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780.4: Dizziness and Giddiness.

Deep breath: I still felt out of place. I turned the engine off. Quietly, I promised myself: once you get commissioned, maybe after you go through ODS, they’ll give you a Geneva Conventions ID card and you can stop showing your driver’s license at the gate. You’ll have a uniform and you won’t be the only one on base wearing jeans. You won’t have to be on a guest list.

I got out of my car and walked inside. The National Naval Medical Center was a labyrinth, but this was my third and final physical—putting a bow on the package, as my recruiter had told me—and I knew my way to the health center. As I sat between two men waiting for their pre-deployment physicals, I couldn’t have felt less proud. An academic in a hornet’s nest. But, I promised myself: one day you’ll deploy too—as a doctor—and serve your country. One day you’ll use the Arabic you spent four years in college studying. You’ll be able to tell your children that you fought in war. You’ll justify your departure from the intelligence community: to be one who does, not one who says. I thought of a picture hanging in my bedroom. Deep breath.

The path to a military scholarship for medical school is lengthy: background investigations, essays, fingerprinting. Letters of recommendations from current or retired officers; my grandfather wrote mine. A personal interview with a current military physician: I got taken out to lunch by a Navy doctor who also happened to be a reality star, and then got mentioned in a gossip blog. And of course, a slough of physicals. Today I was to go over the results of my blood work from the previous appointment, and sign the appropriate forms. My insurance company had faxed over the entirety of my medical records, including my broken arm at the age of 7. I was tying the bow. I wiped my palms on my jeans.

787.01: Nausea with vomiting.

“When were you planning on telling me about your cervix?”

I looked up from my phone. “Excuse me?” The NP had been silently going through my paperwork for the last five minutes; she hadn’t asked me to sit down. Over her glasses and up at me: “Your cervix.” She slid my medical records across her desk with a finger, as if it were soiled. I sat down. In thin, wobbly blue, she had circled the results of my most recent pap smear.

I read: high grade cervical intraepithelial neoplasm. CIN II/CIN III. Possible malignancy. F/U with biopsy to confirm. I knew enough medical vocabulary to know that a neoplasm is never good. I started to shake: “what does all of this mean?”

She never looked up from her computer. “It means you need to see your gynecologist. And that you’re disqualified from military service.” Behind her, the printer started to whirr.

“No, I mean—” My voice broke. I was never good with stoicism; maybe that’s why I chose the Navy over the Army. “What does CIN mean?”

She grabbed a hot sheet of paper off the printer. “It means,” she said, underlining a blank box and her exasperation, “that you need to sign here stating that you understand you have been disqualified from service in the United States Navy.”

I signed. “Do I have cancer?”

“Do I look like a doctor?”

I sat in the courtyard of the National Naval Medical Center and cried. I think a three star general walked past me; I couldn’t have cared less. I called my best friend, a doctor; he told me more about the staging of cervical dysplasia and the next steps. I started to get dizzy. He told me he would meet me anywhere. I called my mom; she cried too. I wiped my nose with my sleeve as some foreign dignitary walked past. I drove to a lake and waited for my friend. My phone rang. My doctor’s office: “This is Kathy, the pap smear tracking nurse, and I’d like to talk to you about your most recent pap smear results.”

Hi Kathy. I’d like to talk to you about timing.

301.51: Hospital addiction.

In medicine, you are devolved to your diagnoses. You aren’t Elise, wife to Marc, a mother of four who contracted a disease from a blood transfusion and is getting so sick that your husband can’t take care of you anymore. You’re a 62 y/o female, hx of Hep C, cirrhosis, hepatic encephalopathy, who presents with increased agitation, confusion, jaundice. If we can make it a list, we do. If it can follow an algorithm, it will. If we can make it an acronym, we capitalize at will: CVA, DM, ESRD.

And when letters fail to capture the full extent of your illness, there are always numbers: the International Classification of Disease codes. The Dewey Decimal System of medicine, it uses a tiered system of three digit numbers to succinctly summarize your life. Broke your jaw? 170.1. Acute appendicitis? 540.0. Accident involving a spacecraft? E845. If you can live it, we can dehumanize it.

In the hospital where I worked for three years before starting medical school, I taught myself radiology and pathophysiology by meticulously studying the electronic medical records of every patient that crossed the doors of our Emergency Department. I learned about when you do a lumbar puncture on a newborn with a fever (always), what a STEMI looks like (tombstones), when a D-dimer is diagnostic for a PE (almost never). To learn the medical history of a patient, I used to comb their charts, looking at every previous hospital visit, until a resident clued me in: “It’s a lot easier when you’re writing up a consult just to click ‘PMH.’ It’ll show you every diagnosis they’ve ever had and you don’t even have to talk to them about it.”

Click. And before me was a chronological list of everything the patient had—everything the person had experienced—since they had been a patron of our hospital, all conveniently organized as ICD codes. A 23-year-old girl who slipped in the bathroom, fractured her cervical spine and is now a quadriplegic sounds a lot better when you say it as 806.09.

I read these codes dispassionately, like a biologist recording lab data. Things could be good or bad, things could be happy or sad, but ultimately it was easier and better to see a woman with a history of stroke, hypertension and aphasia instead of a grandmother who is confined to her bed, cracked open like a book with bedsores, caged in by her brain and only able to whisper one word: speak. 434.91.

