The Aftermath: Searching for Swords

A few years ago I was working with Outward Bound in Marble, Colorado. Outward Bound (OB) is a nationally recognized outdoor leadership school, we take kids and adults rock climbing, hiking, backpacking and the organization is staffed with wilderness therapists. During a 10-day trip where I was tagging along as a photographer, a bunch of us in my 12-woman group decided at the last minute to scale a 13,000 foot peak. For the fittest among us this wasn't going to be a problem. No, the problem began when a few of the less fit ladies wanted to also climb the peak. Now it wasn't an early morning stealth mission but a potentially half day if not all day event. The main instructors formed us into a group and we talked about it, the pros and cons, and it was quickly and unanimously decided that we would all go. After all, each of us was there to be challenged.

Curtis Glacier, North Cascades, Washington 

On the way up the mountain one of the OB instructors told me about the "dragons, the dreams, and the swords". For anyone who has gone on an OB excursion the leaders are full and rife with metaphor, with lessons to be found in nature, and with ways to take personal obstacles and turn them into something reflective. I listened to the dragons/dreams/swords with a thoughtful smirk on my face. The dream was the thing you wanted. To put it metaphorically, climbing that mountain could have been a dream that day for several of us. On a larger scale, the dream is anything you dare to dream and aspire to attain. The dragon, or dragonS, is whatever is keeping you from attaining the dream. And, finally, the sword is what you use to kill, maim, destroy the dragon, so that you can have your dream! All a bit cheesy, but I put my legs and lungs into overdrive and didn't think much about this again. 

After a solid 4 hour uphill battle we were within about a mile of the summit. During this time I dropped back a bit to hang with one of the slower ladies and also the one woman I hadn't really gotten to know very well during the previous 9 days. Lou was quiet and seemingly withdrawn. A few times, during some of our greatest physical challenges, she would break down, cry and leave the group. But that is what OB does - it finds our weaknesses, and breaks us down. Being extremely comfortable in the outdoors I found myself often volunteering to go first: rappelling down cliffs, swinging across a river on a rope, doing anything physically stimulating. By recognizing my own comfort, I aimed to find discomfort. For me, I found if I went last, and waited and encouraged everyone before me I could work on something I direly needed to, patience. For others, being out in the woods so exclusively was so terrorizing that just crossing a river was a success. Their challenge was different than mine, but these were our challenges nonetheless. 

Lou began to tell me why she was on the trip in the first place and climbing up that mountain. She had just moved to Colorado from a Midwestern state. It was a hard move, she told me, after a nasty divorce. The divorce turned her kids against her and many in the town where she was living. Her husband had a way of bending the truth and so told lie after lie until her children, both in their late teens, wanted nothing to do with her. The pain was so great, she moved to Colorado, where she had extended family. She hadn't seen or talked to her two kids in a year. This, she said, was breaking her heart. 

As we approached the summit several of us realized we wanted Lou to be the first to summit. So we slowed down, encouraged one another, and cheered when she stood up on the peak. At 13,000 feet in the Colorado Rockies we were still dwarfed by several nearby 14,000 foot mountains, but we still had an eyeful. One of the OB instructors told us to fan out, find a space of our own on the massive summit and reflect on the days prior and on that moment. She told us to pick up a rock that maybe symbolized our own journey and, when we were ready, toss it out into the great abyss of the Maroon Bells Wilderness. 

I chuckled a bit. There they go again, I thought, giving us some metaphorical reflective moment to embrace. I began awkwardly picking through stones at my feet, the nearest ladies a good 15 feet away on either side of me, when I heard a high-pitched scream. A scream I have never heard in the mountains, or perhaps anywhere else. A scream that carried and ricocheted off the granite peaks. The scream was followed by belly laden sobs. We all stood up and looked. The hair on the back of my neck was at attention, because I knew. It was Lou. 

"I love you Ben!" She yelled, through muffled tears. "I love you Jenny! I will never forget you!" With that she threw two stones into the abyss. She threw them so hard, she spun around, hunched over at the waist and collapsed in a series of cries and wails. Ben and Jenny must be her children, I thought. 

My heart raced. I suddenly remembered the dragons, the dreams and the swords. I realized then that I had been thinking of something in particular as I made the climb that day. Just out of a recent long term relationship, I was having a hard time feeling lovable, feeling loving. My dream, I suddenly realized, was to be in love again. The good kind of love. The kind we all deserve. The dragon was none other than me. I was the only one who could prevent that from happening. And lastly, the sword in it all--that made me realize this, that opened up this unique door and even allowed me to see this conundrum--was Lou. Lou was my sword. 

