Minimally invasive software

By Omar Nabil Metwally, MD

This is a work of satire and fiction.

I arrived at the Quaternary Health Emergency Department with an overnight backpack and nowhere else to go. They took me for a football for the first 16 hours. Someone tucks you under an arm, runs you a few yards down the hall, and fumbles. Then the next humanoid takes a turn.

Then the first one felt me ticking.

I should be clear that I am not a grenade. A grenade is somebody’s decision. I am a medicolegal landmine: I just lie there, patiently, being documented, until someone steps wrong.

So they passed me. Triage to resident, resident to attending, attending to Risk, each holding me a little less long than the last. By the upper floors, they had stopped making eye contact. The second-to-last person, a vice president of something, had me for under a second. I don’t think his fingers closed.

At the end of the hall stood the Head of Legal. All my buddies in the Emergency Department ask about him. Nobody has seen his face or heard his name, and nobody knows what he makes, though the guesses are reverent. He turned out to be a fat man in a good suit, waddling toward me with his arms out, the way you would catch a baby.

It took his head clean off. I want to stress how clean. Not a mark on the grinning face, the body, or the suit.

Quaternary wastes nothing. The body went to the cafeteria, where the interns had blubber soup through the end of the winter. The night nurses took the back, which was extraordinarily hairy, and made furs and moccasins against the cold on the floors.

I found the Head a week later, rolling around a stairwell, unsure whether it was above ground or below. It had never needed to know. I picked it up, tucked it into my overnight backpack, and took it home.

It is a stress ball, a soccer ball, a companion, and a friend. It talks constantly: “without admitting,” “to the extent that,” “at this time.” So I put it on mute, pull it in closer between my knees, and we watch television.

8 November 2026
Ypsilanti

Thoughts of Darkness

I had a lot of dark thoughts today. Not to worry anyone. Not scary thoughts. Just thoughts of darkness.

Specifically, I’m thinking of all the bright things that will come when all of this is said and done. My hopes: that I can walk, live and move again without pain. That no one’s career is hurt in all this, at least none of the clinicians I encountered face-to-face. The Michigan way, the Benign Medicine way, is to be given a chance to learn and improve. That’s the ideal Michigan Medicine strives toward. Malignant Medicine punishes the individual with the primary objective of putting them down, which is evil and counterproductive. There are no free or easy lessons. The most effective and longest-lasting lessons are often painful. They don’t have to be, but that’s often the case. I’m learning so much.

Goethe wrote: “Treat people as if they were what they ought to be, and you help them become what they are capable of being” (Wilhelm Meisters Lehrjahre, 1795–96). That’s the ideal I wish all teachers embodied. My wife embodies it well.

“Think about the good things in Vietnam.” Her advice. I thought about that a lot today, while I was having thoughts of darkness. I had about twenty dark pages ready to post publicly without reading the transcription, and it seems the Lord had mercy on me by inducing a bug in the AI-generated code, which sent the entire thirty-minute transcript into thin air. So before I turn on the light, let me start in the dark, dark place: the bitch box.

I had to put my father in the bitch box tonight. (My father is a bulbul. Long story; another post.) It’s a dark place. Like a dog’s crate. A small cave. I thought I was punishing him, but it turns out it’s the nature of a bulbul to love the bitch box. The dark, enclosed space is actually a den, like a man cave. I prefer the technical term “bitch box,” but to each scholar their own.

When I put someone in the bitch box, I have to ethically set a predefined duration. Like when someone puts in an order for four-point hard restraints on an altered patient from a facility and forgets about it, until an itinerant nurse, twenty shifts later, calls you at 2 a.m. while cleaning up orders and asks, could you put in for something for pain, and also I noticed there’s a restraint order from admission. Fortunately that doesn’t happen much these days, at least not in the hospitals I’ve worked in. And it should never happen. That’s the point of dark jokes written by sidelined professionals.

Sorry. I’m perseverating. This is reminding me of two nights ago. The Michigan Emergency Room incident. That will take me a long time to process. Torture leaves its marks. Let’s turn up the lighting and change the subject. I was talking about the bitch box.

So my Dad’s in the bitch box until the order expires at 6 p.m. tomorrow. That gives me a chance to take a deep breath and keep processing all this.

Today was a special occasion, but I’d like to keep the happy memories separate from the painful ones, at least as far as documentation is concerned. Two nights ago was hell. Everyone knows the 1-to-10 pain scale they use in the hospital. When Grace asked me what my pain was, I said 9. She misheard me and asked, “10?” I was kneeling in the hallway with my face pressed into the stretcher, talking into the hospital bed. Sure, I’ll take 10. Probably more accurate than my estimate of 9 anyway. Oh, Grace. You were excellent. Thank you for being cool, collected, and wise beyond your years. You reminded me of when I used to behave normally after extended periods under bright lights overnight. Showing the team how it’s done, even when everything was out of your control. The people who should really be reading this have no names and no faces in my mind. For you I have nothing but gratitude. If I didn’t, I would have made up a name.

Grace is not in the bitch box. My Dad is, until the order expires tomorrow night. I have my own bitch box, which is technically a den in my case. Apparently the word “den” doesn’t exist in Vietnamese, but my wife is too polite to use the other technical term.

I tried to withdraw cash today and the Chase ATM said it was out of cash. I’m not stockpiling huge amounts, just enough to buy coffee and get me home next time I walk out of a hospital with an IV dangling out of my arm. Or in case I feel compelled to board a flight and beg a foreign government for an emergency medical visa to fix my hip.

