Summary:

This memoir begins in Africa, where Dr. Grim is with Médecins sans Frontières managing a meningitis outbreak in Nigeria. Conditions are appalling, but she has come here because of burnout: "so I won't be back home and in the ER" (11). Later in the book, she describes her other "escapes" from the Emergency Room, caring for war refugees in the Balkans.

The book centers, however, on life in an American emergency department, as Grim remembers it from the vantage point of Africa (where she does eventually become nostalgic for well-stocked supply cupboards and a more comprehensible chaos). She organizes her stories into a series of "Lessons in Emergency Medicine," in which she addresses the reader directly. After going through a step-by-step account of death in the ER, illustrated with several moving and alarming cases, she concludes: "Congratulations: you have successfully declared someone dead. Now, as an encore . . . you'll get to do it all over again" (28).

The ironic, even bitter, tone warns us of the difficulty of working in such perpetually crisis-ridden circumstances, but it does not conceal a vulnerability that seems necessary to doing the job well, such as when Grim has to tell a family that the father has died of the heart attack he had at his daughter's wedding: "you just stood there," she says, "looking at the corsage, the tuxedo and the pearls . . . You had no idea what to say and you don't really remember what you finally came out with" (26).

The stories are organized around several lessons: "How to deliver a baby," "How to crack a chest," "How to write a prescription" (which includes a discussion of addiction to prescription medication and a withering account of the doctor who overprescribes), and, as if it's as inevitable as the rest, "How to burn out."

By the book's final chapter, emergency medicine has merged, along with the vaccination of refugee children and the impossibility of treating tetanus in Nigeria, into the story of almost unreasonable determination in the face of endless frustration--but this, Grim shows in her final chapter, "Why I do what I do," is the point. Against this backdrop her final story, about the rescue of a child, makes its point: the feeling of saving a life explains all the rest.

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August is divided into two sections: "On the Corner of Fourth & Irving" and "To Marie Curie." The narrator, on a street corner in San Francisco near the teaching hospitals and medical school of University of California, San Francisco, meditates on the recurrence of lymphoma in a patient. Evening is approaching, fog blows in from the ocean, and the city pigeons are unsettled--landing and taking flight.

The meditation includes a tribute to Madame Curie and her discovery of the effects of radium. The patient had had a good chance of cure by radiation treatment--unfortunately, this patient is in the twenty percent who are not cured. The narrator, probably a physician-in-training due to the load of textbooks, had read the patient's chest x-ray as negative (normal) previously.

By the end of the poem, we learn that the physician had felt enlarged lymph nodes in this patient's neck today and he bluntly states: "I have failed. He has not been cured." The poem closes with the sound of the wind and the "beating and beating of wings."

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In the first section of the book ("Rejected Prayers"), Liveson proves that the prayers were not rejected; rather, they resulted in a group of thoughtful and moving poems. These poems speak eloquently of suffering patients, especially the elderly and neurologically compromised; for example, "Jenna," wearing her "diapered dress" (p. 16), "Sonnet to Sarah," who "lets her fingers trace the pattern on the wall," (p. 20), and the patient in "Praxis," whose "smile was rare but even" (p. 21).

These poems also speak passionately of social and historical pain, and of injustice writ large. Some of the most powerful are in the section called "Before the Plaster Sets," with which the book ends: "My First Death" (p. 63), "Holocaust Torah" (p. 66), and "Yom Kippur, 5760--Musaf" (p. 68).

The latter poem is a kind of contemporary re-envisioning of Allen Ginsburg’s 1956 poem "America." Jay Liveson writes, "Yom Kippur, this is serious. We sit here / hoping to somehow tune the engine / or at least check the map." Is tuning the engine enough? Perhaps we are fooling ourselves; much more needs to be done. How can we be content to sit and tune the engine in this unjust world? Perhaps the poem that speaks this theme most eloquently is "Statistical Causes of Traumatic Shock Syndrome in Gaza--Chart VII" (p. 72).

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Narrative competence is important for effective health care practice. By "narrative competence" I mean mastering a wide array of narrative skills, ranging from active listening and empathic responding in the client-practitioner interaction to reflective writing about one's professional experience. In the author's first book (The Therapeutic Potential of Creative Writing: Writing Myself, see this database), she explores the potential of creative writing as an aspect of therapy, and also presents some introductory writing skills. This book overlaps somewhat in covering the background for reflective practice, but focuses in considerably more detail on skill building.

Near the beginning of the book, Bolton presents a clear summary of "The Principles of Reflective Practice" (chapter 2). Recognizing that therapeutic writing is often accomplished in a group setting, the material on "Group Processes and Facilitation" (chapter 4), "The Creation of a Team" (chapter 5), and "Assessment, Evaluation, Mentoring and Values" (chapter 6) serves to introduce the last 100 pages of the book, which address specific writing skills, beginning with "How to Begin Writing" (chapter 8).

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A doctor is called to the home of a poor, immigrant family. A beautiful little girl is quite ill. As diphtheria has been going around, the doctor attempts to examine her throat. The girl, however, won't open her mouth. She fights him off and all attempts to cajole her into compliance fail. Yet, the doctor is resolved to see that throat. He forces the girl's father to hold her down, while he manages to wrest open her mouth after a long battle. She does, in fact, have diphtheria.