With that I launched to the ground and picked up a rock that had lichen across its back. This rock represented both life (lichen) and death (stone), I thought. I held this stone to my chest and willed every crappy unloving thought and hard memory I was carrying from that recent relationship into it. When I felt that I had purged myself of at least some negativity, I threw the small stone as far as I could into the crisp blue sky. Only after I threw my stone, and saw the other woman around me one by one throw theirs, did I realize that I, too, was crying. 

**

Becoming a physician assistant was a new dream, only a few years old, but soon after starting my program at the University of Washington I realized how many dragons I would have to slay in order to succeed. I had dragons of self doubt, finances, time constraints of school, moving to a whole new state, loneliness, the discipline of exam after exam. My sword? Well, there were many. In hindsight, I realize they were mostly patients. And, there was still Lou. Now, I am no longer a student. Now I'm negotiating my way into full time studying for my board exam at the end of September. I'm navigating the best first job, wanting to sincerely serve those populations I deem in most need of medical care and kindness and also seek out an organization that will encourage and accept my creative nature and compassionate style. 

And I think about Lou all the time. What her pain and suffering did for me. How her act of letting go was one of the best lessons I could have learned thus far. 

I look forward to sharing this story, or a shortened version of it, with patients and colleagues in the years to come. Never have I felt so excited, thrilled, terrified, and confident that when I throw this weighted stone of studying, self doubt and student-dom from my chest, the past will fall in place behind me and there will be nothing but far exceeding blue sky, brilliant compadres all around, and one hell of a view. 

The Chase

It's been awhile. I've taken some time off the merry go round of my mind and settled on the one thing I probably should be doing: studying. Now that my clinical year is behind me - yes, behind  me! as in the rearview! - I have just a few lingering details to put on the plate, ponder, and eventually devour. Job prospects are materializing, the date of my board exam is set, a few members of my family are heading out this way for their first ever visit to the Pacific Ocean in a few weeks for my graduation, and I am honored and horrified and humbled and giddy at the prospects and possibilities of what the future holds. 

A good crew: The ladies in my class during "Movember" 2011

I've also taken a break from writing because I've been collecting stories and looking for places to put them, as in publish. At the same time, I've been getting up into these glorious Cascades and I've been chasing storms. Maybe I've been chasing stories about people like I seek out a good storm, or vice versa. As a writer, one always begs a bit subconsciously for "unfortunate" events--a storm, a shady interaction, an interesting character--because that is where we get the fuel for our trade. The tinder for the flames that keep us warm through the night. That "night" meaning our entire life. 

Now that I am literally on the tail end of my training as a physician assistant I am left with a handful, heck, a treasure full, of stories. I didn't even have to go very far to find many of them. Some of the most heartfelt ones arrived on my clinic doorstep, precisely on time, on a sunny Tuesday afternoon or in a spitting downpour. I have met middle aged men at the end of their rope, who have never told a single soul anything about how they "feel" or have felt or have struggled or maybe even how scared they maybe have been at some point in their life. Society tells them that, from a young age. The same way it tells my father and brothers: Buck up, be strong, don't show emotion. Well, I see the ramifications of that not so sage advice on a daily basis, on the tear stained cheeks of homeless men who have waited a lifetime to dispense the flood of emotion. 

I've allowed myself to become insufferably close to patients rather quickly, sometimes too quickly, having to hold back a hug because providers need to set boundaries with patients and so many patients do not have good boundaries. You would never think that a hug could hurt, but they can, sometimes even physically. I've wanted to hold the gnarled and wrinkled hands of another human confessing great and personal things to me but then wondered if that gesture was for me or for the patient? I've met women generations older than me. One 90 years old, riding the city bus around like a teenager, coming in to see me because she is only able to walk 8 blocks now instead of 10 before she gets winded. She is going out of the country next month. I don't worry about her one bit. 

I do worry about some of the younger patients. The teenage girls who see on TV that the skinny/waifish nearly starving look is "in" (is it?) -- who decide that looking strung out is sexy, like the lead character in "Breaking Bad"-- who then confess to going on craigslist and looking for a "heroin boyfriend". Who then end up sitting across from me, gaunt, disheveled, with track marks riddling her forearms and several abscesses the size of gulf balls from "muscling" the drug into her body by needle. I have empathy for her, and she is more than one. I ask her, "Do you still think being an addict is sexy?" It is rhetoric. None of it is sexy. 

Now that I have a moment to stop and spin on my own, the stories keep coming. The ones I've already shared and also the ones that have built up, also the ones to come. People are amazing, amazing creatures. So intricate, beautiful. So pained and suffering. So full of hope. 

Watchful. Waiting. The world and I. 

