Table of Contents Views and Mechanics Publisher's Note Editor's Note Review of African Psycho Review of The Life and Times of the Thunderbolt Kid Film Review of "Judith Butler: Philosophical Encounters of the Third Kind" Writing Contest Results Creative Nonfiction Back Pain...Who Cares? By Michael D. Burg Knit Two Together By Jo L. Gerrard Skin Odyssey By Holly Leigh Jacobson Leaves in the Wind By Molly Molloy Hydroglyphics By Phaedra Greenwood Poetry Indiana Poem By Michael Lee Johnson Inspire Me, Ms. Muse By Tony Zurlo A Poem Forgot By Gabrielle Rabinowitz Yours By Sheila McLaughlin Sikorski Confetti By Alan Girling Correction: Drive Me Home Again By Anne Cammon Fiction Scaffold By Joseph Bathanti For the Taking By Anne Leigh Parrish The Artistic Impulse By Johanna Lipford Justifiable Brew Aside By Barbara Anton Stopping at the DQ By Susan White Cover Art Bright Red By Dee Rimbaud About the Contributors © 2007, River Walk Journal and respective authors and artists. All rights reserved. Do not use or reproduce without permission. River Walk Journal, Inc. Board of Directors Chairman - Elizabeth Ross Vice Chairman - Joseph Koch Secretary/Treasurer - Geri Stock-Ross Editorial Director - Patti Kurtz, DA Literacy Director - Vacant Policy Director - PA State Rep. Jess Stairs Advisory Board Chairman - Patti Kurtz, DA Asst. Chairman - Dan Lachenman, PhD Samuel Hazo Christopher Leland Edwin Yoder Joseph Bathanti Journal Staff Publisher - Elizabeth Ross Editor-In-Chief - Joseph Koch Senior Editor - Patti Kurtz Senior Editor - Neeldhara Misra Copyeditor - Kathy Skaggs Blog Contributing Editor - Maggie Koster Education Blog Contributing Editor - Jordan Wirfs-Brock Publicity Director (PA) - Geri Stock-Ross For information about submissions, visit http://www.riverwalkjournal.org/subs.html. Questions about promotions, subscribers' services, and advertising should be sent to publisher@riverwalkjournal.org. River Walk Journal, Inc. is a non-profit corporation run entirely by volunteers. For information about volunteer opportunities and internships, visit VolunteerMatch.

Back Pain...Who Cares? By Michael D. Burg My back hurts. It has been hurting since the morning of April 24th, 2006. The day before, I’d done my usual workout: stretching and sit-ups first, then 20 minutes on the stair climber and 45 on the treadmill. Weights - light stuff - lat pulls, curls, triceps extensions, nothing too challenging. No sense pushing it. I’ll never have huge arms, not with a herniated cervical disk, but that’s another story. After my usual workout I did my usual post-exertion clean-up – shower, spa and sauna. I went to bed that night feeling fine. Next morning, however, was distinctly unusual. I awoke with an intense low backache, fierce, as though someone grabbed hard and squeezed. The juice from the central cramp ran down both legs, largely bypassing my thighs, but pooling in my calves and feet, which felt leaden. All at once I realized why people see doctors for this stuff. It hurt to stand. It hurt to sit. It hurt to kneel or squat or lie supine or prone. It just hurt. It hurt before two extra-strength Tylenol and three aspirin, and a hot shower and rest, and it hurt just as much after I’d done all those things. I know why people see doctors for back pain, but back pain bores every doctor I know. It’s as common as white bread and just as dull. I’m a doctor at a teaching hospital, working with physicians in training. There is supposedly a teaching moment in every case we see. It’s my job to find that moment and expound upon it. But, were I cloned and became my own physician, my back pain wouldn’t interest me. Many times acute low back pain is a mystery. It is unclear what causes it, unclear what causes it to go away. Fine, because mostly it doesn’t matter. The “natural history” of a back pain bout is resolution. Relief of discomfort occurs in 80 to 90 percent of patients regardless of treatment protocol: rest or no rest, heating pads or cold packs, massage or no massage, physical therapy, yea or nay, pain medications – pick your poison – no difference in outcomes, although some are notable for their tendency to cause unpleasant side effects like dysphoria, itching, gastrointestinal distress, and constipation. Then there’s dependence and narcotic tolerance. And, so on and so forth, through muscle relaxants, yoga, imagery, healing spirits, and voodoo. My back pain patients get this standard advice. Use heat, cold or massage if it