this class Man in a Pan. But the man is gone, and I'm dead but not yet gone. Tomorrow I will be cremated with the rest of the body. I don't mind. Better to burn than soak in embalming chemicals I can't metabolize. An ironic purgatory that would be. Like keeping the lungs in air they couldn't move, the heart in blood it couldn't propel.

So I count myself lucky, and I lie on this table. Three medical students—dressed in thin white polyester gowns and purple gloves—pore over us with grave expressions, as if we are holy scripture. They don't have a clue. Not about the how the man who died or who that man was.

So who was he? I wish I could say. I knew him intimately, knew him not at all. I metabolized the nutrients from every bite of food he swallowed, deactivated every drop of ethanol he drank, pulled the iron from his damaged red blood cells and made it into bile, assembled for him countless complex enzymes. But other than that…I know almost nothing.  Other organs would know more, but I was always too busy cleaning and building, building and cleaning.

Before today I've witnessed light only once. Twenty two years ago, the skin near my lower boarder opened. Gloved hands entered and cut out my gall bladder. The stones inside the bladder crunched like gravel when the surgeon rubbed it between thumb and forefinger.

This morning, they cut me out of my abdomen. Nothing gruesome about it. That surprised me. As she worked, the pathologist told a technician about hurriedly undressing and then redressing her six year old son so he wouldn't miss a school play. As she peeled back my body's skin and unfolded ribs that had been broken by CPR, I decided I was undergoing something similar to that impatient undressing. Hurry up now, little guy. We have to get this fat off of you or we're going to be late. Here we go. Off with that fascia.

Later, other pathologists came into the room. They began talking over my case:  Mr. Roberto Gaspar—a 74 year old Hispanic male retired biology teacher—arrived in the emergency department yesterday evening with mild chest pain and bouts of dizziness. Three hours prior, he fainted and hit his head on the carpeted floor. Nothing broken or even bruised, but it scared him. For the past two months he endured increasing fatigue, abdominal pain, trouble moving his bowels, dark stools. Five years ago, he'd survived a minor heart attack.

Sitting up on the ED gurney with grimacing expression, Mr. Gaspar appeared pale and distressed. He stammered when speaking. Both his hands trembled. His heart was beating fast.

A blood test revealed elevated enzymes released by damaged heart cells, but the levels weren't high enough to indicate a heart attack in the past two weeks. His EKG was abnormal, so the physician admitted him to the ICU and gave him medication that stabilized his irregular heartbeats. Mr. Gaspar tested positive for blood in his stool. More samples were sent for tests, but before they came back his heart entered a deadly rhythm. A code was called, CPR began. One rib broken. They shocked him. He regained normal cardiac rhythm; gasped in pain for long minutes; tried to tell the nurses that he didn't want to be shocked again but found it difficult, nearly impossible to speak. Ten minutes later he entered another arrhythmia. A second code. More CPR. Two ribs broken. Shocked him again. They pronounced him dead shortly after 11PM.

His daughter and her husband arrived at the hospital an hour later, unaware that he had passed away when they were driving over from Oakland.

Death within 24 hours of admission to a hospital requires an autopsy. So here the pathologists were. After discussing the story above, they focused on maters pathophysiological—causes of arrhythmia, death, blood in the stool…but nothing about what he had been like, what he had looked like, whom he had loved or hated. Pathophysiology.

But then—in a lull of technical discussion—a pathologist wondered if he had been Portuguese. Gaspar was apparently a common enough Portuguese name. The pathologist in question was of Portuguese decent, had a cousin living near the Little Portugal neighborhood of San Jose. And did the other doctors know the Portuguese had been living in Northern California for centuries? It was true. They left the volcanic islands of the Azores aboard whaling ships, living for a time in New England, before trading Atlantic waves for Pacific blue and settling around San Francisco. Perhaps Mr. Gaspar was descended from one of these settlers. Perhaps Mr. Gaspar and the pathologist in question were related to each other. Pause.

And that was it for the historical trivia and the conjecture about Mr. Gaspar. For the rest of the morning and afternoon, there were nothing but recitations of the past medical history, past surgical history, findings that confirmed or refuted past diagnoses. The doctors waited on some microscopic examination. The results came back. They had a diagnosis. They moved on to the next cadaver, the next case.