And so I catch their stories, I save them. I cherish them, the same way I cherish a good summer storm.  Because both can change a perspective, can level a moment, can change the energy of the air we breathe. Growing up in the midwest, we experienced the epic, green-hued, sky-twirling, riveting cloud storms. The tornado warnings. The sundry dark wind settling over the rural fields at 2pm. The excitement that things just might fall apart. Of course I was much younger then, I knew there would be people to pick up the pieces--those same people if I ever needed them--my folks. 

I think most of us batten down the hatches in the rain. In the hint of wind through the window. It is one thing I have come to love about Seattle. People live in the rain. They walk with briefcases and business suits. They don't have umbrellas. It's just water and as my dad always told me, "Your skin is waterproof". But we don't get those epic thunderstorms out here. When there is thunder its somewhat entertaining to watch my Seattlelite friend's flurry of posts on Facebook declaring "Thunder, yes!" and "Thunder in Seattle!!" 

We are giddy. We are ridiculous. We are sublime. We are each our own individual storm.

I'll keep collecting stories if you tell me where the big storms are. If you post there is thunder I swear I'll feel it too. I think we will probably both be excited in the same way. And either way, there is so much work to do. So many stories to be told. So many stories, to live.

The Worried Well vs. A Train Wreck

Recently, I commented to another provider at the underserved clinic I'm in, on how much I enjoy the diversity of the patients, the teamwork of social workers and diabetic educators, the creativity needed for low income patients and new immigrants to our country. I've often stated that I wouldn't be as satisfied in a middle to upper class clinic with mostly insured patients with minor ailments. The doctor chuckled and said, "That's true. The worried well are not as interesting as a train wreck." 

I have seen train wrecks. Heck, I've even been one at times. But one of the main differences I see while working with underserved patients is the lack of adequate health literacy, and social or emotional support. After all, in some cultures the word "depression" does not exist. In Romania, for example, depression or mood lability is termed a "neuroendocrine disorder". 

Lack of medical literacy in some underserved populations is fine, except that I've spent most of the last 27 months of my life honing ridiculous algorithms of care into my mind, learning the critical stages and cell receptors and medication classes of Type II diabetes mellitus, for example. The interesting, and rather fun part of medicine in my clinic is that all that savvy medical speak goes out the window. Far far out the window. It has been suggested that teaching medicine, and educating others about their own co-morbid conditions, should be conducted at the 6th grade level, no matter who the patient is. Of course, if the patient is younger than 6th grade, you would adjust accordingly. When working with interpreters and patients with limited English, the grade level also drops a bit because you want to make sure they understand every word. Yesterday, I found myself tapping into my art and illustration background by drawing pictures for several patients, about GERD (gastroesophageal reflux disease), an anterior talofibular ligament sprain (ankle sprain), and constipation! I also found myself acting out charades for several patients, out of my chair, enthusiastically gesturing and grinning--much to their entertainment (or dismay? They were smiling..:-)

And I make lists. I make a small list for every patient. A personal one of all the things we have discussed. I find that, for some patients, this adds another element of genuine patient care. Aside from the drawings, the charades, the personal lists, I have about 10 minutes left to really nail a physical exam and come up with a treatment plan. But I am slowly finding that patients seem more motivated, more adherent to recommendations, more compliant with meds, more trusting, if they feel that the provider is also genuinely interested in them. Overall, I think this extra attention not only saves the health care system loads of money, but also saves the providers and the patients time as hopefully that patient won't have to return to clinic as often. Just yesterday, I spent 1.5 hours on diabetic education with a patient with severe diabetes who arrived gung ho and motivated to change his lifestyle. This was a serious commitment on his part and 20 minutes would've barely afforded him the opportunity to share his expectations and plans, not to mention give us enough time to conduct some necessary teaching points, and also do everything we could to ensure he will succeed. His visit was 1.5 hours. 1. 5 hours = 90 minutes. Assuming he comes in every 3 months to have his hemoglobin A1c checked--at 20 minutes a visit--that 1.5 hour equated to 4.5 visits. That means it may very well have taken him over a year to receive the same information we were able to deliver in that one visit yesterday.  

Structured Support. L. Katers 

For as many reasons as I love the community clinic setting, it is also extremely frustrating to work in a community or under served clinic. Many of the things you want to do for the patients, you can't because you yourself don't have the resources, or the patient does not have the money. You learn to Macgyver many things, and think outside the box, and collaborate with all the other providers on unique treatments or protocols that have been tried and worked for other patients.

The lists I help patients make consist of small, attainable things in order to give them something to accomplish. This goes right along with Albert Bandura from Standford and the idea of self-efficacy. Self-efficacy is essentially building up someone's--child or adult--confidence by giving them first one small task to accomplish and succeed at. The idea is that the more small tasks are accomplished, the person begins developing an inherent confidence and belief that they will, in fact, succeed! The more we accomplish as individuals, the move confidence we acquire that we might be able to accomplish more. For someone with health problems and who is already overwhelmed, these lists can be surprisingly simple: Go to grocery store, make med, apply for one job a week. I have seen the power of of a list for some patients; sometimes they arrive back at the clinic clutching only the list. 