helps you feel better. Take some kind of pain reliever so you’re not suffering (I’m happy to prescribe something). Avoid activities that exacerbate your pain. Seek further medical care if your symptoms worsen or fail to fully resolve, or if you experience bowel or bladder dysfunction or additional symptoms that concern you. None of my advice on this subject is brilliant, just practical and well supported by the scientific evidence (if that term can be used in association with back pain). These recommendations are designed to keep both patients and doctors safe and happy. By dispensing these words of wisdom I’m practicing standard-of-care medicine and can stay out of court. Or, at least I can defend myself if I’m dragged into a suit. I broadly assume that my patients are reasonably happy with this approach. Most get better, although that’s likely because the odds are in our favor; remember, 80 to 90 percent improve no matter what. (This statistic probably does not include those who’ve retained counsel and plan to sue those they hold responsible for their acute low back pain.) But then, I’m an ER doc and rarely know if my patients, once treated, return with further complaints. Back pain is the mechanical equivalent of the common cold. If you don’t see a doctor for your cold, your symptoms will drag on for an entire week. If you do see a doctor for your cold, he’ll clear it up in just seven days. Brilliant! Plus, you’ll have the satisfaction of sharing your misery, and perhaps your virus. The only difference is that most back pain clears within a month, not within a week. Certain features of back pain elevate it from tedious toward intriguing. Be forewarned, being an interesting patient is never a good thing. It’s only interesting for the doctor, unless being poked and prodded by hordes of somber, white-coated specialists is your idea of a good time. No royalties are paid if your picture appears in a medical textbook; that’s true whether the publishers put a black bar across your eyes, or not. Fever and back pain is one fascinating combination since it may imply that serious, even life-threatening, pathology lurks. Probably not, more than likely it’s just a kidney infection, but the possibility of something fascinating does suggest itself. Back pain in a cancer patient is never good. As we say in emergency medicine, “It’s metastatic disease (“mets” in shorthand) until proven otherwise.” It is often proven otherwise, but this simple statement encapsulates an ER doc’s charge, which is: search for the worst ailment, not the most common one, and be delighted when you fail to find it. I still remember entering a bathroom stall at my med school and seeing the bold black graffiti scrawl, “GO METS!” I attended an East Coast school, so why not? However, a second graffiti artist had amended this sports cheer by penciling in a caret and the word “brain” between “GO” and “METS!” so that the phrase read, “GO brain METS!” Cheery! Hopefully he’s not now a neurosurgeon. Or, perhaps he designs T-shirts, the ones with catchy phrases plastered across the chest. The rest of the “elevating” features of back pain patients that make them interesting include: concomitant abdominal pain, leg weakness, constitutional symptoms like weight loss, anorexia, and fatigue, bowel or bladder dysfunction, progressive symptoms especially in cases without an obvious mechanical precipitant, and age over 55. There are others that must be considered too, but this list is a good start. It’s really not the back pain itself that waves the red flag of caution, but the accompanying baggage. I carried none of this baggage. Aside from my pre-existing MRI-proven herniated cervical disk, I’m as healthy as the proverbial horse. I work out and run around like a kid with a kite (or did until recently). Although I’m 51, most people think I’m 40. One sweet woman (herself in her fifties) tenderly offered a guess of “thirty-seven” at my age, but spoiled the innocent moment by quickly asking if I was single. I’m not. My wife thinks I behave like a child sometimes, but that’s really another story. My blood pressure does need just a touch of help to stay on the healthy side. But, I’m sure it would be normal without medications if I simply retired from the practice of emergency medicine. That said - there’s no reasonable connection between my mild, easily treated hypertension and my recent lumbago. Now, to complete the picture of my back pain, there was nothing to