Exactly How [Dark] can Writing Get? — Elkins

The so-called Imaginary Situation may be the characteristic form of Child's Play. The role-playing child-doctor-astronaut-Godzilla images itself to be an earnest embodiment of the real thing (and perhaps even believes for a moment). This is also a manifest quality of some very good and very bad writing. "At death we will be together in the tomb," though Aida alights with vigor at curtain call (since it's so boring down there).

Sæterbakken, who has evidently never fallen asleep with gum in his mouth, appears to have imagined himself to have done so (and then to have put it on the page). Why else would he suggest that our chronically (and presumed terminally) ill bathroom-dweller continues to think/speak/write in the kind of goal-directed television-dialogue, which, for some reason, (unfortunately) appears to characterize Nordic prose. On the subject of somatic illness, our author may beguile a certain professor of Art History, Theory, and Criticism, though some of us, for better or (likely) worse, are living closer to the ground. Sæterbakken has a way to go if he intends to portray the (over)burden of disease. Are we to understand our Discontents' Dark-est Dia-logue as child's play or the real thing?

Imaginary History and Physical Note

I had the pleasure to meet and assess @NAME@, who is a pleasant gentleman with multiple chronic medical conditions and significant disease burden (Karnofsky Performance Score 30) who presents with frequent bloody bowel movements and BRBPR. Loose stools progressive over several days associated with abdominal discomfort which patient reports as mild with no modifying factors. Patient reports poor diet consisting almost exclusively of meat products, and denies recent dietary changes. Patient does not take any fiber or dietary supplements.

Family History: Reviewed and not pertinent
Social History: Retired hospital administrator (?). Lives in upstairs apartment with wife who provides all care. Confined to bathroom "by choice" (review this, concern for spousal abuse). No VNA or outside nursing assistance.

Review of Systems:
GEN: Fatigue, Denies fever, Denies weight loss; ENDO: Fatigue, Cold intolerance; HEENT: "Rotting gums", Denies gum/tooth pain, Denies pain with mastication; PULM: Denies cough, Denies SOB; CV: Denies CP, Denies Palpitations, Denies Syncope; GI: Frequent loose bowel movements, BRPBR, Denies N/V, Denies dysphagia, Denies odynophagia; GU: Chronic indwelling urinary catheter, chronic loss of sensation to penis; EXT: Weakness, Denies LE edema; NEURO: Complete loss of LE sensation and loss of sensation to hands, Denies HA; PSYCH: Denies SI/HI

Physical Exam:
GEN: Seated in wheelchair, mild distress; HEENT: Blindness, b/l lens opacification, Edentulous, dry mucous membranes, bolus of chewing gum present in oral cavity; PULM: poor inspiratory effort with impaired air entry, end-expiratory wheeze; CV: RRR, no MRG; GI: Obese, mildly distended, tender, Stool containment system in place (?!); GU: Urinary catheter in place, concentrated urine EXT: Wasting of b/l LE; NEURO: Poor cooperation on exam. 1/5 strength B/L LE. Loss of sensation to b/l hips, chronic venous statis changes with numerous small ulcerations. Subjective loss of sensation to b/l wrists, though able to easily unwrap chewing gum wrappers throughout exam.; PSYCH: Alert and oriented x3/4 (oriented to self, place, situation, NOT year), thoughts linear, goal-directed, mildly tangential, content of thoughts upset and resentful

Problem History

9D90.6 Blindness; laterality: XK9J Bilateral; associated with: 9D96 Impairment of uncorrected visual acuity
8C03.3 Polyneuropathy in nutritional deficiency
GA90 Hyperplasia of prostate
MF50.3 Retention of urine
QF23 Difficulty or need for assistance with mobility
QF27 Difficulty or need for assistance at home and no other household member able to render care
HA40 Aetiological considerations in sexual dysfunctions and sexual pain disorders
HA00.2 Hypoactive sexual desire dysfunction, acquired, generalised
Associated with HA40.4 Aetiological considerations associated with relationship factors
6D70.2 Delirium due to multiple etiological factors