I made my own list today while sitting with a patient who was suffering through a difficult divorce and was struggling with forgiveness, of herself and husband. The list we came up with together, which is also my list today, is positive and present:

- I am present 

- I am beautiful

- I have an open, forgiving heart

- I have the discipline to focus on (work, school, etc)

- I create opportunities to share my gifts every day

What does your list look like, friend?

P.S> Next blog...ECT - electroconvulsive shock therapy, also known as :The Controlled Seizure".

Unbinding Grace

Dear friends, humor me?

First, read these few sentences through. Seek out the quietest place in your house. If it's possible to find absolute silence, go there. Now, sit on the floor, with nothing comfortable underneath you. Lay down if you want. The darker the space the better. It is more accurate, actually, for this exercise, if the room is pitch black. Now, close your eyes. Stay there for a minute?

** 

Now, I want to tell you about Roberta. Roberta is 27 years old and is incarcerated in a correctional facility in Colorado. She is an IV drug user. An addict. She has stolen from friends. She has abused her children. She lies to anyone who gets too near. She has exhausted every social worker within range and refuses to get help or change her ways. She talks loudly and doesn't listen. She will spit on you. She will cuss you out to your face and have no regrets about it. Roberta is a tough, horrible, anxious, and cruel woman. 

But, there is something else I know about Roberta. Her kids, 3 and 7, have been taken away by the courts. They were all she had and now she says she has nothing to live for. But, there is more. Her mother died giving birth to her. From as far back as she can remember, she can't recall one single person saying "I love you". No one ever told her she was good, or beautiful or smart or loved. Instead, Roberta went through her childhood meeting fists with her face, being raped by her father and uncle until the age of 15, when she finally ran away. She was abused to such a degree that she had 3 abortions by the time she was 17, dropped out of high school, and took up with a boyfriend, 20 years her senior, who also humiliated, abused and assaulted both her and her children. She had no job, no credentials, few skills and absolutely no hope or faith for herself or her children to live in this world. 

**

Now, I want to meet you back in that dark room. Perhaps you've been there 5 minutes or so. Uncomfortable, restless, waiting to get back to your life, your good life. There is a restless wind coming in through the screens. Perhaps a dog is yapping out in the neighborhood, the leaves are rustling in the trees. Block that out. Just for a few more minutes. Close your eyes, feel the weight of all of that darkness. 

**

Roberta continued the chain of abuse she experienced as a child. Her children were subsequently   abused. By her, her family, her boyfriend, and the system. Those children were now in their own dark room. With no way out. Perhaps they would end up incarcerated as well. The cycle to continue. Roberta had no way of stopping something that began for her 27 years ago. 

There is an organization I worked with years ago that focused on helping women just like Roberta. Kerry Kurt is the founder and executive director for Unbound Grace, a non-profit organization established by Kurt to facilitate healing and transformation from wounds left by childhood neglect, domestic abuse and trauma through the use of personalized programs involving the arts, the natural environment, physical challenge and the workplace. Unbound Grace uses a three phase program to help motivated women in Denver Women’s Prison gain the skills necessary to obtain and maintain employment that will pay a living wage and support a healthy lifestyle after their release.

Unbound Grace carried out the last of these three phases by partnering with Outward Bound, an  outdoor leadership and wilderness program. Outward Bound (OB) is a phenomenal organization and at the epitomy of "wilderness therapy". If a participant arrives at OB and feels confident and excited about their life, then the OB instructors make sure to "shake up" that person's life a bit, maybe put them in a few uncomfortable positions. The goal would be to quite literally throw them completely out of their comfort zone. But if a participant already has a shaky life, someone like Roberta, and is living not in their comfort zone but instead in their panic zone, then the goal of OB is to give that person a safe place to be. The goal is to offer the wilderness and all of her charms as a safe haven. And also to utilize self-efficacy and give that participant small tasks that he or she can accomplish to begin gaining self esteem and confidence. Roberta was a perfect candidate to experience the power of wilderness therapy. 

**

Are you still with me? Are you still in that dark room? Are you still wondering when or if I will free you and you can get up and go back to your life? Well, one of the main discussions that comes up often for me in the line of work I'm interested in is: WHY help someone like Roberta? She is a felon. She has broken the law. She has hurt and victimized people, including her own children. Why not forget about Roberta and instead put that time and energy into helping her victims? 