There are so many things I love about our life here. I really have no reason to leave. Except a minor one: my inability to get the medical care I need; the absence of a functional healthcare system; the failure of a small but powerful fraction of the population to recognize basic human rights. Other than that, it’s awesome. Nice people, dog-friendly, four-season sports. I don’t know much about public education in America (real public education, not the kind you take out a mortgage for). I’d rather not know. I just know that Eisen’s German lessons started two years ago and I intend to keep homeschooling her until she’s ready to apply to a German university. I consider Vietnamese and many Southeast Asian universities on par with the German ones: accessible, useful, quality education. Not a luxury article. Just basic human rights.

Germany has a world-class healthcare system. If you listen to German radio these days you may hear propaganda suggesting otherwise. Germans love to discuss and debate and complain, as if the ghost of democracy still exists. I don’t have an opinion on that, at least not a public opinion, at least not one I care about sharing tonight. But I enjoy listening to German public radio every day. I’ve been doing so since I started studying German in college.

My original motivation for studying German was to read the German philosophers in pure, unadulterated German. It turned out I could do a lot more than that. Germany is a robust economy, Europe’s biggest, and German culture, intellect, science and engineering are priceless. Germans have a reputation for being borderline cool/cold, but my experience says otherwise. They don’t make stupid small talk like Americans, and they don’t waste energy grimacing out of feigned courtesy. They just say it the way it is. If you’re a stranger at the checkout counter, you’re not getting a fake smile. But once you become friends, it’s a real friendship. I miss that about Germany. There’s a lot I miss about Germany, actually. Healthcare was also great.

I had the privilege of spending a fair amount of time in Germany and central Europe in my student years. As a University of Michigan medical student I did two international rotations in Germany: pathology at the Charité in Berlin, and radiology with my comrades in the University of Leipzig’s Department of Radiology. Unforgettable people whom I haven’t seen or spoken to in ages, but whom I always remember as friends first, and as excellent mentors and colleagues. Both rotations ended with job offers, in Germany and in Switzerland. I loved it and wanted to stay. But I had lived in a lot of different cities by then, and in the end it would still have been the start of postgraduate medical training. Residency is residency, wherever the lights are. So I thought I’d try something different first: I went to San Francisco to live the dream. I’m proud of those moments. They’re part of me. I still often wonder what my life would have looked like if I had taken the other branch of the fork and trained in Germany. I’m not sure what that parallel life would have looked like, but I’m confident that whatever health issues I’d have had to deal with there, I’d have been in good hands. Dealing with health problems while being unable to get the care you expect and need is a synonym for anxiety.

Germans have a lot of trust in their universities and research institutions, rightfully so. I interned at the Robert Koch Institut, a federal microbiology research institute, sort of the CDC of Germany. The RKI headquarters is in Berlin, but I lived and worked in Wernigerode, a picturesque, historical town in the Harz. I haven’t visited in decades, though I hope to return someday. It’s at elevation and relatively cool. My flatmate was a Bavarian PhD student and RKI colleague. Sebastian was my gateway to a busy and eventful social life in a small, unassuming town. We played indoor soccer with the RKI’s driver, Ulli, and the scientists. Seppi introduced me to cross-country skiing, an excellent way to stay fit and enjoy the outdoors in a place like Wernigerode that gets a lot of snow.

The challenge with stream-of-consciousness writing, especially when your attention span is shorter than a toddler’s, is that you spend a lot of time on side roads and tangents. Which is perfectly fine with me. The key is to eventually make your way back to the main road.

Applications for any training or work position in healthcare ask about “gap years,” without exception. I hate the term. It implies that the years you didn’t spend on the medical-career freeway with your life on autopilot were somehow failed years. Not completely failed; there is the possibility of redemption. But I don’t understand why they make “gap years” sound like time spent smoking meth in a laundromat, or an unexplained visit to a country that sparks conversations with CBP agents. “Gap years” have been the most formative, interesting and valuable years of my career. I did international rotations. I learned microbiology skills at the RKI that I continue to use daily for brewing beer and making yoghurt. I applied secret plant-biotechnology knowledge acquired during an internship near the Finnish-Russian border to gardening. I learned to chop firewood and to take care of, and bathe in, a Finnish sauna. I started a healthcare startup with my friend in San Francisco. I dipped my feet in academics and microbiology research, then took those bench skills and applied them to more useful things, like growing medicine.

But I should get back to Germany. I’ve been thinking a lot about Germany these days. I have a great deal of trust and faith in the German healthcare system. Excellent education and training. Capable physicians. Common sense. Humanity. Good old-fashioned medicine, second to none. In fact, most of the MRI machines and many of the scanners I see in American radiology departments are made in Germany. Leipzig had one of the most cutting-edge MRI machines at the time, one of only ten in the world. I imagine that’s still the case, whatever the latest and greatest MRI machine is these days. Surely made in Germany.

I mentioned the pain scale before I got tied up with the bitch box. I’m devising a new pain scale specifically for neuropathic and radicular pain. Instead of asking for a number from 1 to 10, I’m logging my pain in terms of frequency: how many lightning bolts shoot down the legs per minute. The frequency was lower today than yesterday. The severity is unchanged, as is the debility.

Grace. I talked a lot to Grace and Sarah. At least, they let me talk a lot, nodded, and took it politely and gracefully. I told them to get out of healthcare before they burn out, which will inevitably happen, because once they’re done using you, once you’re burned out and useful to no one, you become a cadaver on the road. A meal for the risk-management vultures and the litigators and the health-insurance lawyers to feast on. The most important member of the healthcare team, the one feeding everyone else, directly or indirectly. Feed.

