marginalia

Reversible vs irreversible injury, on the cellular level, is a matter of broken or intact membranes. Rupture the fine integuments, erase encasing boundaries, and you're dying if you're not already dead. I can hear Nabokov in those particulars of necrosis:

I do not know if it has ever been noted before that one of the main characteristics of life is discreteness. Unless a film of flesh envelopes us, we die. Man exists only insofar as he is separated from his surroundings. The cranium is a space-traveler's helmet. Stay inside or you perish. Death is divestment, death is communion. It may be wonderful to mix with the landscape, but to do so is the end of the tender ego.

And perhaps that is all we fight to preserve in medicine -- the profound and perfect isolation that is living. To keep a person discrete and singular and apart (a part apart). Stay alive; do not divest. As long as the walls keep enough of them out and enough of us in, all can be reconciled. For you to die, all it takes is one irreversible injury -- just one unforgivable insult --  so bear as much as you can and then bear more than you can. That's all anyone needs to do. That or kill yourself. 

Another thing we know about irreversible injury: There is a three-part sequence. 

First is pyknosis. Shrink as small as you can. Not so much your outline, but everything inside: your bones, your blueprint. Fill in every gap and lumen until each primary piece of you huddles blindly, furiously into yourself. Dispense with context and crumple all finer distinctions down and inward, into an inkspot. Next, karyorrhexis. Small as you've tried to become, we can do better, be more invisible still if we burst the kernel. Scatter the pieces far and wide just in time for dissolution -- kayolysis. Compression, [that seems enough for now]

There is a weird feeling of stasis or deja vu in jotting excerpts from Pnin in the margins of Pathoma. I swear I did something just like it this same time last year. 

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I can't get over that one panelist from the last MCS large group meeting. I believe she was a fourth year medical student. In offering an example of a good role model on the wards, she told us about a day during her obstetrics rotation.