A technician wheeled me and the other organs upstairs into a smaller lab. There were windows on the far wall, brilliant California daylight shining in. It dazzled me. I've never witnessed daylight. It was like…like…an intoxicant I was not obliged to metabolize. Even now it makes me both giddy…and more acutely sad know that tomorrow I will become ash.

There is another problem with the sunshine: one of the med students leaning over me is bald and the daylight shines unpleasantly off of his scalp. He's a stocky fellow, black goatee, head like a cue ball. Looks like he was headed for a convention for boxing referees, got lost, ended up in medical school. I don't like the way he keeps grimacing at me as if trying to ignore the other two med students. They're more pleasing. Tall, fair. They examine the organs, stand closely together, brush against each other as if by accident. They're secretly taken with each other. It's endearing. It makes me wonder about Mr. Gaspar. He had a daughter, but did he have a wife? Or perhaps an ill-fated romance? Perhaps after years of estrangement, his daughter found him. Perhaps he called his daughter from the ICU and she came driving over the bay to be with him.

You might be surprised to discover a liver with a romantic streak. I've been in this external world for hours only and already I've heard the phrases "listen to your heart" and "get it off your chest." Perhaps it is the heart you think is romantic and poetic. Please, no. Don't listen to the heart. He's got nothing but tda-d'da to say, over and over again. Tda-d'da tda-d'da tda-d'da tda-d'da. The only time he said something different, we died.

The only hearts worth listening to are the broken ones.

Let me tell you something about livers. We're organs of the ragged and the new: master artisans of enzymes, garbage men of the bloodstream. New treasures and old trash, that's our love. Consider this fact: livers are the only irreplaceable organs. Can't breathe? The ventilator can take over. Heart acting sluggish? Not a problem if we catch it early; it's only a pump. Kidneys not filtering? The eggheads invented a hemodialysis for you. No stomach or bowel? They'll push the pre-digested metabolites right into your veins. No brain? Not really necessary for a living body. (And, really, you should have known that last fact. This morning, one of the pathologists spoke at length about an entire American city where people without brains may live and work for years. But, likely, you've already heard of Washington DC.) But if your liver should fail…. Well, there's no machine to take our place. You get a transplanted liver or you die. Simple as that. We're the essentially human component.

If organs could became people, we would become what a pathologist this morning called a "hipster." It seems there are a lot of them in San Francisco. Although, I think we would be less sarcastic. But, yes, brilliant and deliberately run down. Beatnik, bohemian. That's us.

I don't think any of my med students are hipsters. The blonds seemed too done up; she's wearing rouge, he hair product. And Cue-ball, well, him in skinny jeans. Ha. Right.

I'm starting to worry for my med students. They keep looking back to me, remarking on my peculiarities. But the cause of death lies elsewhere. I'd tell them, if I could. Looking on with arms folded is the pathology professor. He's waiting, smiling. He knows that I am his decoy. But a striking decoy. I have a bit of swagger and strange beauty in my dysfunction. Hipster, remember.

I'm half again as large as a healthy liver. On cross-section, I am bright bloody red inscribed with tan reticular lines. As a younger organ, I was respectably brown.

Now my underside has been partially sliced; my one-centimeter flaps lay pressed together like pages. The students flip through me as if I were a book. Each time they stop on the pages of my pale grotesques, my three metastases of colorectal carcinoma. Each is a tight, knobby knot of white. Something frightening in their geometry makes me think of hunger and blindness. My largest tumor has a black rotting center. The cancer outgrew its own blood supply.  The pathologists described this dark center as 'necrotic.' I think that's a very evocative word. It almost hurts to think of that cracking -khr- sound in the center of the word, sharp as the cancer in the center of me. Necrotic, necrosis, necrotic…

It's the grotesques that hypnotize the med students. Fascination with the abominations. They try to keep their faces calm, but you can see the tightness underneath. They can't hear the cancers muttering in their guttural nightmare language about hunger and immortality. The driving wish of cancer is to live forever. That's why cancer refuses to stop growing when the body hands it tiny chemical suicide commands. That's why cancer tears through the body. It kills in an attempt to live forever. Ironic, no? The med students have found the original lesion in the colon. They know portal veins drain blood from the intestines to me, carrying nutrients leached from food…and malignant cells loosed from tumors.