The reason we help someone like Roberta is this: She has also been in a dark room, as I have put you in now. But unlike each of us, she has been there her entire life. She was born into that room with no comforts, no love, no warm touch, no affection and no one to love her. Nothing. The room is so dark she has never been able to find a way out. No one, not ever, has attempted to crack a door in the room for her. By doing the kind of work that Unbound Grace does--thinking and participating in healing outside of the box--and that persistent social workers and health care providers can do, is open a door. Just a crack. 

A few things Roberta, and many of my patients I see in psychiatry with similar backgrounds, have taught me, are:  

- We all need the light turned on from time to time. And we all need to turn that light on for others. 

- Having time to sit with pain causes you far less suffering than if you repeatedly try to run from it. 

- The wilderness alone is therapy; if you take the time to look up, birds still fly overhead. They still fly overhead. But, you have to look up! 

- Through Outward Bound I've learned that challenging oneself with ones biggest fears causes you to become bigger, and less afraid of the smaller things. Also, the best way to make instant friends is by trusting them to hold you steady as you hang by a rope over a raging river. 

- Lastly, women are strong, we are nurturing by nature and caretakers, but if put under enough pressure, we all crack. And the underneath part of our hard shells is soft, and vulnerable and so exquisitely beautiful. 

**

I haven't seen Roberta in several years but I remember the spark in her eyes when the door was finally opened for her, just a crack. When she began to have faith and courage in herself that she could live this life, not merely survive it. When she began to gain the skills necessary to overcome her abuse and also steer her children down a different road than she had walked. When she began to see options.  

Feel free to get up now, shake out your legs and arms, breathe in a sigh of gratitude for your own health and life, and venture out to enjoy this beautiful day. Both Roberta and I thank you for reading this. 

“Live frugally, unsurprised.” – Rebecca Carson – OB Instructor Extraordinaire

Precious Human Life

During my emergency room rotation a few weeks ago one of my supervisors in the emergency room commented: "As a PA-Student, you have to be either really smart, or really entertaining."

I waited.

"You," she said, "you, are entertaining."

We both laughed. I'm pretty sure I'm a bit of both but if I had to choose between being entertaining and being really smart, I'm not sure which I'd choose...

That was weeks ago. Since then I feel my world has spun, stopped, spun. Roughly two weeks ago I walked into the rotation that I craved since all of this PA school madness began. The rotation in the speciality that I felt I was bound to belong too, grow old in, become a master of. 

When I moved out here I heard stories of what it's like to work at the University of Washington's  Harborview Medical Center, or "HarborZOO". I have to say that most of what I've heard is probably true. Harborview Medical Center is a bit of a chaotic madhouse, which is also why it's such an iconic institution in the Pacific Northwest. And also such a fun and world-renowned place to work. The first Washington "county" hospital founded in 1877, it is also the only Level 1 trauma center in a several state region including Idaho, Montana, Wyoming, Alaska and Washington. Level 1 means the big stuff - what you see on TV. At first, I was surprised to find out that quite frequently patients are put on a med jet in Alaska and flown to Seattle if their injuries or the complexities of those injuries is critical or bad enough. From Alaska! 

Harborview Medical Center, on the shores of Puget Sound, Seattle. 

Right now, at Harborview, I'm in a dream state, working in a dream rotation, in my dream specialty: Inpatient psychiatry. There are a few immediate things I absolutely love about inpatient psychiatry. First, and foremost, are the patients. Many of the patients are, quite simply, astounding. With unique insight, sometimes with no insight, with extremely bizarre and curious delusions, with beliefs that, in moments, seem disarmingly believable. Some have extremely horrific stories of abuse. Some we can't quite figure out. For still others, it is hard to know what to believe.

The creative energy of some of my patients is equally curious. As witnessed last week when an impromptu poetry slam ensued after I happened to mention a quote by a favorite poet of mine, Mary Oliver. After the words uttered from my mouth..."tell me, what is it you plan to do with your one wild and precious life"....(from Oliver's, The Summer Day), I had three of the most diversely imaginable patients conglomerate around me in one of the patient's rooms wanting to recite poetry of their own! And hear some of mine! A complete hour passed--we took turns, we oohed and ahhed, encouraged one another. A gentleman patient I barely knew--whom I had never heard utter an intelligible thing--wandered by whispering words from Walt Whitman's "Leaves of Grass." Where am I, I thought for one brief moment. Who are these people? 

Second, I absolutely love the time. I am still reeling from my 20+ patients a day during some of my other rotations. Where I had ten minutes to sort out the most significant problem in a person who may have many problems. I have to choose what to treat, when I often want to treat everything. My ER rotation was excellent for many reasons, one of which was that it taught me I can't fix everything. Not in one visit. So I would patch someone up, give them a pat on the back and send them off into the world knowing that quite a few of them would be right back because the crux of their problem wasn't necessarily medical. For many, it was more emotional, and often when any of us are feeling emotional or off-kilter we seek out others, for listening, perhaps kindness, perhaps simply attention. A ten minute window in which to offer a struggling soul attention is almost never enough. 

