Goals 2016: Work

I’m lucky enough to love my job. Sure, there are politics—red tape, entitlement, insurance muck to slosh through. But most days, I leave the office genuinely thankful that I’m able to do this.

I have big dreams for my patients. B.I.G. (hopefully ending better than the one & only Notorious). But I also have a family that I adore. The truth is that the smiles may come from my patients, but the substance comes from my family.

My age is a touchy subject in my line of work. I feel it my responsibility to seem mature, knowledgeable. But then again, certifications, letters-after-my-name, & ALL THE SCHOOL LOANS kind of prove those things. I get asked a lot. Apparently some think that I graduated from high school at age 11.

When the question is asked, though, I reassure them that I am old enough to have completed my training. The truth is that I want to throw my hands up & prompt a pop quiz about the first line antibiotic for pneumonia or the molecular pathology of diabetes. I am more comfortable there, in the land of blissful academia. I am more comfortable where someone asks the question and, if I did the work, I know the answer. I’ll write you an essay, draw you a picture, or make you the best goddamned color-coded notecard you’ve ever seen. I’ll even use sparkly gel pens if you ask.

But ask me to hold your hand & sit in awkward silence because you just found out your marriage is broken or your father has cancer or your grandmother is suffering? That is the hard part for me.

I realized, not too long after starting work in the “real world”, the post-residency world where neurosurgeon’s call you by your first name & medical students cower in fear of your evaluation, that I was bad at the in-between. I love this job because I get to solve problems; I struggle when I have to sit through them with you.

The hard truth for me is that both aspects are part of my job—the solving & the sitting. The former is the science. The latter is the art.

I’m slowly learning the brush strokes, the color-mixing, the medium to work on. I’m slowly learning the hand-hold to console, to lean into the emotion instead of pushing it away.

And perhaps the most important part of what I am learning is to leave work at work. To close the office door & shut the laptop to just be done. The science is easy to leave, the sentiment drags behind like muddied footprints on a clean floor.

They say our visual memory is like a rolodex of cards—ready to be accessed, spun, at any time. Every so-often a smell, a look, a sense will trigger a memory of a patient or experience. Most are pleasant & evoke feelings of bravery & peace. Some are not, though; some are bitter & course, grating away at the joy that hangs just overhead.

We’ve discovered the difficulty in the constant grating recently. My husband switched jobs, which is what prompted our move. New field, new perspective, new hope.

We are taught that our jobs matter almost as much as our lives in this country. And as an unfortunate consequence, the lowly janitor (who is really not so lowly at all) feels like his life is worth nothing because of his title.

In Mrs. Hays fourth grade class, as part of our Medieval Social Studies unit, we held a royal knighting ceremony. Our parents made food & set out crockpots & snack trays on top of the paper tablecloths we handcrafted. We made a crown, a scepter, & a long purple cape. And, when the time came, the knight of our school walked in, ready to be given what was royally due. Our Janitor got royal treatment that day. He already knew each of us by name--& from thenceforth we got to call him “Sir”. He was a knight in shining (paper) armor, after all.

The symbolism was lost on me in fourth grade. It now brings me to tears.

So the last will be first, and the first will be last. (Matthew 20:16)

The irony does not escape me that my mind is most comfortable in the pretentious world of academia & my heart is brought to tears at the very thought of it.

As much as hand-holding & sitting through it is part of my job, as much as the diagnostics & the competency is part of my job, learning who I am holds an equal place of priority. Who I am to my patients. Who I am for the unacknowledged important. Who I am with my family.

Sparkly gel pens, pharmacology, & ambitious dreams aside, work for me needs to be something in which I can recognize the value of people & help make them better. It is also a tool with which I can teach my kids about the world. So that they can make it better, too.

•  Work for the JOY learning brings & the people it touches.
• Be present at work. Be present at home.
• Dream, plan, create—but savor these years of youth & the beauty of your children at this age.
• Stop working—in every sense of the word—when it is time. Stop working to seek approval. Stop working toward worldly updates on Facebook or the Nightly News. Stop looking for eye-candy; stop searching the outside world for self-worth.  
• Work because I can and because I love it, but remember why God gave me that work to begin with. Don’t let the red tape become the Red Sea, partible only by miraculous intervention.

(See parts ONE, TWO, & THREE)

the best option we've got

It took me 11 years and 8 months to get two extra letters after my name. That’s 4,179 days and almost $200,000 to earn the title of “doctor” and get one of those fancy pen stamps that represents the most-used tool for those of us in the order-signing practice of medicine.

I tend to be on the “granola” side of the large gray line in my profession. If we took a not-so-equal split and divided all the healthcare providers into two sides, I’d fall on the “less is more” category that favors conservatism, supplements, nutrition, and risk assessment (instead of the more statistically brained, medication- favoring other group). I tell my patients to eat grass fed beef and sip sparkling water instead of soda. Half of them don’t listen and balk at my insistence that their nourishment actually makes a difference in their health. But I tell them anyway. And I sign off on lab results that show borderline lipid levels because I know that pharmaceuticals cannot change lives and levels as much as healthy habits for most patients.

This week I spent two days with my young kids at home wiping snotty noses and changing poopy diapers. And I also spent three days in my office; I saw over 65 patients and signed my name-with-two-extra-letters more than I’d care to remember.

 A beautiful 43 year old with jet black hair and flawless skin sat in front of me with a furrowed brow and concerned look and asked me about her cholesterol. A 58 year old female with advancing osteoporosis wanted to know why she had brittle bones despite her lifetime of activity and healthy eating. I saw a 2 year old and a 92 year old, representing the range of life and lifestyle and living.  

In most respects I am a well-trained, well-read, well-educated Family Physician. I subscribe to nationally recommended guidelines in my practice. I use motivational interviewing techniques. I discuss risk assessment and polypharmacy with almost every patient. I believe in intervention when it’s needed and a hands-off approach when it’s not. I believe in the marvels of modern medicine and the old-fashioned art of patient exams. I believe in cardiac stents, laminectomies, and radical mastectomies. I believe in genetics, in research, in bettering the good that we’ve already got in Western medicine. And deep down I truly believe that, just like Loretta Lynn sang in her southern drawl, we’ve come a long way, baby.

Which is why I surprised myself when I didn’t want to vaccinate our kid.