Across the room, the pathology professor clears his throat. He walks to the table side and asks for their diagnosis. What killed the patient?

The students stare at me. No one speaks for a longtime. They look at each other, knowing that they haven't a clue about what's going on. Whoever opens their mouth first is going to reveal their collective ignorance. Seems like a familiar situation to them. It's a contest of who can stand the silence the longest. Cue-ball is going to lose. I can tell; his scalp is flushing pink. It's a pleasant shade, actually. Reminds me of the smooth sheen of the diaphragm muscle that lay above me for so long.

The professor asks again for the cause of death. Cue-ball cracks and starts talking about the cancer in the colon that must have bled into the stool and then metastasized. He gestures toward me, as if my pale grotesques weren't obvious to anyone within a hundred feet. "And the cancer must have…" Cue-ball says before looking at the heart, who is free of cancer, and then at the blonds. They don't know how cancer killed the patient. But all of them look sure that cancer caused the death…that's what metastatic cancer does, after all. Isn't it?

The professor smiles. Trap sprung. He directs their attention to the heart. The pathologists have cut open each chamber so as to make him a collection of flaps, like some complicated garment. The poor organ. He's still muttering tda-d'da gotta get back to tda-d'da tda-d'da tda-d'da. Gotta get back. Tda-d'da. The pitiful, confused bastard.

The professor wants an analysis of the heart. What's wrong?

Silence.

Time for professorial leading questions. Didn't the patient die of an arrhythmia? Yes, he did. Isn't the heart a little too large, a little dilated? Yes, it is. And wasn't the liver too large and bright red with blood? Indeed, I am. How are those connected?

He-blond gets it. "Right-sided heart failure?" he answers and asks at the same time. The professor nods. The right side of the heart wasn't moving blood out of the liver, out of me, fast enough so I became congested with blood.

The students nod.

So what about the arrhythmia?

The students stop nodding.

The pathologists sighs, holds up the ragged heart, who is still muttering. Tda-d'da tda-d'da. The professor moves through the folds of muscle until he comes to a patch of pale tissue. A scar it turns out, from Mr. Gaspar's first heart attack five years ago. She-blonde remembers aloud that cardiac scar tissue can cause arrhythmias. For the first time, the professor smiles. He complements her, and then indicates another patch of gray in the heart; this one smaller and almost yellow. It's a newly forming scar from an unnoticed or 'silent' heart attack the patient sustained about twenty days ago. In all probability, the forming scar set off the fatal arrhythmia. But what was the relationship between the cancer, the silent heart attack, and the arrhythmia?

All eyes back to me. Then the blonds look at each other and Cue-ball scowls. The professor clears his throat. Now all the students look at each other. "The colorectal cancer was bleeding for a long time," says Cue-ball. "So he was losing blood in the stool for a long time. Maybe he was anemic." That's nice. I'm glad Cue-ball finally said something worthwhile.

He-blond jumps in. "And if the patient was anemic, that would have caused his heart to race and made it more susceptible to heart attacks and arrhythmias."

The pathologist points to me and casts out his pearl of wisdom.

My grotesques and I are impressive. It is hard not stare. This led the students to commit the cognitive crime of "anchoring" or "focalism." They were trying to explain the whole picture in light of its most striking feature. But Mr. Gaspar had not died of liver failure. They knew that, but my grotesques were so much more interesting than the heart (it is not a surprise) that they had misjudged his pathology. This 'anchoring' was a vital part of the broader 'confirmation bias,' in which a physician searches for evidence to support a favored diagnosis but not evidence that might refute that diagnosis.

The med students nod, impressed. The professor takes a moment to savor a point driven home. Then, with a curt nod, he ends the class. They pull off their gloves and gowns and leave. The professor heads back down to the basement lab.

I am left alone with the other organs. My grotesques mutter about immortality, the intestines groan, the heart stutters out his remembered rhythms. But I'm quiet, thinking about our story and Mr. Gaspar's story. They both stem from the question: How did Roberto Gaspar die?