In inpatient psychiatry, I have hours with patients if I want. Hours. Hours to accompany them outside for a 20 minute window of "fresh air", hours to get to know them, who they are, what they like, and what happened--what went wrong, how did they get here. Having that kind of time with patients is practically unheard of in medicine. But, similar to neurology (another favorite speciality), more than 90% of the diagnosis of mental illness comes from one source: a detailed history. And to get a good history, one needs to listen. 

Last Friday night--the summer solstice, on the cusp of 2013's super MOON--I had my first experience in Harborview's Emergency Room, a vast maze littered with medical personnel, patients and stretchers. I was working in the "PES", or psychiatric emergency service area of the ED that night. I could tell some of the psychiatric patients apart from the others being triaged and waiting for a bed. The  psychiatric patients often looked a bit more disheveled, some restrained to their stretchers. Several looked just like you or me, but something had gone wrong in their life, maybe just in their day, and whatever that something was they came to us because they didn't feel they had the emotional or psychological wherewithal to withstand the feeling alone. 

Oh, and that brings me to the last thing I absolutely love about inpatient psychiatry. After a few days, or weeks, or sometime even months of staying on the inpatient wards, a person begins to heal, and a new being emerges. Sometimes a drastically different being. Sometimes not. But I have seen the miraculous  emergence of a few "healed" patients in my short time thus far. They wake up one day, like lazy butterflies, shaking off the hard earned remnants of sleep, before bursting up into the light of a second chance at their own life. 

Here is to hoping that they keep gaining strength, find someone to listen--and believe--and never have to come back.

Need Freedom, Published in JAAPA July 2013

Hey all, the following is a short piece I published in the Journal of American Academy of Physician Assistants this month. The short essay encompasses a pivotal moment in my life. I hope you have a moment to stop by and read it!

Need Freedom

Laura

A True Hero: For Kathy

Exactly three months from today I hope to wake up a "free woman." PA school will be a thing of my past. The last 27 months of my life will be a warm, chaotic memory and one that I will rather gleefully move on from. But it's not an experience I'll soon forget and if anyone were to ask me, "Would you do it all again? Would you go back to school knowing what you know now and how tough it would be?" I would answer, without hesitation, "Absolutely."

Such was the response that encouraged me to go back to school in my early 30s. When I asked a PA I really respected what he thought of PA school he told me, "It was two of the hardest years of my life... and ones that I would gladly repeat."  

I am fortunate to have many influential people in my life and I want to take this space to thank one of them. 

Waking up Here. By Laura Robinson 

I was rather ill a few years ago. I was in the hospital with an immune system melt down, had lost a lot of weight rather quickly, and was sicker than I ever thought possible. Friends, family, and my partner were all very supportive. They were sweet and continued to tell me I "looked great"--even though I knew I was a frightening shadow of my former self. They told me things would "get better". At the same time that I was in the hospital, my grandfather was also dealing with a renewed bout of cancer. We had a very candid talk at the time about what it means to be sick, to not feel like yourself anymore, about wanting to give up. We talked about how exhausting it was to try and be strong for family, for those who continued to show up. It was during a particularly depressing night, after one of the most difficult days of my life, that a woman named Kathy arrived at my bedside. 

Kathy was a CNA (certified nursing assistant) and I'd never met her before. The other nurses caring for me were excellent. They were young and funny and my room became a happening social phenomenon where nurses would stop by and hang out after their shifts because I always had friends around who were equally young and funny. All of the attention was wonderful, but I was so tired and what I really wanted to talk about, with someone--anyone--was the one thing I was having the hardest time dealing with myself. 

I was afraid. At the time I was a freelance writer and photographer and didn't have health insurance. I was afraid I wouldn't get better, that things wouldn't be okay. Kathy had just gone through a difficult medical dilemma with a close family member who eventually ended up passing away. She'd heard about me and wanted to say hello because I was the youngest person on the floor. When you work in the hospital you usually work with older people so a patient in their 20s or 30s is unique. For someone that young to be in the hospital they are often very sick. Kathy arrived at 10pm, a whisper in the moonlight, and sat down beside me and asked me the question I was craving that someone would ask: "Are you scared?" My answer was a resounding "YES!" and Kathy stayed with me for several hours letting me vent out all of my fears and frustrations. She gave me the greatest gift she could have: her attention. 

I never saw Kathy again. I was never able to thank her. What I was able to do was make a decision to be someone like Kathy for someone else down the road. When I recovered, when things got better, and I was discharged, I vowed to go back to school someday for medicine or psychology, or both!