I know about statistics. And I know about disease. And epidemiology. And modern vaccinations. I know about thimerosal (and that it is no longer in preparations). And autism (and the concern over its link to vaccination). And adverse effects. And I know what it is like to see a 4 month old with Pertussis he caught from his grandmother. And what it is like to see a 4 year old lose her ability to walk because she was one of the (very very) few with post-vaccination Guillain-Barre Syndrome.

I also know that needles hurt. And that post-vaccination fevers are no fun. I know sleep deprivation and the mind-numbing exhaustion that comes with crying babies after shots. I know the concern over injecting something irreversible into a clean, pure, breastfed kid. And I know the anxiety that comes with injecting six-somethings AT ONE TIME into an innocent little baby. I know that we live in a country where school aged children don’t die from measles, the County Fair is (usually) an okay place to take your 6 month old, and polio is a thing of the past. I know that, for me, taking the advice of a large governing body (i.e., the Center for Disease Control) is sometimes harder than listening to our own doctor. And I know that my own fears about Ebola and parasite-infested drinking water are piqued more by the pretty newscasters at night than they are from my 13-pound medical textbooks.

I know these things because I am a trained physician…and I am a mom.

My generation of physicians has been spoiled. My generation of mom’s has been spoiled. And the truth is that I have been spoiled, too. We’ve been falsely lead to believe that our own opinions about medicine trump the research, that our own fears about side effects might make them come true, and that the advice of those large governing bodies are filled with conspiracy and ill intent. We’ve been subconsciously convinced that feeding our kids the wrong type of baby food might make them fail kindergarten (it won’t), a cold lasting more than 7 days needs antibiotics (it doesn’t), and leaving your children in the car for 3 minutes while you return your shopping cart might get you arrested (who knows). I’ll readily admit that despite my training and my experience, despite those two extra letters after my name that make me authorized to give solid evidence-based advice to my patients, despite all the studying I’ve done, I still cringe when it comes to shots.

I told my patient with slightly elevated lipids to come back in a year. She doesn’t need the risk associated with medication right now. Lifestyle and nutrition changes might not make a giant dent in her lab results, but it is the best option we’ve got.  I told my patient with osteoporosis that we have medication that might help her bones. The medicine is designed to halt the progression of disease. They aren’t perfect medications and they are fraught with potential side effects, but they are the best option we’ve got.

And THIS IS THE TRUTH: When it comes to foods, garden is best, organic is good, fresh is fine. Buy the baby food that is on sale and take your kid to a juice bar with the saved money. Nourish your child. 

Put your phone away, get off WebMD, stop reading Jenny McCarthy’s books; engage your kid, play dress up, toot some trains around the house. Invest in your child.

And despite everything floating around the media, vaccinations are good. They are backed in research, statistical success, and positive epidemiological transformation unlike any other public health movement (aside from using toilets, but I think we are beyond that…). I won’t deny the side effects. Or the post-vaccination fever. Or the screaming that comes when your kid is poked. So protect your child. 

We vaccinated our kids.

The truth is that most of this argument isn’t about vaccines at all. It is about kids. And health. And very real disease (that has recently made a comeback). And it is about parents doing what they think is best for their kids.

Maybe it is time we all stand in that gray area together. The physicians losing a bit of our objectivity and looking concerned parents in the eye, recognizing that vaccines can be scary stuff. The parents giving up a bit of our subjectivity and listening to educated professionals who care about our kids, recognizing that vaccines are lifesaving miracles…sometimes with side effects. And in the best world, both sides coming together to admit that, although vaccines aren’t perfect, they are the best option we’ve got. 

coral

Glossy coral polish covered her toes. It was a newish pedicure, I think. No chips, at least. It was my third week of ICU & I hadn’t even thrown a glance toward my feet since starting. My toenails probably resembled a troll’s. The other intern even commented on how pretty her toes were. Of course, they stood out against the drab walls & maze of medically-acceptable colored tubing—helping her breathe and pee and live.

She died within two hours.

Her daughters, two of them, held her hands when we detached the tubes and lines and bags. They held on tight, almost as if they wished life could somehow be transferred from one warmed being to a cold one. Kind of like a Fairytale collision of Tangled & the laws of thermodynamics.

I stared at her toes.

There was life there, once. A mother—one who held her babies tight and folded their laundry and kissed their chubby, drooling cheeks. A wife—one who made dinners (only sometimes burnt) & tirelessly folded and scrubbed and comforted and loved. A daughter who made her parents proud, a sister who was present in all those childhood memories. A lover. A reader. A cookie-eater.

A woman.

A woman with coral-colored toenail polish who fretted about her post-partum figure and the finances and friendships.

I haven’t had a pedicure in over two years. It isn’t that I don’t like them—I can usually justify spending the money elsewhere. But just yesterday when I was trudging through the sixth load of laundry, losing my patience with Thatcher, and wiping the spit-up off my already-wet shoulder, I remembered her coral polish. And for the first time since my rotation three years ago, I thought of her. And I thought of her daughters.

I thought of how they loved her and honored her, even until the last breath. And I thought of how, at some point in her life, she loved and honored them, too. And all that mothering;  the love that was so expansive it was barely contained in those frail bones and lentigo-skin and the hours of the clock that those eyes saw when her daughters were little and the loads of laundry folded by those hands and the places visited by those feet and the secrets whispered between the sheets…

It is an honor to be a woman.

And mother.

And wife.

Most days, I don’t carry that honor well. I mess up. I get mad at my kids. I get madder at Jon. I lose my patience over pretzels dumped all over the floor, spot-cleaning the seventh outfit at noon because of poop explosions, giving baths and smearing creams and administering medications. I tend to get lost in idealism, robbing reality of its Fantasia. And some days I don’t even carry love well.

This post-partum stage is a melting pot of emotions and hormones and sleepless fury and broken expectations. I get lost in the have-nots and could-have-been’s and should-have-done’s. And I go sniffing for unicorns and hunting for rainbows because I’ve somehow convinced myself that this life, loving these littles, is not enough.

Life only comes once.

These years, the ones in the trenches of selfless demand, are the ones that women across the globe look back on with fondness. The sleepless nights etch crows feet, the tired feet form bunyons, and playing at the water table for a few hours too long cause solar lentigo spots.

Someday I’ll learn to cherish each of those little sun kisses and callouses and crows feet.

And one day, hopefully not soon, there will be contrast in my life as well. I’ll miss the scrubbing and cleaning and whispering and snuggling. I’ll miss the “mommy pay twains” and the incessant demands for graham crackers and nursing. I’ll miss the warmth of Jon’s embrace after a day of cold-shoulders from the kids. And I will miss mommy-ing these two miniature souls.

