Heart Sounds
How a Stethoscope, a Magic Wand, and a Fishing Pole Teach Us to Listen for what Matters Most
Preparing To Listen for the Sounds of the Heart
Heart Sounds: medical jargon referring to the different types of "lub dub" sounds the heart makes when listening through a stethoscope.
It also means the sounds our souls make when listening deeply with the heart. Whether you choose to don a white coat or a cozy blanket, listening for what matters most is clearest when the heart is allowed to lead.
Truth be told, I have always preferred blankets (and stuffed animals).
(Yeah, that’s me, and my beloved, Scotty1 and one of my many favorite blankets.)
This is the very beginning of the introduction to Heart Sounds — a collection of true stories of people for whom I have cared.
This is the very end of the introduction…
My path to practicing hospice and palliative medicine was far from a straight line. It took time to find my way. Many of the stories that follow are about my early days as a medical student and then as a resident and fellow in training, with an ultimate unanticipated turn to becoming a physician who cares for people who are living while aware they are dying. All are true and only when explicit permission was unable to be obtained, were names and identifying details modified.
I share these stories in the hopes that you will feel welcome to witness the importance of being an advocate for your own care. The adage that “the doctor knows best” should never suppress your own inherent expertise that you know what is true and therefore “best” for you and those you love. Given the culture of medicine, this is rarely easy and will likely take practice. You don't need to go to medical school to learn how to advocate for what you need. Rather, it is about being curious about your care so that the care that matters is the only care delivered. The stories that follow are of real people making choices as they face life-limiting circumstances. Which is ultimately all our stories.
May their unique Heart Sounds illuminate our shared humanity, such that they become the stethoscope for listening to the heart of what matters most.
I will leave the in between parts for the print version.
For now, I will transition to the first chapter of the book. Everyone is invited to read it in its entirety. EVERYONE’S feedback is deeply appreciated! Please leave comments below or in the chat on the substack app or send me an email at dawn@dyingtotalkradio.com. Most importantly, thank you for reading!
Violet2
"Mom, why do you do it? Take care of the people you do? Couldn't you be any kind of doctor? Maybe one more like dad?" my daughter Isabell asks. At the time, she was still in elementary school and had recently become a volunteer, joining me on some of my visits to see patients in their homes, but not in the hospital. This week, I am caring for people in the hospital, and Isabell is feeling a little (okay, a lot) neglected.
She and her two younger brothers, Joshua and Kalel, have grown up like many of their friends, listening to both of their parents discuss work over dinner. Our discussions focus on patient care, and Isabell had begun noticing how many of my patients tend to die, while my husband Andy's patients tend to live—or in her mind—“not die.”
"First of all Isabell, not all of my patients die while under my care. I mean we all die, eventually. And many doctors take care of their patients for a long time. Just ask your dad. It's just that most have never been taught how to actually take care of people as they die."
"But why would anyone want to?" Isabell asks.
"You want to know why I gravitate to being with people at the end of life?" (Perhaps it is my Talmudic Jewish upbringing or my academic medicine training that has me reflexively respond to all questions with either a question or a story, or as in this case, both.)
"Let me tell you about Violet. Maybe then you’ll understand.”
****
It is an otherwise typical morning in the hospital. Our team, made up of seven, moves in line akin to a mother duck with her ducklings. The newest to the hospital waters, Laura and Ngoza, are medical students in their fourth and final year of school. They know to keep pace just behind our pair of young doctors-in-training: Allea, an intern just a few months into her first year of officially being called "doctor," and Nicholas, a senior resident readying to spread his wings into independent practice. David, the team's dedicated social worker, and Miriam, our chaplain and spiritual counselor to patients, families and team members alike, stay near the front, closest to me, the mother duckling. Commonly referred to as the supervising or attending physician, it is my job to navigate the waters, keep our team afloat and guide our team members in caring for patients living with life-altering and life-limiting illnesses.
At 10:50 a.m., I feel my right hip vibrate. Slipping my hand through the slit in my white coat, I finger for the pager attached to my belt to slide it out of its case. I glance at the blue digits flashing on the display then clutch it in my hand and reach for the nearest housephone. David had split off from our rounds a few moments earlier to help a patient get ready to go home with hospice. I assume he’s the person now paging me. I look at the number and recognize the extension. Curious, I think as I push the buttons. I wonder what David is doing there? The page is coming from the intensive care unit (ICU).
"Hello? Is this the palliative care team?" a frantic-sounding young doctor answering the phone asks.
"Yes," I say, somewhat surprised before re-claiming my well-practiced calm reply. "This is Dr. Gross. How may we be of support?"