V15.81: Personal History of Presenting Hazards to Health

After I found out that my body had betrayed me, I took the appropriate next steps: I had a biopsy. I Googled. I cried. I had the carcinoma in situ burned off me with a loop of hot wire. I ignored instructions and left to backpack Europe two days later; I collapsed in Westminster Abbey. I listened to a lot of Elliott Smith. I called my recruiter, who told me that the health waiver process could only start after I had a normal pap smear, a minimum of six months after the operation. She promised to get back to me with more information; she never called me again.

Medical school—and the military—were two big gambles for me, and I had decided to pursue both on the same day. I was sitting in a café in Cairo, reading Exit the King by Eugène Ionesco, in which a dying king realizes how much of his life he has wasted. He laments: “we haven’t the time to take our time!” I understood. The night before, a friend had sent me a picture of the casket of a Marine, draped in the American flag, being unloaded from the cargo deck of a passenger jet. The civilians above, safe, warm and curious, strained their necks along the windows to see. That disconnect—the gap between the citizens of our country and the people dying for it—was something I couldn’t accept. I was good at Arabic, but I hated studying it, and I didn’t have time to waste. I would do something crazy: go into medicine, the career I’d always dreamed of but had never been smart enough for, and join the military. I printed the photo and hung it on my wall. Quietly, I promised myself: I’d make my family proud. And if I did both, I’d get the tattoo I’d always wanted but hadn’t earned: Greek, from Thucydides, molon labe: come and claim them.

Being rejected from the military over something as small as an abnormal pap smear was inconceivable. I was angry. I got the tattoo anyway.

And I never heard from the Navy again.

308.0: Anxiety in acute stress reaction

I started medical school. I lost 15 pounds. A year after I had unceremoniously sobbed in the presence of generals, I found myself sitting in a classroom learning about the human papilloma virus, how it’s the cause of 100% of cervical dysplasia and cancer, and how there’s a great new vaccine for it with a 98% success rate. One of the creators of the vaccine came to speak to us: this is a cure, he said, for your generation of women to never experience cervical dysplasia again. I wanted to strangle him: I got the vaccine when I was 19. It didn’t work.

The same day that we learned about how insidiously the HPV molecules inculcate themselves into your genome, I had follow-up pap smear. I walked out of the office, visit summary in hand: “This is a 24 y/o female with a history of CIN II/III s/p LEEP who presents for pap smear f/u. Dx: 622.12.”

622.12. Deep breath.

E876.8: Other Specified Misadventures During Medical Care

I lost the invincibility that working in medicine sometimes brings: them, yes, how sad—but never me. I started seeing the circled acronyms and ICD codes as less of a summary and more of a story. I stopped looking at the PMH tab so often. I told all my friends to get pap smears. I started finding more of myself in patients. I knew: the other side of the diagnosis is a cold, sterile place. A few days ago in the ER I had to tell a patient he had a bleed in his brain and needed emergent surgery. I made sure I held his hand. But still, when I looked at his chart, I thought in my head: HTN, Hep C, makes sense.

Reading a numerical list of your medical problems is as close as you’ll ever get to reading your tombstone: it tells you where you got, but not how you got there. I cannot express what it is like—just as a list of codes cannot enumerate—the feeling under your heart when you hear someone talking about you and your body and your illness so dispassionately, reading off PowerPoint slides in an auditorium full of your colleagues. To read someone’s medical history, to see their slow descent towards death—but instead of words it’s numbers: I cannot tell you how brutal and necessary that is.

I understand everything, but I still don’t know: I didn’t know what to do when I got an email addressed to ENS Gorder, so I punched a wall. I still don’t know what to tell my grandfather, who has told all of his friends that his granddaughter is going to be the first Gorder in two generations to join the military. I don’t know how to explain the tattoo to people who ask. Sometimes I feel sad; sometimes I feel like I’ll never live the life I didn’t have time to waste. But quietly, I promise: there is more to your story than a summary.

And the picture still hangs in my bedroom.

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5 Responses for “Numbers Instead of Letters”

  1. Craig "Quack" Vickstrom, M.D. says:

    Wow. Great story. I think you’ll be a great doc, but they will torture you for it. Good luck to you!

  2. Navy’s loss. Typical nonsense. Glad you are okay. That is what is most important. You can follow reality MD @andybaldwin

  3. Simply this: thank you for telling your story in a way that illuminates the full tragedy of what modern medicine has become. Best line: “If you can live it, we can dehumanize it.”

  4. Andy Hopkins says:

    I found your article very interesting, thank you for sharing. Do you know anything about natural remedies and/or causes of DVTs or blood clotting in the lower legs? The VA refuses to try any natural alternatives to Warfarin or Cumadin. I am only 48, in great health, was a member of the CO Air National Guard of which I had the Anthrax vacination back in 2002/2003 and required to take 7.5 mg/day. If not, do you know of any experimental studies or recommended naturopathic doctors in the Denver metro area?
    Thanks!

  5. Andy Hopkins says:

    I was kicked out of the military for being on blood thinners with only 5 years left for a 20 year retirement. Any advice?

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