From the Wards

[Thank you to the medical students of the UCSD School of Medicine for allowing San Diego Physician to reprint articles from it's The Human Condition.]

It is an oft-repeated cliché among students at my medical school that the patients at the Veterans Affairs hospitals all tend to look the same after a while. Men, usually in their 40s or older, with chronic health problems brought on by lifetimes of smoking and alcohol use — casebook presentations of hypertension, diabetes, high cholesterol - these patients are the bread and butter of our rounds each morning.

Clichés have a way of hiding more than they reveal, though, and this proved to be true for me over the nine weeks that I spent on the VA's surgery rotations. Perhaps it started with my conversations with Al, a homeless Vietnam vet who spends a lot of his time in the vicinity of the hospital.

In what was perhaps my second conversation with him, AI let slip that he was interested in mathematics. This caught my attention right away because my dad is a mathematician, and I grew up studying math. Al explained that he was interested in the repetend problem.

If you take the reciprocal of any prime number expressed as a decimal, it will repeat itself. For instance, if you write "1/7" as a decimal, it will be "0.142857142857 ..." with the last six digits repeating endlessly, ad infinitum. But, for any given prime, is it possible to predict how long the string of repeating digits (the "repetend") will be?

Al had been hanging out on campus, attending the occasional campus event, eating the cheap food offered by the Hare Krishnas, and thinking about this problem. He explained to me that when he solved a math problem he felt completely unfettered and free — that his mind could relish a triumph that depended on nobody else's approval, that he felt ecstatic and blessed. By the time he shared his problem with me, it became apparent that he had grown sophisticated in his mathematical thinking.

For the next few months we played tag team, meeting occasionally at the VA cafeteria, to discuss the problem. Neither of us figured out the answer, but we did discover something interesting.

In mathematical terms, for a given prime p, the decimal expansion of 1/p will always include a repeating string of length (p-1). In other words, expand 1/7, and you will find a repetend of length 6. Expand 1/19, and there will be an 18-digit repetend. And so on. Apparently this follows from a theorem that Pierre de Fermat came up with in 1640, known to mathematicians as "Fermat's Little Theorem."

It gets more complicated, though. There's no way to tell if that repetend is itself composed of smaller, repeating strings of digits. Take the number 13 — it's supposed to have a repetend length of twelve, as Al and I predicted — and it does. But those twelve digits consist of a doubled-up string of six digits. Neither of us has yet discovered how to tell in advance which primes do that.

But we're working on it. And 1 have a feeling that it will be Al who will figure it out first, sitting outside somewhere on campus, homeless, living among the elements, but nonetheless a king in his own domain, for a moment, privy to the thoughts of God in a way that few people ever can be.

As I left Al to navigate the mysteries of the mathematical phenomenon, I came across another veteran who wrestled with his own personal mystery. In the same nine-week period, I met a Czech man in his 50s, I'll call him Ludvik, who was in the hospital for surgery. My attending surgeon explained, "If you meet a Czech who came here in '68, they came here because of the Prague Spring." Ludvik was a teenager in 1968 when President Dubcek launched the reforms that were answered months later when Brezhnev ordered Soviet tanks to roll into the streets of Prague. Three hundred thousand people fled, among them Ludvik, who never saw his parents again.

He'd tried to join the resistance. Who could blame him? He was probably like any other teenage boy at the time: He had heard stories of Molotov cocktails being thrown in the narrow streets of the Czech capital, saw his uncles and older brothers and friends taking up arms, and wanted to contribute to the defining struggle of his time.

But when he lined up to receive a weapon, he reached the front of the line, and the man handing out weapons looked him up and down and said, "Kid, I appreciate your spirit, but you're too young for this," and turned him away, probably saving his life.

He fled, made it to the United States, and joined the army because that was what the other new arrivals were doing — one sure foothold in a foreign land for a newcomer who barely spoke English. He made it through Vietnam, survived, returned, and now, forty years later, was being wheeled on a hospital gurney through the VA for a minor surgery.

After surgery, patients are returned to the post-anesthesia recovery room, and the nurses have six slots to put them in. They put a travel poster over each slot, to make it easier to roll the beds to the right place. "Hip replacement done — put him in Hawai'i!" they call out, and the gurney is rolled over underneath the big poster of Hawai'i.

When Ludvik came out from his surgery, guess where they sent him? That's right, into the slot marked by a kitschy poster of dancing Russians, the kind you'd see in a high school Russian classroom. Which just goes to show: Symbols, posters, and empires may all eventually fade, but people will survive. By hook, by crook, and sometimes by the concern of complete strangers, still they survive, and move on to a new chapter.

And then I met one of the greatest survival stories of all. I'll call him Bill. Bill was in his mid-'90s. Bill had served in World War II, and he was, to the best of his knowledge, the oldest still-living Marine Corps survivor of the battle for Iwo Jima. He'd gone out in March of 1945 - not part of the initial assault, but to take part in the fierce battles that followed. He'd returned to Southern California after the war, and opened a barbershop.

When the attending surgeon walked into the pre-op area to introduce himself, Bill looked him up and down and said, "Young man, when this surgery is over, I'd like to give you a haircut." This is really only funny if you happen to know that the surgeon in question, while not completely bald, doesn't have a whole lot of hair. He took the ribbing well, and told Bill he'd be happy to take him up on the offer.

We went over the details of the surgery with Bill. We all stood in a circle around his bed — the pre-op "huddle" of nurses, surgeons, anesthesiologists, and medical students. For a moment I wanted to take a picture of the scene and send it, a single time-defying postcard, in violation of all of the laws of physics, back to the younger Bill, as he sailed across the Pacific in 1945.

He must have been terrified. Who wouldn't have been?

Lying in the belly of a troop ship, the throb of diesel engines around him, surrounded by salt, sweat and fear — he knew exactly where he was going. In some units, as many as three out of every four marines were killed. Those were the men he was going to relieve.

The U.S. Air Force had bombed the islands until they looked like the surface of the moon. In response, the Japanese had retreated to a network of tunnels that gave them complete cover as they picked off the Americans who were scrambling on the rocky surface above. This was their destination, and they all knew it.

I wanted to send a message back through time, telling him: Look, this is how it ends — not cut down by a bullet on the surface of the moon, but instead, more than sixty years later, in San Diego. Here, a team of compassionate and dedicated people will care for you, you will go home, and one day, you will experience a dignified, peacetime death.

But then I realized that there was no need. If Bill had faced Iwo Jima the same way he did his surgery, he already knew. It didn't make a difference — he had no control over how things turned out, but in his imagination, he was already giving a haircut to the attending surgeon. Maybe that is what let him survive Iwo Jima - in his imagination, he could already see himself on the other side.

Because in the end, we don't know what fate has in store for us — but if we live as if fate will be kind to us, at least we can make the most of every moment that we are granted.

And perhaps, in the end, that is what makes all of us fundamentally human: In the space between what we know and what we do not know, there is a gap. How we navigate that gap and stay afloat within this mysterious balance, determines how we live and how we survive.

For Al, exploring the space between knowledge and mystery in mathematics blessed him with his greatest feelings of freedom. And for Ludvik, his life was probably saved by an anonymous man whom he'd never be able to thank - the mystery of that would remain with him forever. And for Bill, the very definition of his courage was in the divide between what he knew and what he did not, and how he faced that division while confronting danger.

And for me? From my experience with VA patients, I have learned that old words such as freedom, compassion, survival, and courage, could mean more things than I ever expected. And when I hear people say, "The VA patients are all the same," I know that I will never agree.