By Colleen Corcoran
The rib cage can function as a ladder in the tradition of Chinese medicine. Each intercostal space the foothold for the soul to rise up on its journey of progression to leaving the body when the work of the climb is complete, when the ascent is over. I think about this silently as I examine and palpate the slight swelling on my patient’s left clavicle, causing him pain. He reports the pain began suddenly while watching his grandchildren play one afternoon, and has persisted, worsening ever since, but all results and findings have been returned unremarkable. He laughs, as he tells me this word “unremarkable,” with glinting eyes and laugh lines like canyons speaking the story wordlessly of the many years of joys that came before this moment in time. “I just don’t know,” he says “it certainly feels pretty remarkable to me.”
After he has come and gone from his appointment and I am reviewing the historical chart notes yet again, looking for anything that could be causing this pain and finding pages and pages of no answers, I carry with me the rest of the day the laughter in this man’s eyes and the feeling of his clavicle under my finger. Where usually there is solid bone and perhaps some muscular tension or even a feeling of hollowness in some, there was the feeling of marshland beneath my gloved hand. The geography of the body was a bit boggy I joked to myself silently, in worried memory of when the patient spoke to me at length of his frustration of having no clear diagnosis but persistent inexplicable pain.
This is where my work as a hospital acupuncturist and Chinese medicine clinician can shine—I have the luxury in my field of being comfortable with uncertainty in ways not possible for other clinicians. This is why so many of my patients get referred to me, having run the gauntlet of so many specialties and tests to no satisfactory end point, I serve the role of end point into uncertainty at the hospital. My clinical role becomes the punctuation to an often long-term searching for an “aha” sentence. I serve like the last rung of the rib cage, a stopping point. Yet in the geography of the system, murky and unclear at times in a defined standard care practice understanding of this field—much like my patient’s left clavicle, I have to map a territory comfortable in the still unknown, in the marshlands of definitions. Having climbed the mountainous ladder of the healthcare system, we’re now in the land of the story of the fully dimensional human being, more than a sum of its parts, and in the places where soul meets body and was never separated to begin with, an old knowing having to prove itself anew in a different hierarchy.
This is not to say my work is not diagnostic or exacting, or that my communications with my patients are unclear or only spiritual; the weight and responsibility of evidence-based and effective care still rests very heavily on my shoulders. It is to say that I have the fortune of multiple lenses to choose from for framing, including one where there are acupuncture points on the
anterior chest that can function as doorways which can open and close, become active and inactive at different times in our life story in ways that may not make sense in what we’ve come to understand as routine narratives of defined pathology. I have the privilege of working with patients at times and in ways to help us tell another story, together, and to see this story embodied sometimes outside of the lab markers and imaging’s resonance and logic.
What does a swollen and marshy clavicle tell us if we are able to quiet our own narratives and presumed terms enough to listen? Sometimes a closing off of a door to the heart and lungs can protect us, shield us from an exterior pain or pathogen even. Other times the door can get stuck, like a rusty hinge in need of a good oiling, and when the flow of circulation is stopped for too long, the rivers of lymph and normal blood flow can get backed up, much like a canal lock frozen in time. While this may not present on any report of findings, my patient is right—his pain is indeed pretty remarkable and telling a story worth listening to with my fingers’ trained palpation and open ears.
Tell me your story, I think quietly and open to hear over multiple sessions with this tender man and his tender clavicle. “I have no answer,” I find myself saying out loud, and over time his response is less angry at this indefinite space. My role is not to have to expound on an answer sometimes, an extreme luxury in healthcare, but to hold space for the patient to meander into their own answer when no one else can find what is wrong. The answer is a patient’s to find on their climb through this life. But here, in this patient, where the tissue holds stuck with baggage just at the ascent, I can help restore free flow and acknowledge, yes—yes I can see and hear the marshland and it is as real as the canyons of his laugh lines. Here his body is telling a different part of his story, with my job being to connect it all in validity of the whole.