Assessment:
@NAME@'s loose and bloody BM's in the setting of poor diet and chronic constipation with mild impairment of mental status is concerning for sepsis secondary to diverticulitis. Differential diagnosis also includes GI bleed, Catheter-associated urosepsis, malignancy, and superficial erosion of anorectal epithelium from stool containment system for which there is no active indication. Patient currently unable to manage activities of daily living at home with evidence of poor diet and reported confinement concerning for spousal and elder abuse, and will require long-term placement. Patient will be transported by ambulance from clinic to ED for further evaluation. Although septicemia is life threatening, patient's overall presentation is encouraging, and the absence of obvious terminal pathology suggests potential for significant longevity pending recovery from acute illness and appropriate home care. Detailed plan as below:

#NEURO
#Peripheral Neuropathy
Likely secondary to poor nutrition, though also concerned about distant cauda equina in setting of possible incontinence
-Thiamine, B12, Folate levels obtained
-Thiamine, B12, Folate, and multivitamin recommended.
-Dietary supplement with Ensure TID

#HEENT
#Edentulous Oral Cavity
Does not have dentures at home
-Referral to dentist
#Blindness
#c/f Retinal Degeneration
#B/l Cataracts
-Encourage verbal communication
-Delirium precautions

#CV
#Chronic Venous Stasis Changes
-Wound care for leg wounds
#Concern for heart failure
-TTE

#GI
#Concern for diverticulitis
-Recommend CT Abdomen/Pelvis for evaluation of suspected diverticulitis
-Recommend removal of stool containment system, no current medical indication
#Concern for GI bleed
Also long overdue for screening colonoscopy
-CBC
-Nil Per Os
-Proton pump inhibitor IV twice daily
-GI consult for EGD/Colonoscopy pending CT A/P

#RENAL/ENDO
#Concern for Acute Kidney Injury
Reports only drinking warm soda
-BMP
-Recommend initiation of maintenance fluids while NPO
#Concern for hypothyroidism
-TSH, T4

#GU
#Concern for catheter-associated UTI
#BPH
-Urinary catheter removed and replaced
-Urinalysis sent (catheter source)

#ID
#Concern for Sepsis
-Blood cultures x2, CXR, UA as above
-Cefepime/Flagyl, avoiding vanc/zosyn in setting of unknown renal function
-MRSA nares
#Concern for Sacral wound
Patient with remarkably intact skin given reported absence of movement
-Wound care consult
-Turns Every 2 hours
-apply Mepilex

#PSYCH/SOC
#Concern for MDD
-Recommend initiation of SSRI
#Concern for Elderly abuse/Spousal Abuse
-Social work notified, requires further evaluation and likely placement in long-term care facility

Greater than 50 percent of this visit was spent in direct counseling, coordination, and patient care

@SIGNATURE@
@DATE@

CPT Billing Code 99204 (New Patient, Level 4 decision making)
Procedure Code 57102 (Replacement of indwelling urinary catheter)

"Is this tight [dark] enough for you?" — Pynchon

( )

Is there something wrong with me? I thought that, far from being a grotesque descent into the depths of human hideousness, this was a fairly touching novel about how two people, even in the absolute depths, can get along okay. The invalid doesn't do anything too bad to his wife. The wife doesn't do anything too bad to his husband. Perhaps the obviously Beckettian set-up made me expect something a bit colder; perhaps the translation doesn't really do justice to Saeterbakken's prose, which seems, on the evidence here, to be quite jaunty. Perhaps I'm just not interested in physical disgust unmediated by intelligent reflection.

If I want to be disgusted, I'll read Swift's poetry. That way, I get way more disgusted, but amused, as well. ( )