“This is Emily, I'm one of the interns in the ICU." Her voice is high-pitched with a hint of breathlessness. "My patient, she’s having a lot of trouble breathing. She’s really struggling. I think … I think she might be … dying.”
"We'll be right down," I say and motion for my team to follow.
Like the myriad medical TV shows depicting the dramatic behavior of code teams racing to the aid of a patient whose heart has suddenly stopped beating, I’m on a crash team of sorts.… We just crash differently.
We bolt for the end of the hall, creating the distinct sound of a hospital stampede as we barrel down five flights of stairs. (Waiting for an elevator impedes the momentum generated in a medical emergency.) People in the stairwell respond to the sound the way drivers respond to a siren, halting in their tracks and hugging themselves to the walls until our team passes. First to burst out of the stairwell, I pull my I.D. badge to wave it across the entry lock of the ICU; its thin cord tethering it to the lapel of my coat makes a zipping sound like the reel of a fishing line being cast. The double doors click and slowly begin to swing open. They lack the sense of urgency I am feeling, so I push hard on the heavy doors to make them move faster. Emily is waiting just inside and waves us toward her.
Violet, an elderly woman with white wavy hair, is lying in Bed 12. Her eyes are already glassy, a clear indication of a point of no return. She is gasping for air like a goldfish forgotten on a table next to its tank. Most striking about this scene isn’t the paleness of her skin or the ominous beeps emanating from her room. It is seeing her all alone. Other medical staff are standing outside the open sliding-glass doors of Bed 12. Only Violet is inside. Emily stays tucked outside the door to the left, clutching her stethoscope and phone, waiting for her supervising physician to answer. The ICU nurses are hovering over the vital-sign chart resting on a small laminate table in front of the right-side door. But where Violet lay, no one dared trespass—until we, the palliative care team, sprint in and fan out instinctively, surrounding her bed.
I move to her right side and place one hand on her right arm and the other over her heart, saying, “You’re not alone. We’re going to make your breathing easier now.” Laura and Ngoza take up a position together in the corner of the room, eyes wide. Without leaving her side, I turn to Nicholas—farthest from the patient’s bed and nearest a computer monitor—and call out, “We need whatever opioid is immediately available.”
Miriam reflexively begins to move away from Violet in anticipation of a need for more medical personnel to enter the space. I reach out and grab her arm. “You I need right up here,” I say, bringing her back up to stand opposite me at the head of Violet’s bed. “You’re the most important person in the room for her.”
Miriam holds Violet’s left hand and begins speaking in soothing tones, like a mother to her child. “You are surrounded by love," she whispers. She briefly raises her gaze from Violet’s face to mine and then the foot of the bed, saying, "You are surrounded by two—no three—mother forces.”
Allea, a mother of a five-year-old and an eight-month-old, stands at the foot of the bed, her look of compassion intensified by the headscarf framing her face.
Our chaplain continues to stroke and soothe Violet’s head and face with her touch and her words as we each hover close and witness the grace in the moment.
The nurses begin entering the room and weaving between us, thanking us for being here.
Medication arrives, we stay with her. Her breathing eases. We stay with her. When her heart stops, we stay with her.
I ask Nicholas, still clinging to the computer monitor, to find family and call to let them know what has happened. He quickly searches the chart, tries making a call, then looks up at me. “No immediate family identified, only a friend not picking up the phone.”
“Don’t leave a message,” I urge. “Just ask them to call the ICU as soon as possible. You never want to leave that kind of information on a phone message. Imagine.”
At 11:20 a.m., I leave Violet’s room to find Laura and Ngoza fighting off tears in the corridor. This was their first witnessed death. I place my arms around them, trying to find something to say. This is important, a rite of passage I know too well. Remembering my first medical-school brush with death—being marched outside and told never to cry in front of my patients again—I take a different stance.
I speak slowly with intention: “These tears are good. Never question that. This is sad, and you being sad, well, that means this matters to you. May it always matter.”
Allea is equally distressed, as well as angry. “I just can’t get that picture out of my mind … her all alone in that room. Everyone else standing outside … but Violet, alone.”
And then Nicholas bravely speaks up. “I would have done what Emily and the nurses were doing. I would have gone to the hallway computer, checked her medication list or talked with the other medical staff first. I wouldn’t have gone to her bedside. It seems crazy, even embarrassingly obvious to admit, but it wouldn’t have occurred to me until I saw it—that you can be with the patient and bark out orders to get what you need without leaving her side….”
Nicholas spoke with Violet’s friend later that day and learned she was part of an organization called No One Dies Alone. It’s a group of volunteers who choose to sit with strangers, people without friends or family when they die. This woman was so grateful to hear what we had done for Violet.