Officially for this patient, his anecdotal finding self-resolved after several visits of targeted application of needles to restore movement and free flow in the local area. Unofficially, I listened to unfulfilled childhood dreams of playing professional baseball and, instead, taking the safer, more responsible road of a designated career path in civil engineering. I listened to fears of cancer and not having lived the life the patient had wanted in his heart while tenderly applying my needlework to his chest. Transversely sewing invisible threads of connection, tying together the stories of the heart, lungs, and the words spoken in this unclear swamp of stickiness until gradually, and fortunately, the unremarkable pain dissipated in restored connection. This dense pocket of lost dreams dissolved into the solid ground of bone and blood again in acceptance. Remarkable.
The strings of life do not always tie so neatly in a bow or in such a beautiful outcome, even in the most poetic of medicines in the most heart-filled moments. I also remember what it was like to feel under my fingers the ribs and hollow flesh, like an empty drum barely beating in my hands, of my mother’s dying rib cage. Gingerly walking this ladder with her, quietly and simultaneously wishing
both for a merciful and quick end to her story that wasn’t coming, and to have her as she was before years of illness took their heavy toll. It felt unreal in a way, as if there was some mesh under the skin, holding it up for the bones that could no longer do their job. Like a chain link armor wrapping around her heart, now bared under thinning skin and exposed to speak its own story of the times of guarding and soldiering on when she had no words but only endurance. A story told in gasps and flickers, each little link rising up to not give voice to words, but pooling deep in my own feelings and in the fluids that gather in the back of the throat of the dying that were now collecting in hers. There was no happy outcome or meeting of integrative medicine-inclined minds here, and yet…
There is a phrase in one of the great Chinese medical compendiums, the Neijing, often translated as “the spirits no longer send.” This is a fatal statement of prognosis, indicating in a way that the heart is no longer telling the story, no longer guiding the circulation and other organs to function in the ways of order they are designed to, and the song of the body is lost, the pulse notes can no longer play in order or at all. The ascent is over. There are no more steps to climb. While this may sound poetic, it’s also very much biomedically what happens as the heart fails, and our blood fails to circulate. The lungs lose their vibrant inhalation and exhalation, and the breath of life becomes lost in translation and lost altogether to our other organs, movement stops, the brain stops, the story of life ends. None of this is helpful in the extraordinary moments when a patient codes and the team is working in the most adrenaline- fueled ways to keep the human body song playing. Yet at the same time, in the before and after, all of this happening can offer perhaps a chance to tune our own instruments and remember sometimes it’s not our stories to tell as clinicians but the patient’s to be heard as being or not being, an unopened gift of time and space in the realities of practice.
There are days in my own practice when I feel I cannot keep pace with the patient list and needs for the day, let alone spend the deep time required to truly hear each patient’s story told with their own words, or what is spoken in the words they choose not to say. I am pressed by the demands of keeping the bigger machine running, and lose the feeling of the story their body is telling me. The day I saw the man with unremarkable clavicular swelling and pain was one of those days. Yet somehow, in the marshland of his benign lump, I felt and remembered my mother’s rib cage and story asking me to do better. A gift to be opened and remembered in practice, reminding me of how much even a moment of presence can matter. Holding the patient’s sternum, I remembered how my mother was still so beautiful to me, even in the ugliness of the physicality of dying. She had reached the ascent. No more words at this place. She had told her story, and I only wish I had listened better, with more open ears. Do it now, listen now, I hear the empty drumbeat of her hallowed chest tell me.
Now, when I find myself on this climb with patients, it feels as though we are mountaineers roped together for a finite time, looking for a diagnosis; frequently the patients are approaching end of life and trusting in my care and I try to remember what my mother taught me: be present with this body, be present with this embodied person. Hear what the steps on each ladder rung of life tell you, this is a form of treatment. Hear the words caught in the tissue, help them move. When I get caught in the fifteen-minutes-or-less time increments of modern medical practice that hit all providers in healthcare systems, on a good day, I take even the briefest of moments and feel my own rib cage, palpate not like I’m looking for the point of maximal impulse or fulfilling the requisite BLS recertification, but instead palpate like an open-ended question— where am I on my story of life? What ladder rung am I stuck on or do I believe I should have climbed? Where am I on this ascent, and how can I meet my patients where they are on theirs? Where do we go when the ascent is over and all we can do is acknowledge the journey of each rung if we are lucky? And being able to answer this question can turn the unremarkable finding into a remarkable outcome.