I’m working on carrying that honor a little bit higher,  a little bit brighter, and a lot more proudly. I’m working on grabbing ahold of each day--& welcoming whatever comes with it. And I’m working on finding that Neverland of balance.  

I have a pedicure scheduled for next week.

Coral, in honor of her. 

Everything.

[originally written 07.28.2011 during my ICU rotation]

The stories these walls bear. Miraculous recoveries. Unspeakable tragedies. And mostly everything in between. The flow is steady, rhythm strong. The floors covered in blood and in tears. Sometimes independent, but usually all at once.

And oddly enough it seems like that how the patients come, too: steady, independent, and all at one.

The man in room #44.

The woman in room #22.

The alcoholic grandmother. Smoker. Mother.

The trauma. The car accident. Pneumonia. Hemorrhage.

We see them cycle. And sometimes they leave us floating—smiling at their recovery, body full of miracles and fervor. Others make us shake our years. Thirty-seven, so young; her liver aged  and poisoned from alcohol. And then, in some rooms, tears track in and out all day long—the goodbyes too much to handle, the dying too long and life too short. The hanging on—just barely, and the holding on—too strongly.

All sorts are wheeled through these doors. It’s a battle of the heart and mind, the practical and the justifiable, the quality and the quantity—of life, illness, moments, and madness.

Days have been tough for me. Upset families. Dying patients. Tragedy striking unannounced just one time too many. And for some, the inevitable finale rearing its ugly black head. My tears have been tracked, too. Implanted on footprints, dropped on sterile lines, hidden in the cuff of the white coat I’m forced to darn.

I’ve lost more sleep over these patients than over the sick babies, the neglected children, the homeless asthmatics in the dead-of-winter, and the cancer filled ovaries I’ve seen. Not because they don’t make sense—that an obvious part of the conundrum, but because we don’t make sense.

It’s been a soul-filled journey. Soul and sour, actually, depending on the day.

George, the hilariously absent minded, misunderstood character in Grey’s Anatomy pre-raunchy Season 1 was distraught about pouring his every drop of energy into a code on an already obviously-dead patient—antiarrythmics, defibrillation, chest compressions. But his all-knowing supervisor reminded him WHY those measures, ridiculous and seemingly wasteful were necessary.

                Because we have to be able to tell the family that we did 

EVERYTHING WE COULD.

And now—at the end of these five weeks. A the end of my nights of lost sleep and growing gray hairs.

At the end of this rotation, I finally get it, too.

This isn’t about the medicine. It’s really not about the disease or the diagnosis, the tears or traffic or tragedy. 

It is about TRYING. 

Giving the body one last chance to heal, the family one last chance to say goodbye, and Jesus one last chance to say hello. And at the end of the day, we go to bed knowing not what the future may hold, but knowing that what we tried was 100% and what we gave was EVERYTHING. 

holding hands.

They held hands.

Not in the way they used to, of course.

Her hair was curled—a white a-line bob. Crows feet framed her eyes. “He’s an ornery man,” she said. I wasn’t sure if the wrinkles were from years of joy or months of pain.

He gurgled.

And coughed.

And then tried to spit.

But that strong, 6-foot-2-inch man was no longer coordinated enough to even expectorate his own sputum. In more ways than one, he’d become a child again. Cooing. Gurgling. Pointing. Pulling at his gown, then her jacket, then the tubes and lines and electrode’s.

The words I imagine she once used in adoration toward the father of her children, words like “strong”, “handsome”, “helpful”, “leader” had turned into something entirely different.

“Isn’t he cute?”, she giggled, “…just adorable.”

And if I didn’t know better, I might have guessed she was talking about her grandchildren—the ones who never knew their grandfather for the strong, handsome, helpful leader he was.

It hit him hard about five years ago. And to everyone’s surprise, he made his way into the Emergency Room because he “just wasn’t feeling right.” He left with a new diagnosis: Severe Progressive Dementia, Alzheimer’s-type. Low-and-behold, the atrophy had started. Amyloid plaques & neurofibrillary tangles set up house. Then ever-so-slowly and almost instantly, her big, strong husband regressed.

He forgot her birthday.

And then their anniversary.

Eventually, he forgot her.

And that’s when the words changed. The world’s changed, too.

But still, they held hands.

She said no treatments. And he couldn’t move his right side. Paralyzed, both of them—one by a stroke & the other by the stinging pain of love. She filled out the bright green form:

NO INTERVENTIONS.

We disconnected the fluids. Took off monitor stickers that were so bothersome in the first place. The medicines were stopped, Hospice was started. And we waited. She waited. And he kept on grunting.

All the while, they held hands.

I saw those crows-feet again. And I knew. I knew they weren’t from pain. Or joy. Or even age.

They were from LOVE.

And it was then that I realized: love really is choosing the highest good for the other.

Even if sometimes, it means calling them cute, holding their hand, & letting them go…

who he once was.

remember old mr. huldorn? his life stored in two hotel-style dresser drawers, days spent on the fifth floor of the concrete rectangle in the countryside. walks, privileged. and when i visited him, they’d just taken away his green card—which for mr. huldorn was like taking away his prized collection of special edition baseball cards: devastating.

and so he spent his days on his bed. eating snacks of chocolate Easter bunnies & orange-wrapped Skittles from last Halloween. his mom sent him boxes, usually weekly. but he’d ask at least twice a day to please check the mail for more treats—a request usually followed by more hollering about his bathroom habits.

mother-mrs. huldorn sent packages full of chocolate bunnies & orange wrappers because she couldn’t stand to visit anymore. she as getting older & it was just too hard to see her forty-something son holler about his bowels.

i kind of don’t blame her.

mr. huldorn taught me a lot about waiting, patience. and not surprisingly about his bowels. and he also taught me about his daily bathroom habits…

but what i didn’t tell you was that old mr. huldorn, before he hollered about the bathroom, was a valedictorian. a true 4.0-earning, graduation-class-speaking high school valedictorian. it was in another life, now irreconcilable to his own fragile memory. as the story was told, he was a up-and-coming computer genius. the second bill gates, some even said.

his parents were proud—or so the story goes. their prominent positions in the community, country-club lifestyle & ritzy vacation on the Carolina Coast seemed to be the perfect formula for a life of leisure & success.

the story of mr. huldorn’s young Hollywood life goes on as any other—full of drama, suspense, & a small dose of personal tragedy.