There’s only one way to keep scavengers from feasting on a not-yet-dead person. Warning shot. Loud ringing and smoke. Birds scatter quickly. No creature is hurt. That’s the whole point.

I told the nurses about an incident I saw at the county hospital in Oakland where I trained. I’m very proud of that hospital and of my training there. I believe I got the best internal medicine training around, and I’m grateful to my program directors for the doors they helped me open. I’m also grateful to the outstanding humanoids who cared for patients there. Those humanoids taught me a lot, inspired me, and working alongside them made me happy. I’m not sure humanoids are still considered part of the healthcare system. There are probably a couple of them still out there in white coats, thinking about medicine the way I learned it in medical school.

Highland Hospital is the best. I always told my comrades that if I were hospitalized, I’d want them to take care of me at Highland. A colleague in a white coat was quick to disagree. He said he’d go to the hospital across the street. It was easy for me to say as I started my evening shift, freshly shaved, carrying the scent of soap and naivety, on a first-name basis with most of my colleagues.

Something about a bright hallway brings out personality in people. I remember the bright lights at Highland. The corrections social club at Oakland’s county hospital has a much larger membership than the Ann Arbor club. Sure, anyone foolish or miserable enough to have entered the UM ED knows it’s a dumpster fire of a county hospital with an “M” stamped on it. That’s a compliment. Michigan. Malignant. Madness. A bit of all of the above. Surely marvelous, too. Some things never change.

Back to the hallway in Oakland. The lights. Must have been around 11 p.m., when the swing shifts I worked officially ended. A man in custody was getting worked up. Unfortunately there was no Leigh, no Grace, and no Sarah that night, just a tall, quiet deputy with 0% emotion in his eyes. The deputy pounced on the patient’s stretcher and tased him. It was the first time I’d seen someone hit with a stun gun: 50,000 volts and a hard reset. It was not something I wanted to watch, and it’s something I hope I never see again: the full power of authority electrocuting a patient in the hallway as he, too, wondered whether he was still a patient, or a human, or even alive. This is not a rant. I love Highland. It is my clinical home, at least in my heart. This is just the United States healthcare system at operating temperature. Each one is worse than the other.

I thought a lot about the tased patient while I was in the hallway at Michigan’s emergency department. As a freshly shaved resident roaming the ED hallways of Oakland’s county hospital, I witnessed that event from the perspective of a doctor. A lawyer defending the PD, or a jaded physician having a bad end of shift, could argue the patient was belligerent, verbally abusive, uncooperative. I’m not qualified to be a police officer, and I don’t know the details. It’s too messed up to joke about or make things up. I’m not doing accounting here. I’m still trying to forget it. I just recall witnessing the incident as a healthcare provider trained to recognize uncooperative patients, patients violating some sort of care contract they never saw and can’t actually agree to, as captives. That’ll teach you to let the phlebotomist draw AM labs without a fuss. It was fucked up. It should never happen. There is nothing funny about a man handcuffed to a stretcher in a bright hallway, a man who was probably on drugs, or coming off drugs, probably both, who had probably been in the hallway for days and had seen this rodeo before. And then tased, while handcuffed, while in an altered mental state.

That image kept circling back during my interrogation by Michigan Medicine. It’s hard to call it an interrogation, though. No one asked questions. I wish they had. I’m waiting for my turn to ask questions, and I have a long list. It was just torture. Assault by negligence. A trauma patient dumped in the hallway and forgotten. Happens all the time. This one just happened to be a physician and an alumnus of the institution. In a hoodie, and apparently playing the role well. We all know the script. “Can I get some pain meds?” “I’ve been here for hours.” “Is anyone going to see me?” “Can I eat?” “Can I have some water?” (Unless you’re a doctor, like me, in which case you ask for two one-liter boluses of lactated Ringer’s.)

It was not technically an interrogation because everyone already had the answer. It’s a job for someone, like construction season in Michigan. Who cares that it’s sick and futile. Something to juice up the young guns and keep them awake until the AM shift takes over: a delirious trauma patient presenting six months after the incident, desperate for help and saying things I won’t put in writing here in case someone I know reads this.

“Think of the good things in Vietnam.” My wife’s voice, in my mind, keeps pulling me back. Her actual voice from today pushes me forward. I’m not sure whether in a good or a bad way, but it’s a push and a change of momentum in any case.

The lightning bolts in my legs are less frequent, allowing me to return my attention to my right hip, which still aches and burns like it did before, deep in my groin, with every movement. I’m starting to remember that my right hip is messed up. The lightning storm almost made me forget. After you’ve lived through so much pain for so long, it all blends together. I can imagine the Head of Legal for Malignant Medicine waddling into a courtroom to cross-examine the L5 disc. “Now explain to the jury, if you really are guilty of inducing pain in the plaintiff’s foot, admitted in his own words as ‘excruciating electric shock pain in the plantar aspect of the right foot,’ how this testimony could possibly correlate with…” It’s a pre-settlement hearing, and the S1 disc walks into the ruckus.

It’s late. I’m not sure what time it is, but the lights are bright and I’m lying in lithotomy waiting for God to open the patio door.

Sorry. Thoughts of darkness. What would Grace have said to cheer me up? Or the ortho resident, over the phone? I can imagine (not medical advice, just a silly thought experiment) a parallel universe where wishful thinking is realized: I’m standing again at State and North University, slowly understanding why everyone is smiling so warmly at me. The IV, the hospital bracelet, the caffeine withdrawal. Things are adding up. I don’t think Grace could have cheered me up in that situation. Actually, she’d probably think of something. But I can make myself laugh. That’s one of my superpowers.