Violet died in our hands, far from alone.
****
At the conclusion of Violet's story, I watch Isabell's eyes fill and brow furrow before saying, “I get it, mom.”
“What do you get?” I ask somewhat hesitantly of my literal daughter, who, after having watched the movie Big Fish with me and hearing me say, “That’s what I want when I die”—meaning to be surrounded by friends and family telling stories—concluded that I wanted to be thrown in the river.
“No, no, mom. … mom, really. I get it," she says now wiping her face with the bright yellow sleeve of her goalie jersey. "From now on when I see you so busy working at the hospital, I’ll know you’re okay.”
“How?”
“Because I’ll know you got to be with Violet.”
I hope you enjoyed this first chapter of Heart Sounds. Many more stories are waiting to greet you in your inbox. They are also in the process of being transformed into a unique, calligraphic form to adorn the hard copy experience. Here are some beginning drafts of how a new font is invented3:
Fist, take one part pirate and one part calligraphy wizard and place them on the beach:
Add in a golden day with a golden gate backdrop…
Then pick up a magic wand and make a Wish…
This is not the finished lettering, only the beginnings of a draft. Illuminated letters and flourishes are also on their way!
Why do all this instead of just printing it as it appears to you on whatever screen you are reading from right now? Because I want to offer a particular experience for those who Wish. And since I Wish and …because I can, I am!
My intention is for you and me, as readers, to experience this book the way one enjoys taking time to sip tea from a specially selected tea cup. It need not be expensive or fancy. The meaning comes from the intention -- the process of selecting the tea and the cup. In other words, Heart Sounds will be something of a sacred object. Something to be savored. From cover to cover, I wish for you and me to be present to attentive care -- a sense that we are being held and hugged each time we choose to open the book and enter into a story.
If you cannot wait to read more and hear all the “lub dubs” beating within the virtual pages of Heart Sounds, here are ways to engage:
Become a Feedback Friend: (Maximum of 5 readers) In exchange for completing a brief feedback form for each chapter, I will make all of the coming virtual chapters fully accessible for free! The chapters are short and the form is even shorter so both should be a fulfilling experience (pun intended:) Your name will appear in a special section of acknowledgements and you will be entitled to receive a signed, free copy of the print edition! If you have questions or know you are interested in this option, please email me at dawn@drasyouwish.com or leave a comment below saying, “I’d like to be a Feedback Friend” and I will set you up!
If you just want to read the full chapters as they are released and not be left hanging like a dangling participle… AND have the option to offer informal feedback whenever you are moved… AND know that your support is making the tangible version possible, then please sign up for a Paid Subscription. You can choose monthly or annual as well as Gift Subscriptions to share with those you love! I have set the monthly and annual fees to the lowest substack allows to make this as accessible as possible. If you select the annual option, you will instantly be entitled to a signed copy once the book is in press (in early 2024) as you will have already paid for it! Plus, you will already be in queue to begin reading the sequel/prequel!4 Your name (or the name of your choosing) will also be included in a special acknowledgement section of the print edition.
If you know you cannot wait to make the tangible version possible, then please consider selecting a Founding Sustainer subscription level. In addition to having full access to each story as it is released in its virtual form, as well as having your name (or the name(s) of your choosing) be included in a special acknowledgement section of the print edition of the multiple signed copies (based on your subscription level) that you will receive, you will also be gifted extra magical surprises, some of which sparkle! And, if this doesn’t already sound like a ginsu-informercial5, just wait!… you will also be in queue to begin reading the sequel/prequel to Heart Sounds as soon as it is released!
If you LOVE all of the above AND want to make a larger sustainer donation that supports additional research I am developing at UCSF based on this work, please reach out to me directly at dawn@drasyouwish.com so I may guide you to creating a directed, tax-deductible donation.
If you have additional ideas on how you’d like to engage PLEASE leave a comment or reach out directly and make a WISH! I promise to listen for the heart of what matters most to YOU….!
With Gratitude and Love, Dawn
Scotty is featured in the prequel to Heart Sounds which will actually be released as sequel… because I can:)
A version of this story first appeared in Tell me again: Poetry and Prose from The Healing Art of Writing, 2012. Eds Baranow J and D. Watts University of California Medical Humanities Consortium, 22-27, 2014.
Ben Yates is a master mixologist, pirate and calligrapher, though he would humbly say otherwise. If you’d ever like to learn, or hone your own skills with a quill, you can find him and other exquisitely talented and generous artists at (where else) Castle in the Air: https://www.castleintheair.biz/classes/
See footnoe 1:)
You can look up “Ginsu Knife Commercial” on the internet… or just take my word for it and keep reading Heart Sounds instead…