it was during college, his sophomore year that the senior mr. huldorn fell out of love with his family & in love with a much younger, thinner, perkier version of the original mrs. huldorn. i can only imagine the wildfire of gossip that spread through those streak-free windows & red-roofed houses, between the mouths of the Stepford Wives on Wisteria Lane.

and the then-young mr. huldorn was, i would imagine, nothing less than devastated.

i was told, the story sounding much like a ghostly tale from a far off century, that the voices started then, after the new mrs. huldorn moved in. the voices got louder & stronger & bothered him more frequently. they talked to him in class, in the library, & during dinners in the dining hall. they told him he was stupid, undeserving. they tried to convince him to jump off roofs & smash computer screens.

and soon enough, it was just too much. the senior mr. huldorn, horrified at what had become of his valedictorian, country-club son waived goodbye for good.

which just left mr. huldorn and his worn out mother. and while the voices taunted the mind of young mr. huldorn, the rumors taunted that red roofed house on the real wisteria lane.

it was his breaking point.

so young mr. huldorn was taken to the hospital. his mother soon discovered just how severe her son’s schizophrenia really was.

fast forward twenty years. and we arrive at the concrete rectangle in the countryside, the fifth floor, the boxes of Easter bunnies, and…the bathroom.

you see, the case of old mr. huldorn’s hollering wasn’t just about the bathroom. it wasn’t just about his rather odd fixation on his bowel movements. and it wasn’t about his green card, either. no, the tale of old mr. huldorn is really about his STORY. it is about second-chances & loving anyways & accepting the seemingly-devastating & rising to the occasion.

and maybe most of all, it is the poignant reminder that none of us should be who we once were.

we have a voice who speaks to us, too. jump, it says, let me catch you. dare, it warns, i will continue to provide. and while we go on in our daily trudge, hollering about the weather & the boss & the clogged toilet, that voice knows where we’ve come from.

and that Voice has big plans for us.

which may or may not include things like green cards & orange wrapped candies & weekly boxes full of chocolate Easter bunnies.

she says, he says.

she says, “give me some energy.”

he says, “my child, i’ve given you food to eat.”

she says, “help me lose weight.”

he says, “i’ve give you two feet to walk on.”

she says, “but i’m feeling so depressed."

he says, “look at all the people i’ve surrounded you with!”

… “i just don’t look right”

“beauty is determined by the soul.”

“fix my stomach problems…”

“i’m growing fresh foods for you to eat.”

“i’m just not getting better fast enough".

“i’m teaching you patience.”

“there seems to be so much wrong with me!”

“i want to hold you closer.”

“i don’t think i have enough…”

“for where your treasure is, there your heart will be also.”

“i want to heal my body.”

“i want to heal your heart.”

“i don’t want to die…”

“i never said you had to…”

me & them.

i look at them sometimes and wonder. wonder how they perceive life. do they know they are alive? can they see? hear like i do? can they taste food, enjoy chocolate, drink the sweet nectar that drips off the summers ripened tree? do they notice the wind in their hair, kisses of sunshine on their skin, drips of heaven on their face? is the smile real joy? the crying real emotion? the moaning real pain?

neurologists may say no.

preachers may say yes.

but what do i say?

i say love them. most of the time.

but sometimes the “love them” can’t find an anchor. it drifts into that raging sea of judgment. the sea, angry & gray, where my thoughts are tossed about in swells. the sea that convinces me that science rules: the smiles are random neurological firing, the moaning a sequence of reflexes. the sea, white capped & turbulent, convinces me that they are shells—defunct brains, malformed limbs, hopeless cases of life. i stay submerged in that sea. gasping. drowning. thrashing. until a Hand reach in & scoops me out of the abyss.

me.

the Hand rescues me.

the Hand carries me, pulls me, guides me, pushes me, & wheels me. me—a spiritual shell of a defunct heart & malformed grace. a hopeless case of life. and in that angry sea, the Hand becomes my life boat—pulling me back to the safety of the shoreline.

to finish the race.

victoriously.

that Hand hoped in me & knew that i was more than a sinister case of genetic misfortune.

their malady, physical.

mine, a sinful spirit.

neither fixed by medicine, only the Hand of HOPE.

and it is then that i realize, wet & cold, shamed with the salty drops still clinging to my skin, that me & them?

we’re not so different after all.

Dear Angry Mother, From Regret…

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Dear Angry Mother:

when I plotted your sons BMI on his growth chart today & the dot barely made the margin of the page, I knew we had something to talk about. and i also knew that it wasn’t going to be easy.

so i walked into your room to do a well-child exam & found your 161-pound 10-year-old son quite pleasant. nice kid, you have.

but what i didn’t know, Angry Mother, was that my mentioning your 161-pound son’s weight was going to offend you so. i didn’t know that my preceptor would be 30 minutes behind schedule because of the extra time she had to spend explaining to you why we needed to talk about your son.

i didn’t know, Angry Mother, that my recommendation to eat more fruits & vegetables, my telling you that the acanthosis nigricans rapidly spreading on your son’s neck was linked to childhood diabetes, or that my explaining that he should try his best to be more active was going to send you stomping out of the exam room to tell the nurses just how offensive i was.

and i know, i know i’m just a student. i’m still learning. and when i walked in your exam room today, i tried my best to use gentle words & approach this confrontation with empathy.

i heard later from my preceptor, who was gracefully able to diffuse your anger over my audacity, that your son cried because he apparently wasn’t aware he was overweight prior to our chat today.

really? really Angry Mother?

i guess he thought it was normal to have oozing hydadenitis suppurativa in his skin folds, normal to look down only to find his chin was in the way of full neck flexion, and normal to have a stomach covered in white striae from skin stretched too far by the bounty of adipose underneath.

i’m no exception from flaws, failures, and need-for-improvements, Angry Mother. but this is YOUR time—this is YOUR time to guide him, teach him, challenge him to eat right, better, purer foods. this is YOUR time, Angry Mother, to pass on good, healthy habits that he will carry with him to old age. and this is YOUR time to be a positive role-model for him with regular exercise & healthy eating. even still, our physical flaws, mine included, are no reason for condemnation.

i guess i was out-of-line today. and rude.

and i guess i’m sorry.

but Angry Mother, i want to tell you now…that less than 25% of childhood obesity is because of genetic predisposition. i want to tell you that just because your kid doesn’t eat protein, mac+cheese isn’t a healthy substitute. and i want to tell you that today when i tried to encourage you, you spit the forewarnings i had about the long-term complications of childhood obesity right back in my face.

so thanks for that, Angry Mother. and thanks, too, for the now-permanent hesitation i have with ever being honest with a patient again. you’ve changed my perspective—& i’m sorry to say that it isn’t for the better.

best of luck with your 10-year-old.

sincerely,

regret.

lies.