Everything so far is, unfortunately, real. This is where the fantasy begins, and ends. To repeat: the following didn’t happen, except in my mind. I use my advanced powers of persuasion to round up all the ortho residents who are supposed to be in the hospital, and we meet on the deck in my backyard. They’re cool guys. Muscle heads. They’re cool with my dog, and he likes them. If Malignant Medicine doesn’t know where in the algorithm chronic trauma belongs, then my deck it is. One of the orthos gets the fiber-optic scope. The other, a scalpel and Everclear in a spray bottle. You can keep the anesthesia; I need to witness the procedure. I don’t want to put anyone else in the bitch box tomorrow, so I’ll skim the details. I’ll just end with my dog Sy dropping a tennis ball into the still-open incision, just as the ortho bros are suturing the torn labrum with fishing line and nylon paracord. The operation is a success. Two of them are grilling hamburgers and popping beers. Throw the dog a ball and tell the intern to hose down the wound. I’ll be fine. We’ll all be just fine.

I’m thinking a lot about Germany. And Vietnam. I hear Korea also has excellent healthcare. And Canada’s right across the bridge. Someone out there has to be reading this. I don’t need an airlift. It would be nice, but I don’t think I need it just yet. I just need a health-tourist visa.

It’s late for accounting. The bitch box beckons.

A nightcap on the eve of Eisen’s fourth birthday. Two recordings, sixteen hours in a hallway, one walk, and a root system in a container too small for it.

November 8, 2026 · Omar Nabil Metwally, MD

I. The Gardens Saturday, November 7th, 2026. I’m calling this the Bonsai Monologues.

One of our family’s favorite places is the Botanical Gardens. When it’s cold out, it’s a little tropical vacation. You walk from climate to climate.

The first time I went, I was a senior in medical school, so probably 2013. I took my grandfather, God rest his soul. He lived with us for over twenty years and earned his U.S. citizenship in his eighties. It was one of the things he was most proud of. He went back to Egypt a year before he passed away.

He was in a wheelchair by then. It was a long drive, and moving him took extra planning. It didn’t stop us. I pushed him from climate zone to climate zone, and we had a really great time. I always wanted to go back.

Lo and behold, two decades later, I live ten minutes away. Now it’s one of our rituals.

I love the desert room with the cacti, especially when they’re flowering. When Eisen was younger, her favorite thing was running loops in that room. Full speed. Laps. She has never run into a cactus. My nonstop warnings to slow down and watch out for the spikes seem to be paying dividends so far.

II. The Bonsai There are bonsai there. Really beautiful bonsai, some of them about a million years old, by my estimate, displayed against Japanese-style screens.

Depending on Eisen’s developmental stage and her interests of the day, the bonsai are where I always like to stop. Our interest even took us, as a family, to bonsai events where people sold trees and tools.

At one of them, a judging competition, I discovered by accident that one of the people competing was my old internal medicine clerkship director from U of M.

A twist of fate. Not a surprising one. Bonsai is an art and a science.

I never wanted to go into internal medicine anyway. Or radiology, for that matter. I went into IM to make a point. I wanted to show that smart-ass old man that I was capable.

I aced the pattern-recognition part of the clerkship exams easily. The so-called red flags. The clinical scenarios you’re supposed to know reflexively, even after months and years of sleep deprivation have eroded your frontal cortex.

Like the Babinski. A reflex. Something you perform unconsciously.

Going back in time, I don’t think anything would have changed. I wouldn’t be the person I am now otherwise.

I know nothing about bonsai. But I don’t understand how you keep a root system in such a small container for so long and still have the tree flourish. It must be somewhere between growing in soil and pseudo-hydroponics, where everything depends on nutrient flow.

Roots, in a small container, for decades. Still thriving. Remember that.

III. The Basement I’m in the basement, walking around with headphones on, music playing, talking to myself. One of my trade secrets.

I’m pruning plants.

Since my injury, cannabis, CBD especially, has been tremendously effective for my pain. Pain in general, but especially neuropathic pain. I haven’t done a recent literature search. I’m speaking as a patient: cannabis is medicine. There’s no doubt in my mind. It isn’t a cure-all and it isn’t snake oil. It isn’t harmless either. It’s a personal decision, and I’m not giving professional advice.

It’s also expensive. So I started growing my own: CBD plants, THC plants, CBG plants. They do different things, and not all of them are, quote unquote, psychoactive.

Like bonsai, it’s an art and a science. You learn by doing, and the learning goes faster when you know the core concepts: light, airflow. I’m not discrediting theory. Theory is why we go to university. I just wish formal education, everything past kindergarten, were more experimental. Hands-on learning is greatly underappreciated.

I’ve grown gourmet and medicinal mushrooms. I’ve brewed beer, which means understanding yeast. I tried to make sake. That’s the one microbiology experiment that didn’t work out. I’ve made cheese. I make yogurt continuously. It’s a staple of my diet. My track record this year: nothing has made me sick.

My approach to cultivating living things is to observe. It isn’t sufficient, but it’s the most important thing. Point a fan straight at the leaves and they dry out, and you get a stiff, bushy plant. Give it no airflow and you get something delicate and flimsy. A plant needs attention. It needs to be touched and moved: a little stretch on the branches, a pull here and there, opening things up, checking for mold and insects. At the slightest sign that something is wrong, you don’t panic. You observe, and you react quickly.