Edwin lives in his bathroom. A rocking chair placed within is his world, and a nearby dresser holds his cups of flat soda and boxes of Orbit gum. The floor is wrinkled with wrappers, and while he’s blind, an overhead fluorescent light illuminates his miserable existence. Once an exacting businessman, overseeing a convalescent home of deteriorating elderly people, he now sits in his own waste, deteriorating slowly as he chews gum and has conversations with Death. Screaming at Elna, his wife, is his only source of distraction from his roving thoughts.
Siamese examines the inner thoughts and outer actions of this strange pair, in the most intimate of ways. Elna is so involved in Edwin’s death (as it is he is more dead than alive) that she lacks the most basic grasp of common sense, unless it comes to deceiving Edwin. Edwin glories in his demise, cataloguing each symptom and detail with relish. It’s almost as if his decay proves that he existed in the first place, because in his constant reminiscing he often tries to analyze if he really did live. His thoughts are random, vulgar, and filled with hate. He asks himself: “Where is this road heading? What will become of everything? Will the future be like what’s already going on in my head? No, the world’s still out there. Nothing ever goes away, it just accumulates. Especially for me, who can’t see worth a damn, yes, I just sit here with a head full of stupid pictures…”
It’s clear that even in younger days, Edwin was far from kindly. He treated the patients in the rest home with distant efficiency but secretly thought they should be suffocated in their beds. He loses his job just as his sanity lapses: he attacks a nurse. From then on his busy career fades into the small, smelly room where he ruminates about prior patients and coworkers and pleads for Death to arrive soon to release him from his thoughts:
“Take it all, I mean it, don’t leave so much as a bedroom slipper behind, annihilate me, smash me into kindling, into dust, then vacuum me up, leave no evidence, I don’t want to be remembered for anything…I long for you to come and beat my thoughts into submission…they’ve plagued me long enough, do nothing but torment me,…all they can think about, all they remember, is themselves…But I don’t want to think about them anymore…letting them have their way with me is a worse defeat than death.”
Elna, for her part, remains distant from Edwin, as his still breathing corpse is no company and company is what she craves. A broken light bulb, necessitating a visit from the building’s young superintendent, finally gives Elna a chance. And the malevolent force that enters their miserable life changes everything.
Siamese is not a mystery novel, but at times I had to remind myself to breathe as the suspense built. A character study of two deeply connected but polarized individuals, it is fascinating to read and see how their actions push each other into reactions that are both ugly and frightening. It’s also terribly frightening: the helplessness and lack of contact along with the certainty of impending death gave me chills.
The novel was originally written in Norwegian and was translated by Stokes Schwartz. ( )

Exactly how black can writing get?

At first it seems Saeterbakken is mainly indebted to Beckett: the blind old man's hopeless, self-imposed situation, sitting in a chair in a bathroom for years on end while his circulation shuts down and he slowly decomposes, would not have been possible without scenes in Beckett, especially the man in 'The Unnamable' (1953) who has been sitting so long he cannot be sure he still has legs. And then it seems Saeterbakken is more indebted to Thomas Bernhard, because of the vitriol, the petty paranoia, the hatred and spite, the disgust that pours from the old man's imagination like one of his many pustulent infestations, imagined intestinal worms, scabs, psoriasis, boils, blackheads, pellet-like shit, or powerful farts.

But Saeterbakken has an imagination of his own, and it comes out in an amazing continuous invention of his characters' inner lives. The man's wife is an excellent study in emotional paralysis. I can imagine the Joyce of 'The Dubliners' enjoying the way she passively and inaccurately mulls over the many things she hasn't quite said or understood. The man himself is not just desperate or angry, because in the past he was a compulsively accurate record-keeper, and that compulsiveness has an unresolved relation to his current intermittent dementia. The usual way novelists balance irascible senility is with moments of sentiment and lucidity; those do occur here, but they don't do much work. What matters instead is the puzzle of how the middle-aged irritating micromanager chose his muddled but constant wife, and how he then became the old man in the novel.

There are a few problems that I would like to assign to Saeterbakken's age: he was only in his thirties when he wrote this. First, it is often possible to tell when he is recording things he learned in hospitals and old age homes. Sudden precise details from the world of hospitals and critical care facilities take me out of the novel and remind me Saeterbakken must have kept real, or mental, notebooks in preparation for this novel. Second, there are set-piece scenes that a greater novelist, like Bernhard, would have washed away in a flood of anger, nihilism, or some other driving concern. One is the first meeting between the man's wife and the superintendent of the building, which reads like a sketch by Ibsen about some claustrophobic and embarrassing domestic life. And third, the relentless inventories of the man's body are clearly intended to shock, but as Roland Barthes knew, shock quickly becomes 'shock,' which in turn becomes irritation. A purer version of this book could have done without them. And fourth, there are attempts at black humor and campy funeral-parlor jokes, like the old man's diet (Orbit chewing gum by the case, Coke, and meatballs): they also go from funny to 'funny' to irritating. Better here to follow Beckett, and let things like food be forgotten. 'Black humor' is a rum category, because it pretends it isn't serious about what it actually most serious, its ambition to be as dark as possible.

Those are flaws, because they are less than total blackness, and once blackness appears it wants to be total. ( )