I think about the students and what they will remember: cognition errors, pathophysiology, a story written by the organs not by the man. How Roberto Gaspar died. But what of his last night? Did he sleep, or toss and turn? Did he wake early and call his daughter and say that he had been thinking of her mother? Was the daughter scared by the strain in his voice, unsettled because she too had been thinking of her mother? Did Roberto go to the church? We are going to be cremated. That's less common for Catholics, so perhaps he wasn't very religious. Doesn't mean he didn't light a candle for the memory of his dead wife. His lost wife?

On his way home, did he wonder how he had gotten so old? His muscles so much weaker than they had been. His heart was scared from the attack five years earlier. Part of his bowels had been removed fifteen years ago when they found a small cancerous lesion. Then there was his painful hip, his sore back, his fatigue. All his lost abilities. Did he think back to his young self and marvel at how he had never once suspected that he would eventually become this disabled? Did his chest hurt before he fainted at home?

This was the story the students would never know; worse, I would never know.  How Roberto Gaspar died.

Inside, I feel something both sharp and hollow. It seems in death we do not know ourselves.  I haven't much longer. Maybe twenty hours. Maybe ten. It's not a pleasant feeling, this sharp hollowness, but it does make this striking world around me more striking, the bright daylight brighter.

My Second Bookday & Booktour

Dearly Beloved You People:

Bookdays are to authors what birthdays are to everyone. The analogy is a pretty good one: each is an excuse to party, each may cause joy or anxiety, and we attach a great significance to each even though little to nothing of importance actually happens on the given day. That said, today is my second book day, and it has so far been wonderful! My heartfelt thanks to out to everyone of the Dearly Beloved You People who have wished me well on this blog, Facebook, & Twitter. So, how about a few things to celebrate?

1) More Sample Chapters! I'm excited that Aidan over at A Dribble of Ink is showing off chapters 3 & 4 of Spellbound! (Chapters 1 & 2 up via Tor.com).

2) Some new free fiction: I've got one or two stories in the trunk that I think are weird enough that I probably can't sell them anywhere and think it might be fun to throw one or two up on this blog to celebrate the launch. Check back tomorrow.

3) Booktour details: I implore you to come to any one of these wonderful indies. Also, I've been practicing my authorial new-book-schtick, and I hate to brag (not really) but I'm serve up a pretty damn good new-book-schtick.

In other news, the upcoming Spellbound book tour has grown larger. I'm very pleased to announce that I'll now be traveling to Houston and Dallas in addition to the previous destinations. Here's the line up so far.

September 16th, 7pm Launch party at Kepler's Books (store page, FB event) Menlo Park, CA

Come to the BBC afterward for a drink and to chat.

September 20th, Powell's Books Beaverton (store page, FB event) with Kate Elliott!, OR

Come to McMenamins just across the way at 5pm for drinks and conversation.

September 21st, U of W Bookstore (store page, FB event) , Seattle, WA Friday,
The Signed Page, Seattle, WA
September 23rd, Mysterious Galaxy (store page, FB event), San Diego, CA
September 24th, Murder by the Book (store page, FB event), Houston, TX
September 26th, A Real Bookstore (store page, FB event), Fairview, TX

Whither Blogging?

Dearly Beloved You Guys:

I'm not entirely sure when but somewhere in the past year my capacity for blogging suffered. I could blame the usual suspects: writing deadlines, a demanding day job, the need to have a personal life, blah blah blah. But really, true culprits are my Twitter and Facebook accounts. Between medicine and publishing, the past few months have been filled with wonderful, horrible, life-changing events, all of which I have tried to ball into the most concise phrasing possible to fit into social media. Where once life inspired essays, now it inspires tweets.

One of the most thought provoking books I read this year was The Shallows by Nicholas Carr. I strongly disagree with much of of Carr's pessimistic analysis, which can crudely be summed up as 'the internet is making us dumb.'  I do not think it is necessarily a bad thing that social media has induced me to try to write and think concisely. It's not such a new idea after all, witness Strunk and White.

However, I cannot deny that the internet and social media in particular has changed how I express myself and how I think. It has given me a preference for the concise, witty tweet that will win an instant response. I should hate to let the mental capacity for longer expression atrophy. So, as I prepare for Spellbound's book tour next week, I'm making a resolution to try to produce more blog posts, fewer facebook statuses. We shall  see how that works out.

Meanwhile, on the update front, I'm proud to report that Spellbound has earned a starred review from the notoriously difficult to please Kirkus Review!