That’s growing. That’s working with living organisms in general.

Humans included.

I kept a lab notebook over the summer. One time, outside, I was overwatering. Too much love. The leaves started to yellow. It looked like a mineral deficiency, which was strange, because I was fertilizing, it was getting a ton of water, and the sun was beating down. Then I realized that the excess water was the problem. When soil stays wet too long, the roots can’t absorb certain nutrients.

That’s theory I wouldn’t want to learn purely from experience. Experience teaches you to be observant and to look up what you don’t know.

My 95/5 rule for AI applies here too. Use it to monitor the plants. It’s fun and informative. Most of the time it’s right. The other five percent is why you keep watching.

IV. The Root Cause I’ve been thinking a lot about trainees and residents. As I said earlier, they’re innocent. They aren’t paid nearly enough to be smacked around and blamed, unless they’ve done something egregious or morally wrong.

Before my spine became the main problem, there was the labral tear. I went down a rabbit hole with it. It still hurts and still limits my mobility. And I couldn’t find an orthopedic surgeon willing to touch me, except probably the on-call intern.

I did an orthopedic surgery rotation at Michigan. It was awesome. They’re the stereotypical contractors, but they’re cool guys and they really fix people up. And what I’m learning as a patient is that an orthopedic problem is serious. It isn’t an isolated quality-of-life issue. It affects your whole health, mental and physical. You can’t say it’s just an elbow, just a shoulder.

Most honest internists and family doctors will admit they can’t do a proper hip exam. The best you can hope for is someone who can describe it properly: proximal, distal, medial, lateral, anterior, posterior. Severe burning pain on the plantar aspect of the right foot. A doctor should recognize that and know how to look up which nerve root, and where the lesion is. In medical school I loved neurology. They drilled it into us until we knew it inside and out. It was like debugging code.

So I needed somebody to point a finger at. As my dad says, point a finger without anger and without wanting revenge.

I pointed it at one of my jiu-jitsu partners. He’s an orthopedic resident at an institution I’ve recently had contact with, mostly by phone, trying to get authorization for an outpatient appointment, and then failing to find an orthopedist during my recent hospitalization.

He takes people apart in the gym and puts them back together at work the next day. I say that jokingly. He’s a great guy. He’s always mindful of his force. He never hurt anybody on the mat, as far as I can tell, and he never hurt me. He’s always teaching along the way. He never gave me medical advice, and I never asked for it.

He’s bigger than me. Younger. A lot more muscle. A very handsome mustache. He consistently kicks my butt. So whatever he’s doing is clearly working. I thought: an orthopedic surgeon, that’s what I need. Stat.

Six months later, the stat order is still pending.

To be honest, I’m a risk management landmine at this point. No one willingly catches a landmine thrown like a Michigan quarterback’s throw.

The only one who accepts it is the captive on-call ortho resident, putting in his time. His attending is home, trying to take care of his family and planning tomorrow’s OR day.

I had full faith and conviction that orthopedics was the answer. The part of the brain a good doctor is supposed to use, the part that tells you to pause, step back and look at the forest and the trees, went on cruise control. I fixated.

The hip is still a problem. Classic hip pain. But I also have spine pain that keeps getting worse. You don’t have to be a genius physician at Michigan to put two and two together.

It hit me somewhere between the MRI machine and the CBD hits. All the times I got thrown on the mat. All the times, more often, I threw myself on the mat. That isn’t on the training or on my partners. It’s my lifestyle catching up with me.

V. The Mat The mind and the body are not separate. Whatever you’re carrying emotionally shows up in the body. In different ways for different people, and differently over time.

I’ve done martial arts my whole life. Judo at eight. Krav Maga in Oakland, which made me feel confident walking around Oakland at night, with a great group of people. I still remember the drive along the water, the bridges, the cranes moving the containers, and the one spot that always smelled overwhelmingly of weed.

After one of my first Krav Maga lessons, I showed up for the evening shift at Highland Hospital with every knuckle on both hands busted open. I’d gone all out and didn’t notice until afterward. The nurses had invisible bandages ready. I only stopped going because of the pandemic and the move back from California to Michigan.

There’s no wall between mind and body. That’s why sport, and martial arts especially, has always been as much about my mental health as my physical health.

In jiu-jitsu I’ve rolled with bears. The last guy I rolled with was a 350-pound human grizzly bear, one of the contractors of the greater Ann Arbor area, where the revolution will begin. There were moments I thought, well, that’s my neck. I got lucky.

My personal philosophy on the mat is not chasing belts, or muscles, or submissions. It’s to not get hurt and to not hurt others. If everyone on the mat follows that, you can’t go wrong. Everything else is details. Important details, but details in service of that.

VI. The Recording Earlier that afternoon, the eve of Eisen’s fourth birthday, I hit record on a different monologue.

Ba Me, Eisen’s Vietnamese grandparents, are here from Vietnam. Perfect timing. They and Eisen have video called every single day for so long that they already know each other well. Now they get to be in the same room.

I started a backup recorder on my phone too, because I learned the hard way. The backup needed charging. The power bank was missing.

If you see the other power bank, please let me know. Just in case you see it. You don’t need to look for it.

I said it twice. The transcript is very clear that I said it twice.

Then I lay back down.

Ouch. Ouch. Ouch. Ouch. Ouch. Ouch. Ouch. Ouch. Ouch. Ouch.

I turned on the air purifier so Eisen wouldn’t have to hear it.