As I begin to wade through all of the ideas in my head about where I want to end up practicing medicine, which patient population and perhaps even what specialty, I came across a rather serendipitous opportunity. Last night I was invited to attend the spring fundraiser for Neighborcare--Seattle's largest provider of primary medical and dental care for low income and uninsured families and individuals. Neighborcare is a 40 year old organization with impressive roots in Washington. The event subsequently brought me back to my roots, reminded me of why I decided to pursue medicine in the first place, and reminded me that people like Kathy are the real reason that we heal. There are pills and prescriptions and appointments to keep, and then there is the greatest service we can provide our patients: our attention. 

Thank you, Kathy. You continue to be an inspiration for me as I move forward with these last few months of clinical rotations. I see nothing but opportunity every day to be of service in the same way you were for me years ago. I am proof of the ripples you created with your kindness. 

The B Sides

Wheeling a stretcher down a narrow hospital hallway at nearly full speed can be a harrowing, exciting, and somewhat terrifying experience.

Especially for the patient on the stretcher.

The OR (operating room) suites--all 20 of them--are eerily quiet on my last weekend in neurosurgery. Those of us on call cool our heels not hoping (hoping?) for an "emergency" surgery. These are the ones, as a student, you somewhat cut your teeth on. Because they can happen at anytime, at all hours of the night, and the learning opportunity is enormous. The last major surgery I took part in during my neurosurgery rotation happened to be an "emergency" surgery, and I was on call.

The only post-operative recovery room on a Saturday at one of Seattle's largest hospitals is the "B room", so we maneuver the large unwieldy stretcher to "The B Side," which is what I've come to call it. Like so many names in medicine it sounds like a band name, The B Sides.

For "brain surgery" it was, for all intents and purposes, an easy operation. A month prior, I would have thought that no brain surgery is "easy". The patient arrived in the emergency room on Friday night, I did her intake and exam myself. She was feeling fine other than a complaint of "the worst headache of my life." As students, these exact words cause our ears to prick up. Could it be, I wondered? Nah...

After a CT scan was done, my suspicions were correct. It was eerily obvious from the image we acquired of the patient's brain that a healthy amount of new and old blood was occupying nearly the entire left side of her head. The patient had fallen a few weeks before, hit her head, and suffered a subdural hematoma, a brain bleed. Blood was continuing to bleed into her skull and as this blood built up she finally began to have symptoms, like her horrible headache.

A subdural hematoma can be handled in a pretty straightforward procedure where the surgeon puts in a few "burr holes" (yup, just like a drill) that then allows the stagnant blood from the bleed to drain. It's, literally, a quick in an out procedure, and from the few I've helped with, the surgeon is all wrapped up in less than an hour.

Of course, not everything always goes as planned. A patient, for example, may have a difficult time waking up from anesthesia, he or she may have some brain lability as the tissues expands back into the space that was taken up by the blood. If the bleed happens on the left side of the noggin the left side of the brain then "bounces back" after the blood is removed and this person may wake up with "aphasia" or a problem finding words. If the bleed happens on the right, they may wake up with some motor or movement abnormalities. Much of this is to be expected. Much of this should go away. But, oh, the moments when the human body surprises me is precisely why I have come to adore and also bow down to the enigma of all that is flesh and bone.

Human bodies often do exactly as you would expect. People come out of anesthesia just fine. They get hurt and they heal. There are band aids for cuts, aspirin for fevers, and burr holes for brain bleeds. But sometime the body does exactly the opposite. And you are left with a mystery, a moment of uncertainty and concern, a test of everything you have ever learned, an opportunity to see how fast one can do extensive medical research online to find a next step, a solution, a new potion. There are the moments when the body does, quite literally, fail to follow through. And that is what happened with my patient that day.

~ 

Tonight I begin my 4 week rotation in the Emergency Department, or ER, of a large hospital in the PNW--in fact its the busiest ER in all of Washington State. I hear the place is as big as "a football field", has over 100 beds, and I am nervous. I have classically been the most vasovagal person I know--in other words, I'm a fainter. Years ago, the sight of blood would surely do it, but as recently as a year ago, simple stories of bleeding would quicken my heart rate, turn my hands sweaty and put that nauseous feeling in the back of my throat. Watching someone suture up a laceration put me in a tailspin where I had to sit down. In fact, even the thought of suturing! But, my surgery rotations changed all that, or did they? 

Surgery is elaborately deliberate. There is a system to surgery. A protocol. There is a sterile field and patient preparation and draping and deliberation before the inside of a human body is exposed. There is a chance to get to know a patient before they end up on the table. The privilege of knowing and appreciating a personality. In neurosurgery especially, this was often more critical than the operation itself. Does the patient have more motor deficit after surgery? Does their personality seem altered? Are they acting "funny" and do we need to be concerned? After all, its a brain we are talking about. For the patient mentioned above, the one with the subdural hematoma, knowing the patient's history and personality beforehand likely saved valuable time when it was noted that the patient was not recovering from the operation as expected. It was painfully obvious to anyone who had met this patient that they were not the same person when they came out of surgery, and wouldn't be for nearly a day. 