In the sick room,

ten cents' worth of human understanding

equals ten dollars' worth of medical science

. ~Martin H. Fischer

we’ve lied to you. spoken through our teeth, nodded yes when we should have been honest, gestured “no’s” when you needed to hear the truth. we’ve lied to you.

we told you that we would fix it. cure it. heal it. mend it. stitch it. image it. detect it. prevent it.

and we’ve lied to you.

me? i’m sorry for the lies. the mistruths. the skewed beliefs that we’ve planted…and the rumor weeds that have grown from those seeds. i’m sorry for the smiles that should have been empathy and the attitudes that should have mirrored grace. i’m sorry for the “yes”’s that should have been “wait longer”’s & the “no’s” that should have been explained.

but none of us are perfect.

it keeps me up at night. i recount the day, wondering when the seeds were planted. wondering who bothered to water them. wondering why no one cared to notice weeds are clouding our perspectives. because those seeds we’ve planted have grown indeed. they’ve become redwoods of expectations. they’ve been tossed about in seas of worry. they’ve been thrown into the valley of mis-education, pulled through the pipes of uneducated requests, & regulated by the second-hands without adequate knowledge.

and here we are.

me: sorry.

you: lied to.

but here is the truth: medicine is not always the answer. pills are not always the fix. runny noses are not always pneumonia. fevers are not always raging bacterial infections. cuts don’t always needs stitches. menopause can’t always be cured with pharmaceuticals. muscle spasms won’t always be fixed with written prescriptions. snotty nosed-newborns don’t always have meningitis. muscles aches don’t always mean your medicine is toxic. that diet pill won’t always help your health. the CT scan won’t always show us everything. your blood tests don’t always have the diagnosis. we don’t always have all the answers.

those weeds are clouding our clarity. and we ask for Claritin to clear us up. the expectations we’ve swallowed haven’t broken because we haven’t taken the time to learn. so we ask for expectorants to help break up the excess. the seas of worry we swim in aren’t always full of sharks—sometimes just little goldfish, challenging our bodies to work as they were created; but we ask for a life ring for happy moods & less-hazy days.

i want to stop nodding yes. i want to stop saying no. i want to stop gardening weeds. and i want to stop being sorry.

i want to start investing in something bigger, greater, grander, better. i want to start with me. and then you.

we’ll start with your ten cents. and make an investment. together.

flower child.

Hey, How you doin’?, he said, the vowel of “hey” lagging in speed, voice smooth as black coffee. I was a little taken-aback by his greeting & even more shocked to find him lounging on an elbow wearing shiny metal-framed Blues Brothers sunglasses. His speech was slowed just a bit, vowels & syllables dragging here & there creating an accent I couldn’t quite pinpoint.

It didn’t take me long to figure out that he was a child of the 1970’s; a kid of peace, love, & rock-and-roll; a teen of smokes & drugs & all-you-can-get. At age 63, the youth had long been gone, but the cheeks below his tousled mop of thinning hair were rosy.

We learned he loved music—guitar, in particular. And I pictured him in a field of daisies, some blonde haired Farah Fawcett whirling around like in the opening scene from the Sound of Music. We learned he loved art…and I figured something odd like paint splattering or wood carving was probably his forte. We learned he loved traveling, & road biking, & Harley’s, & the Beatles.

We also learned that, in his days of freedom, he really loved his booze. He’d get drunk, shoot up, wander a bit, love on some lucky woman, sleep…& start it all over again. And suddenly my picture changed. Instead of fields of daisies & VW Vans & the happier scenes of Forrest Gump, my imagined pictures of his life turned gray, hazy, chaotic.

I couldn’t quite grasp it. Not him. Not the 1970’s. Not the drugs or sex or rock-‘n-roll. But I could grasp the fact that his abdomen was packed with fluid that would have to be drained. I could grasp the fact that his liver was failing, secondary to Hepatitis C he contracted sharing needles. I could grasp the fact that his lungs were destroyed, the consequence of smoke inhalation from years of sacred puffs. And I could grasp the fact that he had regrets.

“My mother told me never to touch the stuff”, the “o’s” & “th’s” lingered in the air, “and god I wish I would have listened.”

My words were gone. I stood silent, not knowing what to say, where to console, or how to encourage.

“But you know”, he said looking at me, “we sure had fun.”

Finally my smile came.

I’d run out of questions & continued my exam in silence. Meanwhile daydreaming about my own future, wondering if I’ll look back at age 63 & take the good with the bad, the life with the malady, the health with the sickness; wondering if I’ll cherish the residue of my memories & poorer decisions or choose to live in regret.

…wondering what substance in my life right now will propel me into remorse; wondering how to squelch it.

And wondering how to make it all more fun.

clarification.

It isn’t often that I publicly change my opinion. And really? Most often, it is because I deliberately think through my words, my thoughts, my actions before making them public. But I’m finding that more days than not, my opinion of life, of people, of faith, of stuff is just changing. The changes are largely out of my control... fed by my experiences, resurrected by my stories.

And tonight? You deserve to hear more of the story. Instead of changing my opinion, however, I’m going to make an addendum.

To this post.

You see, when I wrote this story about this giggling girl’s mommy, I was writing mostly out of frustration. Because it IS frustrating to see patients that don’t have emergent (or even urgent!) problems, that are not sick, not in pain, not needing immediate medical attention in what is supposed to be the emergency room. In my ideal world, we’d see emergencies in the ER. And if you talk to “old-time” physicians, you might find that Emergency medicine has mercilessly changed. In most community (read: smaller hospitals without advanced trauma units) medical centers, the ER is filled with a myriad of patients on any given night. And what used to be a population of patients with what, in my opinion, were true emergencies or urgencies have now become patients with minor medical problems that very-well could have waited for tomorrow…or 2 days from now…or next week when they could have gotten an appointment with their primary care doctor.

I fully (FULLY!) realize that other issues are present in many of these cases. Patients may not have insurance. They may truly be worried…& in many cases, the patient truly does know best & their concerns are fully warranted. They may have an underlying condition or problem that would not have been discovered had they not come into the ER. But for the most part, the patients I was referring to in my post were those who did need medical attention…eventually.