Burning fire on the bottom of my right foot. The plantar aspect. A good doctor should be able to localize that.

Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow. Ow!

VII. The Algorithm According to the transcript, I then said “So where was I?” twenty-five times in a row. Then “I guess a good place to start is my surroundings” five times. Then “Thank you” eight times, to no one. In the bonsai recording that night, it thanked the empty basement four more times.

I did lose my train of thought. I did not lose it that many times.

Speech-to-text models don’t really cut out silence. They fill it in. Give one a long quiet stretch, some breathing and a fan, and it makes up stock phrases. “Thank you” is the classic, because so much of the audio it learned from ends that way. Or it gets stuck on the last thing it heard and loops it, perseverating like a patient after a bad night.

The algorithm turned my silences into a man who is very lost and very grateful.

I wondered aloud which would be worth more someday: the silence, or me continuously losing my train of thought. My thoughts were like lightning bugs flickering in and out of the darkness. Some of the flickers, it turns out, were the machine’s.

VIII. Between the Hits Most of the U.S. healthcare system, if you look closely, is actually the legal system. A big chunk of the rest is law enforcement.

When things go wrong, leave the trainees out of it. Attendings get paid. A huge chunk of what they bill goes to overhead: insurance, liability, and administration skimming the cream off the top.

A friend once asked me how much professionals really worry about malpractice. I had two answers. One from my father. One from my grandfather, the same man I pushed through the climate zones in his wheelchair.

My grandfather always told me—

“Baby! What are you doing? Is that a birdie? Is that a badminton birdie? Where’s the racket?”

That’s me, interrupting myself. Eisen had walked in holding a badminton birdie.

My grandfather’s answer will have to wait for another night. Eisen had something more important to ask.

IX. Hour Sixteen Cameras at the ED entrance. An intimidating presence. Before anyone says hello, you’re on film.

Then, conspicuously, no cameras at the nurses’ stations. None in the hallways.

The wheelchairs were so painfully uncomfortable that I think my discs exploded in slow motion shortly after I strapped myself in.

I lay in lithotomy in a hallway for sixteen hours. People came and went.

For a significant part of those hours, I lay with my hands cupping my balls, like I’d been kicked in the balls and someone froze the frame. Then they forgot to unfreeze it, until I reminded them after shift change. I would pay money for that footage. As far as I know, it doesn’t exist.

After sixteen hours, I lost my mind. I remember security’s body cams. So the footage that does exist probably starts there.

No one asked me to sign a behavioral agreement. Instead, Leigh, the night charge nurse, an experienced colleague, told everyone to simmer down. Everyone. Even me.

And Grace. Twenty-three. An awesome nurse. She proposed a reset.

I thought: wow. What a smart and wise thing for a twenty-three-year-old nurse held captive on the night shift in the ED. She’s probably been doing this for a year or two.

I do feel a little bad for the EM resident who saw me. I’ll remember the look on her face, and eventually on her attending’s face, when I told them who I was and what brought me in yesterday.

Farsi subtitle: “Fuck. I have ten admissions waiting, and I have to get the medicolegal admission with a sleepover backpack?”

I was surprised. Most of the Iranians I’ve met are in California. Or Toronto.

I don’t envy her.

I wonder what the medical student version of me would have done, walking past that hallway.

He probably would have said, this is fucked up, and gone to get me water.

Then he’d have helped me carry the go-bag I’d brought for the sleepover to the Taubman back door, and used his M card to get me out of the building.

X. The Gate Outside the back door, I walked toward campus, against medical advice.

There’s a gate near Taubman. If you’re inside, getting out is easy: a short detour around a wall and you’re free. If you’re outside, you can’t get in.

Clever. Very clever. Security must love it.

I went to medical school here. I remember the layout. I remember the shortcut. The shortcut doesn’t remember me.

I was late for PT.

XI. State Street The phone rang in front of a cafe on State Street. Busy intersection, a few blocks from where I lived in college. Then in medical school. Then never again.

It was the ortho resident.

I made him an offer. Cash. Bitcoin. A gold bar. A Rolex. Whatever he wanted. Just fix my flipping leg.

Come to my desk and operate there.

Correction: my deck. The backyard.

The venue was not the problem.

XII. The Saline Lock Everyone who walked by smiled at me. Warm smiles. I’ve never gotten so many in my life.

Only later did I notice the saline lock still taped into my arm.

The hospital couldn’t keep me, so it sent a piece of itself along with me. And strangers on State Street did what the building couldn’t. No chart. No liability. No risk management. Just a look, and a smile, at a man with a limp and an IV who was clearly having a day.

That’s benign medicine. It doesn’t need a license.

XIII. The Lunch It still hurt like hell. I lay down to decompress my spine and had lunch with my Vietnamese parents.

Then I texted: I was delirious.

Then: I can’t believe I actually proposed that as a treatment plan.

The doctor in me, reviewing the patient in me, after the fact.

XIV. Midnight It’s past midnight now. Eisen is four.

I’m feeling a little better. My medicine is right in front of me. I’m not in a cold, bright hallway with people walking past me for sixteen hours. I can drink water. I grow my own medicine and give it to myself. It’s beautiful. It’s green and bright. I can feel it. I can smell it.

My right foot is still burning. Ouch. Ouch. Ouch.

Once, at Beaumont, now Corewell, I stumbled onto a door marked Trauma Clinic while looking for my secret bathroom. I thought: what? You’re going to schedule an appointment for trauma?

Now I understand.

