Margaret

It’s odd when someone who has been a fixture in your life leaves. Although I had seen her only infrequently in the past few years, in my mind she was that stone figure, the thing that could never be moved. She will forever be in my head the person that told me “Santa accidentally left one of your presents here last night, but I figured that was ok because you were coming over for Christmas anyway.” The person who cooked wonderful pies, who put up with all of our arguing about whether pecan or pumpkin was better, and was always trying to find a compromise. In my memory, I saw her grow into a grandmother, and enjoy a more laid back role in retirement. She will always be that fierce Oklahoma fan, ready to throw down with anyone who thought otherwise.

I don’t want to remember her in her last days. Emaciated, barely able to move, uncomfortable in her own skin. For the first time, appearing frail to me. Emanating a sadness that sent out waves from her core – from the epicenter of her pain. If I had had xray vision, I could have seen inside her body; tumor littering and wasting her insides, strangling her organs and nerves, trying to squeeze out her life force.

And it did.

I don’t want to remember her remarking that the medical system was torturing her. I wanted her to stop fighting it, to think of herself and her own comfort. To acknowledge that this wasn’t going to get better. To think of her comfort and not keep trying to go for the cure.

I had a dream – the night I found out she died. She was alive again, sitting comfortably, knowing the end was coming, but embracing it. She had given up on the belly taps, the blood transfusions, the chemotherapy that gave her more side effects than relief. She was sitting in her chair, her Oklahoma blanket covering her skinny legs, serene and peaceful, satisfied with what life had brought her.

I guess my mind somehow had to work out how I needed to remember her. To need to know that her sadness had gone, that she could see the beauty in her death rather than just the bitterness and pain.

I know I need to now imagine her in a better place. Her body is free and weightless, all of her limbs work again, she is uninhibited. She can look down at her husband, her children and grandchildren, and smile because she now knows the secret. She can once again sit in her mother’s lap, a child again, receiving relief and comfort from what she had been through.

Those last words still echo in my head “Goodbye, I will love you always, see you soon.”

I grew up having what I believe to be a pretty realistic view of life and death. It is something my parents were very open and honest with us about. My mom was a hospice nurse, taking care of people in their last 6 months of life. My dad's mother, my grandmother (and my namesake), lived with us when her health started it's final decline. And I always remember (although I dont know that I could have put words to it at the time, although I sort of did with my poetry), that there was the sense that death was imminent, but that it was not something to be fought with.

That is an ethical issue I deal with a lot in work these days. While some of my patients are very realistic with the fact that death is a part of life, some want to fight it tooth and nail to the end...Even after they have done everything, fought with every weapon we have, and their cancer is still spreading, they want to be in the hospital, getting another surgery, or more radiation, or whatever...Fighting tooth and nail to the imminent conclusion. And sometimes they stroke out their brains, and their families want to keep them on life support indefinitely, even transporting their lifeless bodies to ventilator facilities, where the shell of what they once were lives for years by the machine. And I have a hard time with this. It is hard to not impose my own values on things. But I think in the US, we have this false sense of control over things that makes us think that we even have control over our own deaths. I still think death is just a part of life, and sometimes you just have to accept it. I think sometimes you have to allow it to be a beautiful, if not heartwrenching thing. If i were dying, of course I would accept treatment, but if it became apparent that it wasn't working, I would want to spend my last days with the people I loved, at home, or the beach, or whatever, rather than in the hospital trying to cheat off death. That is why I love hospice care.

I even hate that we use the word "fight" when we talk about cancer. I understand that the treatments are draconian and terrible, and you need to have some sort of mentality like that to get through it. At the same time, if you "lose" that battle, what are we saying? That the patient just didn't fight hard enough? That they were defeated? Are we calling into question the person's strength and character when they really entered a battle they couldn't possibly win?

THis weekend I am in Bakersfield to say goodbye to my aunt who is dying. I am glad that I have the opportunity to see her, and the warning that the inevitable is imminent, often when we lose people we are not so lucky. I am sort of nervous to see her, I know she will not be the aunt I remember, and her body will be wasted. I am wondering if we will talk and acknowledge how sick she is, or if we will avoid it, carry on as if it is business as usual, and ignore the elephant in the room.

