Practice pieces
===============

* John Stewart

**Practice pieces; Wardlife: the apprenticeship of a young writer as a hospital clerk**; Andrew Steinmetz; Véhicule Press, Montreal; 1999; 188 pp. $15.95 ISBN 1-55065-121-8 FIGURE 1

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/4/541/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/162/4/541/F1)

Figure 1. 

This slim volume, the first book from a young Montreal writer, is sure to appeal to physicians. The setting is first the ICU and then the emergency department in a Montreal teaching hospital. The author introduces himself: "I am the unit co-ordinator. The UC. Non-medical staff. A civilian among the troops. ... Someone who sits on the guard rail between sickness and health." Just what is this civilian writing about that excited and moved me to the point of volunteering to write this review?

The book evolved from what Steinmetz describes as "practice pieces, finger exercises," written quickly in moments stolen on the job. At first glance it seems an untidy collection of vignettes, anecdotes, snippets, jottings and hasty scribblings. But what emerges is a unique picture of the remarkable sociological phenomenon that is a contemporary teaching hospital. Steinmetz marvelled when he viewed his own large intestine on the monitor during an endoscopy; in this book, he gives an endoscopic view of hospital life. He writes of patients, families, physicians, nurses, orderlies; of operations, deaths, heroic treatments and miserable failures. But mostly he writes about people - physicians not least. A feeling I had throughout was that strange combination of curiosity and pleasure I experience when reading sympathetic articles about Canada in foreign newspapers. Reading this book we become, with Steinmetz, voyeurs, peeking at medicine through his sensitive but never squeamish, admiring but never sycophantic cyes. What a relief from the doctor-bashing and hospital-bashing we are used to.

Steinmetz is not short of amazing stories, such as his account of helping an understandably bemused nurse apply leaches to reduce vascular congestion of a skin flap, or of the use of a pig's liver to salvage a very sick patient waiting for a transplant. "Can they do that?" he asks. Steinmetz ruminates about the ICU medical staff and then concludes with unabashed awe: "They can do anything." I feel the same way when I visit the ICU and see what my technodoc colleagues are doing. But his greatest strength as a writer lies in his quirky observations of people. As in his description of "Veronika, in her early sixties, Romanian, one of the night orderlies. Forty years of hospital service, only minor repairs. Growing old, grown old, wiping bums, folding sheets and bringing water. She wears a white tight blouse, a piece that billows below the waist, tennis style, circa Billy Jean King. Beside her co-workers, a parade of shiny males with greenhouse-grown biceps, Veronika is stringy meat, obsolete." And of "the flamboyant Dr. S, a jolly, efficient, eccentric. Tonight he sports a pair of black, anti-embolic, spandex cycling shorts. He's on his way out. His mountain-bike is chained to a lamppost outside. He's nouveau young." I chuckled again at his depiction of a neurology resident who "waltzes in carrying a small, black leather handbag. He's here to tune the piano. Press keys, check the action, elicit notes, reflexes, involuntary body responses is the game."

Then there is the story of K, a dying man who "arrived on the unit several weeks ago. A symphony of symptoms. ... K is the property of Vascular Surgery. Not much they can do for him." The story of this man's slow death unfolds in delectable and poignant snippets that pop up unexpectedly. K's wife and daughters sing melodious Ukrainian hymns on and off for days by the bedside: "They are burying him with songs, draping words and melodies over him, elemental as fire." Steinmetz listens unabashedly, and is moved - as we are.

More ruminations (certain to meet the approval of this neurologist): "Blood. One of the lower classes of body fluids today, an untouchable, a caste below urine. Spinal fluid remains aristocratic, silver clear, pure as spring water. But blood has taken a beating. Yesterday it wore a cape, blood was valiant, vital, a bright, red metaphor for courage. The quarterback of life. Today blood is just another body fluid, dark, mischievous, heinous, sneaky, and untrustworthy."

Out of the high-tech, brightly lit, protective cocoon of the ICU, Steinmetz is booted into the ER. Things are different there. How well he describes the humiliation patients suffer as a result not only of their own bodies suddenly failing them but of the awfulness of our overcrowded emergency departments in spite of their heroic, exhausted staff. Not to mention the cold fury of the appropriately appalled family members. This is what wrenches my own gut when it's my turn to do neurology consults in the ER. Steinmetz is no fact-producing newspaper hack; he wields his steel-edged scalpel with a delicate, nimble touch, and his political thrusts are the sharper for it. Meanwhile, he quietly agonizes over his own impotence in the midst of this sociomedical carnage. As the reader, I quietly admire the decency of this UC/civilian/writer.

A recurring theme in a book built of recurring themes is Steinmetz's fascination with the medical history. This is hardly surprising in a writer. He is intrigued by the process of history-taking and by how the history is amended and polished as it ascends from the quick and pragmatic first pass in the ER. He is also fascinated by diagnostic processes, as when the cardiology resident "plugs into her stethoscope and lowers her head down over the man's chest. Tick. Tick. Tick. Shush. She's picking his lock, his safety deposit box." This is powerful writing. FIGURE 2

![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/4/541/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/162/4/541/F2)

Figure 2. Fever therapy room, Christie Street Hospital, Toronto, March 1945

This book makes me, as a physician, both proud and ashamed of what I do. Buy it and read it. Give copies to your physician friends. You will laugh, cry and sometimes curse, but you'll be all the better for it.