I’m basically a trauma patient at this point. Six months of waiting patiently. Then, the day before, I’m told I have to spend the day with the insurance company so they can whisper the blessing of prior authorization.

Calling to schedule an appointment with the trauma clinic, and being told to wait six months.

It’s the whole joke that’s not a joke.

I have an outpatient ortho appointment next week. I’m considering wearing a body cam. As a backup, in case the Vietnamese can’t save me from the US healthcare system.

I mean, I am just one person.

Ba Me are asleep a few rooms away instead of a few thousand miles. The other power bank is still missing. Two boxes of plastic parts are open in the basement, next to the plants.

I’ve thought about learning bonsai. Honestly, I don’t think I have the patience. Pruning cannabis is more interesting to me, and more useful. At the end you have medicine that makes you happy when you see it, when you smell it and when you take it.

But I keep thinking about those roots. A whole living system held in a container too small for it, for decades, and still thriving, because someone watches it every day, adjusts a little, and doesn’t panic.

Somewhere in my spine, a few nerve roots are in a container too small for them.

Bonsai has its own wisdom. Maybe when I’m older and wiser, I’ll understand.

I’ll understand.

I’ll understand.

XV. Magic This afternoon, between the ouches and the lost threads, Eisen came in with a badminton birdie and a question.

“Can I use magic to make people play with me?”

“You want to use magic to make people play with you?”

“Yeah.”

“Oh, you don’t need magic to make people play with you. I want to play with you. I’d love to play with you. What do you want to do?”

“I want to build.”

“You want to build? Okay, let’s build.”

Then I remembered that Curie and Mimi had sent us two big boxes of plastic parts. They were in the basement, the same basement as the plants.

“Come on. Let’s go.”

I turned off the recorder. The pain came down the stairs with us. It always does.

We went anyway.

---

Not medical advice. Cannabis is a personal decision, and home growing is legal for adults in Michigan, within limits; check yours. If you leave against medical advice, ask them to take the saline lock out first. My jiu-jitsu partner is a great guy who never hurt me and never gave me medical advice. And if your transcript says you thanked an empty room eight times, it was probably the fan.

FIN.

Part II of The Mastermind. Or: what happens when you call your brother a bitch right before a one-hour MRI.

T–minus 5 minutes. The tech asks whether I have any metal in my body. I say no. She doesn’t ask whether I’ve just insulted a family member, which in hindsight was a gap in the screening questionnaire.

I had. Earlier that day, as I walked out of the hospital against medical advice, Ummy threatened to call the police on me. On his own brother. A grown man limping out at the speed of a Roomba, with what he thought was spinal stenosis.

A little later, the same man pulled my IV out for me at York.

Let’s go over the timeline. In the morning he’s a concerned citizen, ready to get law enforcement involved. By lunch he’s my discharge team, removing hospital property at a café table. He went from snitch to accomplice before noon. That’s clinically consistent with being a bitch in the acute phase. So I made the diagnosis and texted it to him: “You bitch.”

To be clear, Ummy is a man, my brother, and someone I love. That’s why he gets the diagnosis. Strangers get “sir.” Onset was sudden, the presentation was classic, and the prognosis is good. No police were harmed. One IV was removed in a non-sterile setting.

Minute 1. Earplugs in. The table slides into the tube. The machine starts up, and it sounds like a bad impression of someone firing an air machine gun at a kid’s birthday party. DA DA DA DA DA DA.

Minute 3. My own words come back to haunt me. Given nothing to do, the brain sets the insult to music. The gradient coils keep the beat and I do the vocals.

DE DE DE DE DE. You bitch.
DI DI DI DI DI. You bitch.
DO DO DO DO DO. You bitch.

It turns out I’m a very funny man, and I can’t get away from my audience.

Minute 5. I’m laughing. An MRI has one rule, and it’s “don’t move.” Motion artifact makes the images non-diagnostic. I picture the radiologist dictating: “Study limited by patient convulsing at his own joke. Recommend repeat, ideally after brother drops the charges.”

Minute 8. I bite my tongue. It doesn’t work. Now tongue pain is competing with the sciatica. The sciatica wins. It always wins.

Minute 12. Last resort: I hold my breath until I reach an altered state of consciousness. I end up on God’s porch. Not inside, just the porch. God doesn’t come to the door. Somebody in there is going DEDEDEDEDEDE. It’s very peaceful, and I’m perfectly still.

Minute 31. The protocol is long. Suspiciously long. I start thinking about Dr. Yahya, the Mastermind, sitting in the control room with one finger on “add sequence,” knowing exactly what he’s doing.

Minute 60. I’m out. The tech says, “You did great, you were so still.” I say, “Thank you. I was briefly dead.”

Minute 75. The results are in. I know what’s in my spine now. Risk Management would very much like to know too. They can wait. They’ve had years of practice: hold, transfer, hold, voicemail. Let them sit on God’s porch for a while.

I check on my brother. “Ummy. You bitch.” The diagnosis is confirmed on repeat exam. Thankfully, the imagine quality seems ok.

---

Medical disclaimer: Don’t hold your breath to reach God’s porch. Not at home, and not in a tube. And if your brother threatens to call the police, wait until after the scan to diagnose him.

To be continued in Part III.

FIN.

Notes toward an advance directive

Omar Nabil Metwally, MD

I have started planning my death the way other people plan a kitchen remodel: with a folder, a rough budget, and a growing list of contractors I will never hire again.