Such was the case with giggling girl & her mommy. It wasn’t the fact that the little girl had a reddened throat that bothered me so. In fact, literature (& Grey’s Anatomy, for the record) cites cases where red throats turned into something much, much more serious. But such cases are, largely, outside the norm. And giggling girl had nothing more than a red throat. No fever. No cough. No signs of infection. But her impatient mother decided to forego waiting for her pediatric appointment just a few days following & rush her to the ER because it might be something serious. That "common sense" doesn't seem to be common anymore...

The patients I was speaking of were those who coming in for toenail trims. Or for hangnail removal. Or who want to “be fixed” in less than an hour after 19 years of pain.

And, more likely than not, the patients I was speaking of…ARE NOT YOU.

So PLEASE….go to the Emergency Room if there is an ioda of concern, of anxiety about your situation that arises in the midst of whatever medical chaos you might be experiencing. Use your best judgement. Think through the situation. Ask yourself if it really is EMERGENT…or even URGENT. I certainly can’t go through each diagnosis here (we’d all be dead by the time I was halfway done)…& that is not my intent. I write to vent, to share my now-feelings with my 40-year-old-self in a couple of decades, & to remind myself that there is PURPOSE, greater purpose, behind the sometimes frustrating-monotony of my days with patients.

I cannot be the judge of your medical decisions. And I cannot be the decisive voice in your care. That responsibility belongs to you. What I can do, however, is share: my opinions, my experiences, my HOPE.

Common sense.

mirror.

So our choices add up.
Habits into hours.
Decisions into days.
Lists into a life.
--Ann Voskamp, A Holy Experience

*******

He shook his head, adamately denying the accusation.

Shirt wet, salty water leaking from pores. Heavy breaths, body struggling against the extra weight.

Ridiculous, I thought.

He was a large, proud man; just a sliver of apprehension between the lines of his bold verbal paragraphs.

“I don’t eat junk,” exasperated.

I sensed his offense at my questioning.

“Mr. Hepp, your blood pressure is still elevated. Your three meds are at their maximum doses. And its been five months.”

I probably should have been more sympathetic.

“Yeah?...and I’m still trying.”

Doubt overwhelmed me.

Really Mr. Hepp? Really? You are still trying?

Judgement shot from my viewpoint.

“Well, let’s talk about what you are trying. We’d really like to see more progress—we are concerned about your health! Both now & long-term. We’ve talked about the consequences of your condition...”

Saccade eye movements disappeared. I’d lost his attention at “let’s talk about it.”

“I really have been trying, you know…”

I bet you have!...

“I cut out the bacon with my biscuits & gravy each morning at Carl’s Jr. And I don’t order fries anymore with my McDonald’s hamburger at lunch. And at least once a week the wife makes me eat a salad, usually at Applebee’s where we eat dinner every night.”

Ridiculous, I thought.

It would have been easier to ignore him…the excess he had. The thousands of extra calories he was consuming each day, the money he’d spent on having his meals prepared, served, & cleaned up for him.

‘Talking about it’ felt like a waste of breath.

******

To satisfy the world's sanitation and food requirements would cost only US$13 billion- what the people of the United States and the European Union spend on perfume each year.

--Thinkquest.org

******

I could picture them, boney limbs & burgeoning bellies filled with parasites. Forever etched in my mind were their eyes, their dirty faces, their fallen homes. The empty bowls. The matchstick arms.

Ridiculous, I thought.

It would have been easier to ignore them…the poverty they lived in, the dirty & smelly & lonely they felt. The deficit of calories that caused autodestruction of their internal organs. The dried-up wells & trips to the contaminated river each day for water. The hopelessness & lack of opportunity that promised the same life to their great-grandchildren.

******

“One out of four children in developing countries is underweight, & some 350 to 400 million children are hungry. Worse, it is estimated that a child dies every five seconds from hunger-related causes.” –Richard Stearns, The Hole in Our Gospel

******

I stepped out of the shower & brushed the steam from my face. It was just what I wanted after a long day on my feet. I’d stepped into the steamy stream of water…& emerged 15 minutes later, the days stressors washed down the drain.

******

“As many as five million people die every year of water-related illness. This creates a no-win situation for millions of parents in our world today—they can watch helplessly as their children die for lack of water, or they can watch them die from diarrhea, because the only water they have is tainted.” –Richard Stearns, The Hole in Our Gospel

******

It would have been easier to ignore that I’d just wasted 21 gallons of water—more than twice the number a person in Africa uses per day. It would have been easier to brush off the contaminants like I’d brushed off the steam. I wanted my steamy solitude.

I can ignore him.

I can ignore them.

But I can’t ignore myself.

When I wiped a small circle from the mirror, I saw her.
I saw him.
I saw them.

I saw the wastefulness.
I saw the excess.
I saw the need.

And I was faced with a decision.



****Change starts in the mirror.****

******

Defend the cause of the weak & fatherless;
Maintain the rights of the poor & oppressed.
Rescue the weak & needy;
Deliver them from the hand of the wicked.
-Psalm 82:3-4

******

“We can be a generation that no longer accepts that an accident of latitude determines whether a child lives or dies—but will we be that generation? Will we in the West realize our potential or will we sleep in the comfort of our affluence with apathy & indifference murmuring softly in our ears? Fifteen thousand people dying needlessly every day from AIDS, TB, & malaria. Mothers, fathers, teachers, farmers, nurses, mechanics, children. This is Africa’s criss. That it’s not on the night news, that we do not treat this as an emergency—that’s our crisis.
Future generations flipping through these pages will know whether we answered the key question. The evidence will be the world around them. History will be our judge, but what’s written is up to us. We can’t say our generation didn’t know how to do it. We can’t say our generation couldn’t afford it. And we can’t say our generation didn’t have reason to do it. It’s up to us.” --Bono

convenient.

I thought of her again today. It’s been 10 months, three seasons, lots of life changes since I saw her. But… I thought of her again today.

Her mom brought her into the Emergency Room. They’d driven for 45 minutes, braving the snow, the icy roads, the darkening sky. And it was “rush hour” when they arrived—the waiting room crammed, beds full, almost shift change.

They waited over an hour in the waiting room. And then another 20 minutes in Room #9.

The nurse told me they were ready. And so, in usual routine, I grabbed the chart & headed toward the hanging curtain covering the mystery inside Room #9.