be done. Many believe an MRI must be performed to diagnose the cause of back pain. This is true in a select minority of patients, but false in most. Many back pain patients have no discernable abnormalities on MRI. And, many individuals getting CT scans, x-rays and MRI's for other reasons have hideously disordered backs, chock full of bulging disks and collapsed vertebrae, but no back pain. So, I followed my own advice for acute low back pain. I took mild pain relievers…repeatedly. I actually treated myself to a day of rest. I soaked in the hot tub, because it made my back feel better, and I did nothing to aggravate my condition. And absolutely nothing changed. My back hurts just as much as it did on day one, sometimes worse, and so do my legs. It has been almost two months since I awoke in pain. Now I appreciate something different. I now understand why people seek attention from me in the emergency department for their mind-numbing low back pain. There’s a certain desperation that takes hold after awhile. If the search for diagnosis and cure crescendos at 2 a.m. on Sunday after months of symptoms, then they find me, pleading for relief and answers. I understand that desperation. I took my search in a different direction. About six weeks into my ordeal, I called my doctor and made an appointment. He squeezed me in, reluctantly. I could tell by the tone of his voice over the cell phone that he wasn’t excited about seeing me. He too is probably fed up with back pain. But I felt fortunate. Not only did I have my doctor’s cell phone number, but he agreed to see me the day after I called - the first thing in the morning. None of my patients have this kind of access. But, I had reached my personal desperation point, and so in I went. I didn’t care if I was boring. I get the sense my doctor leads a pretty dull existence, so I always try to spice up his day. Last time there I enlightened him about the world of cruise ship medicine. He’d actually pursued the opportunity and told me he was scheduled to staff a ship in the near future. Then he got down to business. He asked lots of questions about my back pain. “How long has it been there? Where does it hurt? What have you tried to make it better?” The questions went on and on. “Do you have fasciculations, weakness, incontinence, blah, blah, blah?” I had nothing attention-grabbing to offer. He’s a serious guy, so I can usually catch him off guard with some outrageous statement. When he was through poking and prodding, and making me feel bad by forcing me to jump and bend, and worse by banging on my spine, he sat and “hmmmm’d”. (You know the doctor “hmmmm…”. It’s the monotonic equal to, “You don’t say?” with a sliver of, “And what the heck do you want me to do about it?” as garnish). I saw his “hmmmm…” as the opportunity to say, “Did I mention my cyclical fevers to 103?” He wheeled around so fast I thought he’d topple from his stool. When I had his undivided attention, I added, “Just kidding.” Exactly what every doctor wants, a funny patient. But humor is my favorite defense mechanism. In the end, he decided to do an MRI, grudgingly. “The insurance company will have issues with this,” he said. I’m sure they will, and I don’t care. I want answers. I’m not entirely sure why I do, but I do. The insurance company will (rightly) question the decision to do an expensive test to possibly diagnose a self-limited process. I myself question what I’m going to do with the MRI information. If I have bulging disks, will I consent to surgery and add two months of post-operative pain to the two months I’ve already endured? What if my back pain just goes away? Besides, the stats on lumbar disk surgery to relieve pain are grim, 50/50. Only fifty percent of patients in pain from herniated lumbar disks have sustained pain relief following surgery. The other half continues to have pain, as bad or worse as when they first slid down that slippery slope. Maybe, though, they’ll find cancer or some other unexpected treat on the MRI. That’ll be interesting! As I write this, I’m awaiting an MRI date. The only good part of the test date itself will be that I’ll experience the “devil may care” attitude Valium induces. For me, being in the MRI machine is like being buried alive. With Valium, I know I’m there, but I couldn’t care less. As far as the MRI results themselves, I predict there’ll be minimal to insignificant findings. In short, boring to most . . . but not to me . . . not any more!