 Middle volumes are always tricky, but Charlton succeeds brilliantly here; this is no mere setup for the final installment. By shifting locales from the first book, he widens the reader's view of the author's richly detailed world, characters, and magical systems, all of which are informed by his experiences as a medical student and a severe dyslexic. Absolutely not to be missed.

 

More Spellbound Reviews, More Book Tour

My rotation in pediatrics finished up with a month on the general medicine service at Stanford's academic pediatrics center, Lucile Packard Children's Hospital. It was the most demanding month of medical school so far, not only in terms of hours worked but also in terms of personal challenges. Many of my fundamental beliefs–some of them previously held only unconsciously–about health, healing, and dying were tested, broken, repaired. Like everything else in medical training, it all happened too fast to understand. Looking back now, it is hard to remember why I was so upset, elated, or worried. Perhaps with time and reflection, things become clearer.

Meanwhile, I'm happy to report that Spellbound has received a few more wonderful reviews.

*STARRED REVIEW* A well-written and cleverly presented fantasy with strong characters and surprising plot twists, this saga should appeal to those who enjoyed its predecessor as well as fans of Terry Brooks and L.E. Modesitt Jr.

-Library Journal

Spellbound is a fun, exciting read, one that deserves the attention and more of its predecessor. Rather than retread over old ground, Charlton has paved his way forward based on the lessons learned (presumably from his own experiences) in the prior book, building and expanding them aggressively in the second. The story is loaded with interesting characters, a story that works well and that comes unexpectedly at points, and a world that is worth returning to often. The result is a rich, textured read, one that shows what fantasy should be when it encounters a creative and curious mind, a second novel that doesn't disappoint. I'm already waiting for the final book in the trilogy.

-Worlds in a Grain of Sand

Simultaneously epic and intimate, high-flying and grounded, funny and dark, suspenseful and emotional, Spellbound is a daring new work of fantasy that pushes the Spellwright Trilogy closer to its conclusion while remaining just as emotionally and intellectually challenging as the first installment, and just as compelling as a standalone work due to its expert character study.

-Rob Will Review

In other news, the upcoming Spellbound book tour has grown larger. I'm very pleased to announce that I'll now be traveling to Houston and Dallas in addition to the previous destinations. Here's the line up so far.

September 16th, 7pm Launch party at Kepler's Books, Menlo Park, CA
September 20th, Powell's Books with Kate Elliott! Beaverton, OR
September 21st, U of W Bookstore, Seattle, WA Friday,
The Signed Page, Seattle, WA *Signed by me and cover artist Todd Lockwood*
September 23rd, Mysterious Galaxy, San Diego, CA
September 24th, Murder by the Book, Houston, TX
September 26th, A Real Bookstore, Fairview, TX

Early Reviews of Spellbound

My one day away from the children's hospital this week just flashed by and now I find myself scrambling to blog before the madness begins again at 0500. Sigh.

In any case, I'm very happy to report that there have been three published reviews of Spellbound, all of which I have summarized below.

Romantic Times

This is a well-written and densely plotted story that features characters with disabilities in a positive and prominent manner. Nico and Francesca are both multidimensional and fascinating protagonists and their burgeoning partnership is a joy to see develop. Fans of secondary world fantasy should definitely check this series out.

Bookworm Blues

Spellbound starts with a bang, meaning that events seem to be at a crescendo from the very start, and the pace of things keeps going throughout. While there are quieter moments, the plot never seems to slow past breakneck speed. Wrapped in this quickly moving plot are plenty of interesting mysteries and questions that will leave the reader hanging on to find out (or figure out, as the case may be) the answers.  Spellbound is an adventure fantasy filled with mystery, interesting characters and a unique world that mixes the fantasy cliché's so many of us know and love, with a brand new feel that is purely Charlton. Spellbound is an improvement over Spellwright. It's got the same fun feel, and the same loveable characters, but there's a level of maturity, depth and growth in Spellbound that really makes it fly high. Charlton has made his mark. I am excited to see where he can take us next.

Booklist:

The cast of characters in this book is varied and complex. For those readers who enjoyed the first book in this series, this tale will add to the already complex story line, finishing off certain threads while illuminating new ones.