This is not morbid. I want to be clear about that, because my family will read this and worry, and my wife will not read it and worry anyway. It is the opposite of morbid. It is the single most practical thing I have done since I learned to check the expiration date on the milk before buying it. I am a physician. I am about fifteen years out of medical school. I have spent a measurable fraction of my adult life inside American hospitals, and I have come out the other side with one conviction so clean and so bright that I can hold it up to the light and see no flaw in it anywhere:

Never again.

Let me tell you what a hospital is, in case you have only ever visited one, which is like saying you have visited the ocean because you once stood in a parking lot near it.

A hospital is a building in which it is impossible to sleep. The bed inflates and deflates itself on a schedule known only to the bed. Something beeps. Something else beeps in answer, and the two of them carry on a conversation across the hallway all night like dogs. At four in the morning a kind person arrives to take your blood, not because anything will be done with the result before nine, but because four is when the blood is taken. A television bolted to the ceiling plays a cooking show no one chose. The hospitalist changes every seven days, like a weather front. The nurse is excellent and has eight other patients, three of whom are screaming and one of whom is you. On day three someone orders a scan to explain a finding that was caused by day two. On day five you leave with a discharge summary longer than the Finnish constitution and a new diagnosis you did not have when you arrived.

And then, on the far side of all of it, there is a person whose job title is Risk Management, who has never touched a patient and whose entire function is to make sure the building is never the one holding the bag. I have written elsewhere about the sixteen hours. I will say only this: the day you start wishing broken hips on risk managers, out loud, in a family group chat, is the day you have officially graduated from American healthcare. There is no ceremony. You just know.

Nobody chooses any of this. It accretes. It is the clinical equivalent of a junk drawer, and the horrible part, the part that took me years to admit, is that I helped build it. I have ordered the four a.m. labs. I have written the summaries. I have stood at the foot of the bed at seven in the morning and said “we’re going to keep you one more night, just to be safe,” and I meant it, and I was wrong.

Here is what fifteen years taught me, and I am giving it away for free, which is already more than the system has done for anyone: the surest way to stay well, physically and mentally, is to stay out of the hospital. Too much of what happens inside one is where people go to get sicker, suffer, and die. Not always. Not everyone. I still send patients there every week and I will keep doing it, because there is a real category of problems for which the alternative is worse, and when you are in that category you go, and you go now. That is not what this essay is about. This essay is about everything else, which is most of it, and about one body in particular, which is mine. Nothing here is advice. It is a man describing his own exit.

And when I truly do need healthcare, the kind where a doctor sits down, I will book a flight to a country that has an actual working system. I have been on the receiving end of that kind of care, and I did not know what to do with my hands. Someone looked at me. For minutes. There was no portal. There was no “I’m going to step out and you’ll hear from someone.” I kept waiting for the catch and the catch was the bill, which I paid out of pocket with the kind of money I keep in the glovebox for parking.

When I was in my twenties I spent a summer in Finland measuring trees, and I came away with two permanent injuries: a lifelong respect for a country that treats a sauna as public infrastructure, and the inability to ever again find it normal that a sick person should have to fight. In Finland the hospital was a building where sick people went and then, after a while, left. That is the whole trick. We have made it sound exotic.

---

So here is the plan. When the diagnosis comes, and it will, I have read the actuarial tables, this is what I intend to do, in order. I am talking about the end, the real one, the kind every clinician recognizes from across the room. Not the first chest pain at fifty. I know the difference. It is the one thing the training is reliably good for.

1. I will not be admitted. I will be a visitor. I will keep my coat on, the way you keep your coat on at a party you are planning to leave. If anyone says the phrase “just to be safe,” I will understand it as the sound of a door closing, and I will walk through it in the other direction.
2. If it is the fast kind, the stroke or the heart attack, I will crawl under a warm blanket and thank God, sincerely and for the first time in years, that I do not have to die in a hospital. A blanket. Think about how low the bar is. Think about what it says that the blanket wins.
3. If it is the slow kind, I will go home. I have a garden. I grow tobacco, which is a wonderful plant to grow when you have decided to stop pretending you will live forever, and tomatoes nobody asked for, and I have a four-year-old who narrates all of it. There is a puppy. There is no television bolted to the ceiling. Nobody comes at four in the morning except the puppy, and he does not want my blood, he wants the yard.
4. I will book a flight. Somewhere a doctor still sits down. I am not particular about which somewhere. I have a short list, and the list is organized not by survival statistics but by a single question: in this country, when you are dying, does anyone look at you?
5. I will say no. This is the hard one. Physicians are terrible at it. We know exactly which interventions buy a week in exchange for the week, and we accept them anyway, because saying no in front of your colleagues feels like quitting the team. I am putting it in writing so that I cannot pretend later that I didn’t know. I knew. I know now. No.
6. I will end in a sauna. If it is up to me, and the entire purpose of this document is that it should be, then it ends in a sauna, at a temperature that would alarm a cardiologist, with a lake outside doing what lakes do, and someone I love sitting on the lower bench complaining that it is too hot. That is a death. The other thing, the inflating bed and the beeping and the cooking show, is a billing event.

---

My wife, who is the smartest person I have ever known, has never read anything I have written, and she is not going to start with this. Which means my advance directive will be executed by someone who has not read it. I thought about this for a long time and decided it was fine. That is how most of American healthcare is practiced, and I would hate to be inconsistent at the very end.

So I’m saying it here, out loud, where my siblings will find it and forward it to her with the subject line “did you see this”: When it’s time, don’t take me to the hospital. Take me to the airport.

STAT. It’s hospital for “now.” It is the only word from the place I intend to keep.