I prepped myself for the worst, as I always do in the ER. A bloody laceration? Motor Vehicle Accident? Head contusion? Compound fracture? Drug intoxication? Anaphylaxis?

With a pitter in my heart & a patter to my step, I walked toward the curtain. Anxious at what awesome medical mystery might behold m e…

And then I heard it.

Just three steps shy of the hanging divider, my hopes of awesomeness fell & shattered on the tile floor.

The squeal was unmistakable: a giggly child.

I pulled back the curtain, let out a silent, “hurumph!!” of exasperation & started my exam.

Temperature 99.1
Lungs clear. No cough.
Neuro exam normal.
Bowel sounds present.
Nontender abdomen.
Patent eardrums.

Reddened throat.

As so I told them something I probably shouldn’t have. Which is really why I thought of them today as I walked past the full waiting room outside the ER. The waiting room filled with a echoes of coughs, a handful of grunts, faces covered in masks, and one smiling woman with, you guessed it: a giggling little girl.

The words just came. Uncontrollably, almost.

And 10 months ago on a snowy December night in the ER, I told her to please not come back. To not come back, especially with her little girl; her barely sick, still eating, sleeping, & giggling little girl. I told her about the man around the corner with pneumonia, about the woman with the five MRSA abscesses we’d just drained in the room next door. I told her about the dying woman who couldn’t breathe, & the coughing man with end-stage emphysema.

And I told her this was an EMERGENCY ROOM. An ER where people died, where we saw blood & stool & vomit on a daily basis. An ER where we sewed fingers back on, where we sent 360 Joules of electricity through people’s bodies to bring their hearts back to life, where we dealt with trauma & tragedy.

An ER where she didn’t need to be.

She tried to smile.
I tried to smile back.

And then I walked out. A code blue was coming via ambulance and I wanted to see some real medicine, medicine that actually belonged in the ER.

That squealing little girl and her waiting Mommy visited the ER 10 months ago. They were getting ready to visit again today. And that same little girl & her Mommy will show their faces, voice their concerns, & expect to be cared for at every ER across the country later tonight, tomorrow morning, next week, three months from now…

Along with the H1N1’s, the cardiac arrests, broken bones, respiratory failures, lacerations, the giggly red throat will join the herd & trudge to the ER for medical care.

I’ve heard other stories, too. Stories of brand new parents calling the ambulance in eight inches of new-fallen snow from a far-away location because their two-week-old baby had a runny nose. Stories of elderly women wearing nightgowns & curlers visiting in the early morning for a toenail trim. And even stories of farmers with belly aches because of the salsa they had for dinner.

We are blessed here in America. Blessed to have vaccinations, clean water, sterile needles, & ambulances available when we need them. We’re lucky to have hospitals, contact precautions, & operating rooms stocked with modern technology & highly trained physicians. And most of us are fortunate enough to have a slew of specialists at our fingertips: cardiologists, radiologists, gynecologists, gastroenterologists, urologists, neurologists…the list goes on.

In all our great fortune, our luck, our blessedness; in the midst of those shiny surgical instruments & new hospital blueprints, I want to believe that we’ve lost something.

Our perspective, perhaps?
Our gratitude, maybe?
Even our selflessness.

The night that red-throat giggly came in we had TWO code blue’s. BOTH patients died. The rooms were packed with people needing real medical attention—and needing it FAST. Emergencies truly did walk through the door that night…as they do every night.

But that red throat didn’t need 360 Joules of electricity sent through her body. She didn’t need a shot of epinephrine to open a closing airway or a set of sutures to stitch an open wound. Her visit didn’t require antibiotics or imaging, not even overnight hospital observation.

And truly, red-throat could have waited another 10 hours for the clinician’s office to open. She probably could have waited another 48 hours, 5 days, 2 weeks to see if the redness went away on its own.

But red-throat visited that night.
And she visited today, too.
And she’ll probably visit again tomorrow.

Not because Mommy was overly concerned. Not because she realized the gravity of bringing her eating, sleeping, giggling child into the petre dish of germs that floated in the air of the hospital halls. Not because it was anything but a routine virus that affects almost every child during every winter season.

But because it was convenient.

So I ask YOU: what have you lost in the battle of the newest, shiniest, most specialized treatment available? Perspective? Selflessness? Patience? Reassurance that your body can largely heal itself?

**This is NOT written as medical advice. Personal discretion should be used in individual situations where a visit to your Physician or local Emergency Room may be necessary. The author is not responsible for any consequences that may occur as a result of not visiting the ER.

from the depths.

It is humid as he tip-toes out of bed on the third story of his farmhouse. Harvest moonlight casts shadows on the wall. Floor creaks as his bare feet walk across the wooden beams.

He kisses his wife & puts the envelope on his pillow—still warm from where his head lay, sleepless. Bare feet tip-toe out the bedroom door, away from the bed where they laid side-by-side for over thirty years. Bare feet scuttle down the hallway, past the smiling children in faded photographs. They creak down the stairways, past the Thanksgiving table & the Christmas Tree corner; feet pause, lungs breathe it in.

Pain catches his breath, head in hands for a brief rest.

He hasn’t been the same since the accident. The pain has taken over. And now he’s made his choice.

Cold, hard metal meets his hand. And bare feet carry him across the dirt to the bed of his rusty old 1967 Ford.

Harvest moon & expanse of stars light the country night sky. Crickets chirp & blades of grass sway with the gentle breeze.

Breath.

Small metal vessels loaded. Trigger cocked. Barrel to temple. Bare feet relaxed, pain free for the first time in months.

He closes his eyes, breathing in the last bit of late-summer refreshment.

INTERVENTION.

The bare feet, naked body in the familiar bed of 1967 decides that life is greater than pain. That love wins to selfishness, commitment to contentment.

Cold metal is left with rust. And bare feet carry him across the dirt again, inside the screened porch, passing Christmas Tree corner & Thanksgiving table on the way to the creaking stairway. Bare feet carry him through the hallway of smiling children in faded photographs & toward the bed where his wife slept soundly, harvest moonlight casting shadows on the wall.

He kisses his wife & feels her warmth, “I love you”.

And five months later I hear his story between tears & sobs & unadulterated gratitude. Old 1967 still sits in the dirt, a cold reminder of the life of pain that once consumed him.

“I have a golf game to get to,” he says with a smile, “I’m playing my best par in years.”

I nod & wish him luck, careful to notice the limp that follows him out the door.