My life is so compartmentalized and crazy, I don't know that I have dealt with the fact that she is dying, other than when I am post call and exhausted, and every other defense has been worn down and I have been reduced to the emotional capacity of a small child...I know when I see her tomorrow, it will be real and in my face. And I hope that I can recognize the beauty in this process, even as my heart breaks. I hope that I don't do what the world does - ignoring the uncomfortable, ignoring the depths. I hope our hearts can be out there in the rawness of the coming passage. But at the same time, I wonder what she needs, if she needs some "normalcy."

A Historic Day

I look forward to telling my kids about this day. Today is an exciting day. We say that Obama is for "change," but the fact that he was even in the running, and now that he is our president is CHANGE. Just over 40 years ago, African Americans were not even allowed to vote. And today, an African American is president. I heard on NPR tonight that at the time Barack was born, his parent's marriage was illegal in like 16 states.

I am cautiously optimistic about what this means for America. I hope that it is a time for honesty, for new ideas, for (as my mom likes to call it, in reference to the fact that she married a white boy) "some chlorine in the gene pool." I hope it is a time for politics to be less driven by everyone scratching each other's backs, and about what America needs. Let's hope it is a time to be working together and not be polarizing by race and gender and political party and all that (although my cynical heart says that in that world there is rainbows every day and lollipop trees).

To add to the awesomeness of all this - my brother passed his electrician licensing exam today! IT is the culmination of what has been an awesome work of God. I am so so proud of him, and so so thankful to have my brother back...It was years, when I believed that it wasn't possible.

And one of the funniest things my brother has said lately...When I asked him what he wanted for Xmas, he told me he wanted some work pants or something, and that his cat, Chloe, wanted a sweatsuit that says "sweet" on the butt. I almost died laughing when he told me that.

Idea of Community

So when I was applying to residency, on my many interviews, I was often asked "what do you want your career to look like after residency?"

And my answer had to do with community. I described a situation in where I was working in an inner city community, where my medical practice was just one part of creating healthy community. That it would interact and work with other community organizations that promoted education, infrastructure reform, putting opportunities for healthy foods in the city, mentoring, etc. That I think promoting health is not just the job of the doctor, but that it is the job of the community, and only after you have multiple different aspects of community working together will you have a truly healthy population. You can have the best medical care in the world, but if you are a kid who can only get junk food, no produce (because you only have corner stores nearby), and you can't play outside because of the frequency of driveby shootings (all things that were prevalent in my experience in Detroit), you can't have a healthy kid. I described being well integrated into the community, being involved above the medicine level, and knowing my patients and their issues really well, that we would have long term relationships.

And I didn't say all these things because I thought it was a "good answer," but because I really believe them. It was so cool to work in Detroit for healthcare, and then to be involved in making community gardens out of vacant lots, so kids could grow vegetables and learn about health eating...To work with liberal new art galleries on youth art education and expression, giving kids and outlet and an activity other than hanging out on the streets...To buy my coffee and bread from a local bakery that is all about "green" business, as well as hiring local homeless people to work for them... To live in the city and interact with neighbors who taught me "how it was." ANd there were so many other possibilties for working in the community.

I find a lot that I dream, envision things, and then god puts opportunities in my path to realize this. Since being in SD, the first year I was mostly just consumed with medicine and residency and trying to survive. Now, God has given me some new opportunities to connect medicine with the world and community around me. I get to work with a girl's youth group and participate in mentorship for inner city youth, which is something I am really passionate about. One of the girls really wants to be a doctor, and has a very interesting perspective on health in the inner city after seeing her mom struggle with Diabetes, one of the biggest health problems that plagues the inner city. So she has been helping me with some health educaiton materials I have been putting together for my patients in my inner city clinic, which has been helping me to give better care to uninsured patients, which is another passion of mine. It is cool to see how God is connecting the dots, allowing me to realize the dreams I have. And without too much effort from myself, the pieces have just been falling together. I am reminded that the best things come from God, and not by me "forcing" things to work.