~

I've worked as a graveyard shift and swing shift supervisor in the largest non-profit detox and substance abuse center in Denver, CO. I've been in the middle of extreme chaos. I know I can handle many things going on at once. I know I can verbally de-escalate men much larger and much angrier than I'll ever see and women in the throes of hysterics (and large, angry women and men in the throes of hysterics!) I know exactly how much I can do before I know I can't do anymore. I know my limits. I know it's true: that full moons, Friday nights, and sometimes early Monday mornings (after a long weekend) are often the busiest in a crisis center like a detox, or an emergency department. And I've  had more than a handful of experiences already in several ER's during my rotations that I know I'm in for some fun, some fright, a few firsts, and perhaps, most importantly, some personal growth. I think my preceptor is going to be a big part of that. He already told me he won't allow me to work every day (something I've often tried to do) and that I'm only to work 4 days a week. His words: You will work hard and it will be challenging. But a big part of learning medicine is learning how to take care of your self and your loved ones. He'll probably never know how timely that advice could arrive.

Photograph courtesy of Stephen Hatch: http://www.StephenHatchPhotography.com

Will I be able to handle the surprises? Will I faint? Only time will tell...

Wishing a lovely Wednesday afternoon to you all. If you get injured, please come see me in the ER. I'll do my darnedest to help you and when I run out of ideas I'll go find someone else. Because of my experience working in detox, I now follow the moons. We are currently in the first quarter of a new moon cycle. Perfect for beginnings. Tonight the moon is waxing crescent heading towards a full moon on the 24th, which by the way, is a Friday. Full moon Friday?

Don't worry, I already asked to work it.

The Wind Riders

We are back on campus this week so the only crazy medical stories are the ones my other 45 or so classmates and I share with one another. But, I was inspired recently by the birth of spring around me. There is nowhere quite like the Pacific Northwest in springtime. It is a wild, and reckless springtime. I think us humans feel a bit wild and reckless ourselves as we bloom right along with the world around us. This one is for LJ. 

I notice them now
arriving, listless in the nights,
scattering in the mornings, bending
on the wind, getting caught up
in the window screens, their small
orange bodies a tangle
of movement,
there are hundreds.

Where is the mother of all of these children?
Awakening from her own winter? Where she
filled the cracks in the floorboards
with her own slender legs?

Her babies will grow, through the heat and rain of summer,
through to fall, where they will collapse
greedily, into our shared space.
They’ll appear in troves,
as big as coins, shocking in their glory,
so delicate and quick.

The dawn will bring a fortress weaved of the backyard,
between hydrangea and pine, between
an old wooden ladder and
a favorite chair. And I will stand still
and silent each day
navigating the best path.

This year, I decide to grow with them,
exsanguinate life from the night, elicit a lucid, quaking
calm from the day. Knowing each moment a marker
in a short span of time. After all,
we share a growth cycle,
the wind riders and I,
even as I watch them now,
bending, individual
glistening
whispering drops

of sunlight.

The Ten Thousandth Hour

A very good friend of mine once told me: “If you don’t know where to start, just start where you are.”

And so I’m going to start with my ride home from another day of practicing neurosurgery. Today was a 13-hour day, in a string of 10+ hour days, and the day’s end found me walking through downtown Seattle at 9pm with a grin. I gathered quite a few stares with my attire: cowboy(girl) boots, aqua scrubs, and an outdoor coat from REI. It was as if all of the fractured parts of a personality—my personality—were finally coming together. The animal lover, the outdoor adventurer, and the medical nerd.

I’ve spent time thinking about how someone gets good at something, like really good. I’ve heard that it takes upwards of 10,000 hours to sufficiently retain a unique and demanding skill and declare oneself somewhat of an “expert” at it. I’ve heard that a Buddhist monk will spend 10,000 hours in silent meditation before he or she feels they can adequately meditate. I’ve thought about that kind of discipline and whether or not I would find something I could–-or would want to—dedicate that much of my own precious life to. 

That was years ago. Now, I know I could spend years perfecting lightweight backpacking, long distance running, mountain viewing, meditating, writing, philosophizing. But…nothing has seemed to satisfy my interest, curiosity, and instill such a unique personal challenge quite like medicine.  

That same friend who told me to start where I am also told me to quit while I’m ahead. With another long day of surgery tomorrow and my last few days of this rotation drawing near, I’m going to heed that advice.

Only 9,999 hours to go...