Sometimes life gives us second chances. And because of the bigger choices, the harder road, the more difficult recovery, we often fail to take them. But some of us do take those second chances…& thrive in the alternative route God navigates for our lives.

Some of us are scarred.
Most of us are scared.
Several make full recoveries; others none at all.
A number of us choose to rise above from the beginning.
A few learn to fly after we fall.

Still others walk with a limp.

The point, though, isn’t how we recover…it’s that we are walking at all.

still smiling.

She smiled. And told me her back hurt.

When I asked about her medical history, salty tears dropped.

I was feeling particularly sorry for myself that day…Jon halfway across the world, the stress of boards hanging over my head, residency applications, worries about the future, time management, emails to send, phone calls to make…away from the comfort of my “own space”.

I sighed & tried to show compassion—failing miserably in the process.

Those tears dropped. Tissues soaked. And again, she smiled.

1995: her soul mate died unexpectedly.
1996: her oldest daughter was brutally raped.
1997: her home was robbed, everything of value stolen.
2002: her oldest brother died of brain cancer.
2005: her younger brother died of colon cancer.
2007: her first grandchild came into the world…& left too quickly.
2008: her younger daughter was diagnosed with an aggressive form of thyroid cancer at age 28.

And now, 2009. She is here…talking to me…telling me about the "no big deal" pain in her back. STILL SMILING.

God showed me compassion…and softened my hardened heart with grace.

Because the old adage is true: someone ALWAYS has it worse off than you.

One Pound.

One pound, fourteen ounces.

The weight of the jumbo can of pumpkin I used last night to make muffins. The weight of my cosmetic bag. The weight of my running shoes, my coin purse, my water bottle.

The weight of baby Ella at 26 weeks young.

I donned a mask, grabbing the blue face shield before I walked through the locked door of the NICU. The neonatologist stood watch, clipboard in hand, next to a small plastic incubator. The incubator with tubes & tape & cotton & wires keeping this young, fragile life alive.

Her raw skin peeled already—just four hours after birth. Her chest rose & fell in sync with the sound of “whooshing” air, gentle positive pressure airways held her trachea open to allow adequate oxygen exchange. Like a covered birdcage, the yellow elephant blanket draped over the top of the incubator darkened the fluorescent lights above.

And we joined the watch.

“She is doing well,” the neonatologist told us, “But the next 24 hours will determine everything.”

And “everything” wasn’t an exaggeration. Vitals scribbled on the clipboard, the plan of care carefully dictated.

Just two hours earlier, we’d make rounds with a perinatologist—a specialized Obstetrician whose training in advanced fetal care gave him knowledge to recognize, diagnose, & potentially treat fetal diseases. With years of specialized training & over 30 years of practice in high-risk obstetrics under his belt, he knew. He knew that babies born at less than 27 weeks have a significantly decreased IQ. He knew that babies born at less than 27 weeks have increased risk of chronic disease, increased chance of incompetent bowel, and decreased neuronal connections in the brain. He knew that babies this premature, this underdeveloped showed smoother brains & severe neurological deficits. That these babies had a risk seven times greater than a full-term infants for Cerebral Palsy & that their chance of social competence & marriage was less than 25%.

And he knew that he had to tell the parents.

So while we stood watch over this one pound baby now growing & developing outside the womb, this one pound baby with red peeling skin in a bed of cotton & tubes, he made his way to the ICU…the ICU where Mama lay in a medically-induced coma.

Young & vivacious, mom’s body was suddenly a mirror of little One Pound—limp & red in a bed of cotton, tubes, & wires.

“She lost so much blood,” he said, “and the next 24 hours will determine everything.”

And “everything” wasn’t an exaggeration. Orders written for more platelets, more medication, more bed rest.

Her six year old waited outside, hand firmly in the grasp of wet-eyed husband. Her two-month hospital stay with complete bed rest for placenta percreta had come to an end—the end everyone whispered about & no one hoped for.

The surgery was emergent. Four specialists waited on the sidelines of the main O.R. Blood bank was on alert. The NICU was ready. LifeFlight was warned. And we lingered by the phones for the updates.

And so on this day, we wait. We ALL wait.

We wait for little One Pound to grow. To develop. To breathe on her own.

We wait for Mom to recover. To heal. To grasp the news of that this was her last baby because her uterus had to be removed to save her life.

We wait for the tubes, the wires, the cotton; we wait for the compassionate nurses, the wise physicians.

We wait for the grim news. We wait for the miracle.

Sometimes I think we wait too much—for life, for death, for lab results, for transport. We wait for the bad news…& sometimes the good. We wait for the right time to deliver the diagnosis, to counsel the patient, to give the medication. And in the midst of that waiting, I too often forget to recognize the sensational people I’m surrounded by: Little One Pound. Brave Mama. Skilled physician. Well-versed nurse. I too often forget to notice the miracle of the present moment: A 26-week-fetus—ALIVE. A severely compromised Mama—SAVED. An incredibly skilled physician—MY TEACHER. Those amazing compassionate nurses—MY MENTORS.

The First & Final Physician—MY SAVIOR.

“I think they look good,” I say, “and the next 24 hours will determine everything.”

And “everything” isn’t an exaggeration. A whispered prayer makes its way heavenward & The Physician whiddles the "everything" into a miracle.

fringes of hope.

She told me she felt fine. “Just tired,” she said.

So we transfused blood to bring her dangerously low hemoglobin up. Hoping that the fatigue would subside.

She told me she felt better. “Still tired,” she said.

So we stole a vial of the blood we’d given her & ordered more lab tests. Hoping that we could find some answers.

She told me she felt hungry. “Just no appetite,” she said.

And so we took a picture of her belly. Hoping that the “tired” & the “hungry” would all make sense.

She told me she felt anxious. “I’m just not feeling well,” she said.

******

I looked over those lab results. And so did the residents. And so did the attendings.

And we made the appropriate phone calls.

Oncologist.

Hematologist.

Endocrinologist.

Gastroenterologist.

And we told her that she had cancer. “Everywhere,” we said.

So she started crying, because she’d ignored her body. She’d lied about her vaginal bleeding. She’d forgotten to tell us about her anemia over the last 4 years. She’d skipped her doctors appointments & forgone annual check-ups. She’d deceived herself into thinking that she was fine. When she knew better. She said she knew better!

And we smiled. And tried to console her. And tried to pass along hope on the fringes of anger & resentment & acceptance.

She wiped her tears. And asked if she could “Please go home.”

So we signed her discharge orders. And there was nothing left to say.