I am trying to not feel overwhelmed by all these things, by looking at what I want to do, the bigness of it, in the midst of lots and lots of work and subsequent fatigue.

....out of body...

So I am feeling a little bit weird today...I am coming off vacation. And really, I slept a lot over vacation, and frankly by the end of it (which displays my indoctrination into the world of medicine) I was looking forward to coming back to work - the sense of purpose and mental stimulation...

Now I am back, just feeling insecure, not feeling like I am living in my own body. I feel like I am passively observing my life, looking out of my eyeholes like I am in a costume, like a puppet master, just moving my limbs from place to place. Dragging them to get to the right places at the right time, forcibly pushing words out of my mouth, like actual parcels with weight and mass.

I feel insecure about my ability to be a good dr...Especially in the outpatient setting which is where I think I ultimately want to be...I feel insecure about my ability to work with the youth group girls, even though it is something I am passionate about. I feeling insecure about the future, about what I want to do, where things will go, how things will play out. I feel insecure about the day to day, wondering how it will all play out.

I look to God, asking what he is doing in this season of my life. Making everything feel insecure so I have to trust in him? Have to recognize that there is something bigger than me? Having to stop relying on what I assess as my "own powers" and realize that my value comes from more than what I do, it comes from who I am, what he has created? Hasn't that gotten played out yet? When and how will I learn? How many layers of this onion have to get peeled? How many times do we have to keep going back to the same issues, realizing that there are still remnants there? HOw many times will I mummy myself in blankets, trying to physically feel the presence of God with me, knowing that I am not alone, that HE is there?

And even as I struggle with this, I look to the teenage girls who I am blessed with the privilege of working with. They give me glimpses into their lives, their vulnerabilities, and I have done very little to earn their trust. I see a girl who is deeply hurt, who tells everyone she doesn't need anyone, that nothing bothers her...My heart aches for her, knowing she needs someone to chip away at her exterior, to be there with her in the messiness of life, giving her confidence that someone will be there for her. And I see the girl who is asking boys to love her, and realizing she is not content with cheap love...But continuing to go back...And as much as my heart aches over their lives, the lack of support and leadership and love in their lives, I realize that there is part of them in me, too.

(how about that for some verbal diarrhea?)

The last night

Some thoughts on the recent death of one of my patients, my last night in the ICU. He was young, but had been sick his entire life. Although he had been sick for so long, we had hope, he was listed for a transplant, and had a spirit that made it seem like he wouldn't let death take him.

I simultaneously want to hear it and block it out.
Wanting to compartmentalize like a good dr, take care of other patients
But at the same time, wanting to immerse myself in the realness of their pain
Feel it with them, feel the rhythm of their mournful wailing
Feel the depth of it resonate in my soul.
For once I don’t want to be sterile, efficient, getting things done, checking off boxes

Three women sit at his bedside, more crowded near the door
It is reminiscent of a biblical scene
Their hands, rubbing oil into his young arms
As his head, suddenly lifeless, remains unmoving, eyes rolled back
Just a sliver of white visible, in the slightly parted lids
Reveals that his soul is already departed.
The hum in the corner, white noise of the machine, moving breaths in and out
The shell of his body, slowly expanding and contracting

Like a thief in the night, sneaking away his soul, while we were off guard,
Humbling us again and letting us know loudly that we can’t control
Looking to the skies, our faith again affirmed by our need, our abrupt knowledge that we are not God.

I pause for a moment, and allow myself to listen through the wall
The chosen three are singing
I wonder how they choose, how they know
Their deep, soulful voices harmonize,
Originating from the depths of their souls
It is almost too beautiful to listen to
If you heard it, it would break your heart.

They continue their vigil all night
Anointing his body
Singing, wailing, as their own hearts break
The morning rays break through the slats of the blinds
And they know it is time, they stop their singing and sobbing
The room is quiet
The hum of the machine stops
The air stops moving.
His body stops it’s cycle – up and down with the machine.
And it is done.
Solitary tears fall from their eyes.
They whisper to him:

“You are finally free of this body”
“You are home now”