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This collection contains all 52 of Williams’s published stories, together with a new introduction by physician-writer, Sherwin B. Nuland. The stories were first collected in one volume in 1961 under the title The Farmer’s Daughers (New Directions); that book, in turn, included three earlier collections, plus "The Farmer’s Daughters"(1956), Williams’s last published story.

Thirteen stories featuring physician protagonists were previously collected by Robert Coles and issued by New Directions as The Doctor Stories (1984). (That volume also includes several poems and an "Afterword" by Williams’s son.) Among the stories with medical themes are Old Doc Rivers, The Girl with a Pimply Face annotated by Jack Coulehan (also annotated by John A. Woodcock), The Use of Force annotated by Felice Aull (also annotated by Pamela Moore and Jack Coulehan), Jean Beicke(annotated by Felice Aull and also by Pamela Moore and Jack Coulehan--see Jean Beicke), A Night in June, and A Face of Stone. The tales of a nonmedical nature include such masterpieces as "The Knife of the Times," "A Visit to the Fair," "Life Along the Passaic River," "The Dawn of Another Day," "The Burden of Loveliness," and "Frankie the Newspaper Man."

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Year after year Dr. Lin Kong returned to his country village from his army hospital post in the city with the intention of divorcing his wife, Shuyu. Except for the conception of their single child, Lin and his wife had no conjugal relationship. Their marriage had been arranged by Lin's parents and his wife had remained in the village and cared for Lin's parents until they died and then raised his daughter, Hua.

In the meantime, Lin had developed a relationship with a military nurse, Manna, in his hospital. Manna pressed him each summer to request a divorce from his wife; each summer he got Shuyu's consent, but she backed down when they appeared in court. Still Manna waited--for 18 years she waited for Lin to be free.

Eventually the waiting ended as the law allowed a divorce without consent after 18 years of separation. Lin moved his former wife and his daughter to the city and he married Manna. The remainder of the tale is that of the new marriage. Lin still waits for something that doesn't seem to exist. Manna also waits for a dream that doesn't materialize. Shuyu and Hua quietly wait in the background for Lin to come to his senses.

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Second Opinions, Jerome Groopman's second collection of clinical stories, illuminates the mysteries, fears, and uncertainties that serious illness evokes in both patients and doctors. The book is divided into 8 chapters, each a clinical story involving a patient with a life-threatening illness, plus a prologue and epilogue written by Groopman. The stories focus on people who face myelofibrosis, acute leukemia, hairy cell leukemia, breast cancer, and marrow failure of unknown cause. Two chapters are Groopman's personal accounts of his firstborn son's near fatal misdiagnosis, and of his grandfather's Alzheimer's dementia.

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In this journal, Murray traces a month-long rotation he spends as attending physician in the ICU (Intensive Care Unit) of San Francisco General Hospital. For each of the 28 days, Murray presents the patients he sees, both new and ongoing, along with commentary on the care of each patient and on broader issues raised by their cases.

In the course of the month, we encounter sixty patients, fifteen of whom die in the ICU. The patients are apparently quite typical for the hospital: cases are dominated by HIV, pneumonia, tuberculosis, and drug abuse, or all four. The ICU is not a very safe place: there are twelve cases of iatrogenic pulmonary edema, and several of hospital-acquired infections.

Murray candidly presents both the triumphs and the limitations of contemporary intensive care while giving us vivid glimpses into the lives of both patients and staff. In his epilogue, Murray asks some tough questions about the value of intensive care units, and discusses palliative care, patients' rights to the withholding and withdrawing of life-sustaining therapy, and even physician-assisted suicide, as "more humane"--and economically responsible--alternatives to intensive care in cases of advanced terminal illness (270).

He describes the ICU as a "battleground" where people who are "clinging to life" can "fight for it" (275). This is its value. But the battles need to be better understood and winning must be carefully evaluated. Murray concludes that the last few decades' medical and technical advances in critical care now need to be matched by ethical ones.

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In her Introduction to this posthumous collection, the poet’s daughter writes, "If I had to identify a single distinguishing figure of his imaginative world . . . it would be his preoccupation with the human task of sustaining the intensity of experience against a backdrop of desensitizing forces and death." These 25 poems range across Bruce Ruddick’s lifetime of sensitive responding to those desensitizing forces. Some spring from the pen of Ruddick as a young Canadian poet; others from the life experience of an aging psychoanalyst. All share the discipline, imagery, and economy of line that characterizes them as the work of a fine poet.

In "#25"(p. 10) Ruddick adopts the voice of a medical student who categorizes and quantifies the life of his cadaver. But the patient needs more than this. Indeed, the patient needs "a physician’s ear." ("The Patient," p. 11) Ruddick demonstrates such a sensitive ear in poems like "Ache" (p. 13)," Rehabilitation" (p. 39), and "Fever" (p. 41). And he also puts his "grouchy" heart on the table for all to see in "When the Dog Leaped"(p. 33) and "Spring" (p. 17).

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