How Do You Solve a Problem Like Maria?


One month ago today on Friday the 13th, I flew into San Juan, Puerto Rico.  I volunteered to serve as part of the VA Disaster Employee Medical Personnel System (DEMPS) to assist with disaster relief efforts after Hurricane Maria touched down on 9/20.  I fully intended to write a journal entry every day, just to capture the memories that can be so fleeting in the moment.  I wrote one short blog post on the bus ride to the temporary Federal Medical Station at the Acrópolis de Manatí that I never published, then never wrote another word until now.

Though people have asked me over and over about the experience, though I dream nightly of being there still, and though I know I am forever changed by the patients I cared for and the friendships I made in Puerto Rico, I have been unable to find the words to express what I feel and think about it without feeling completely inadequate to the task, the weight of the experience anchoring my tongue and laying heavy on my mind.

“How do you solve a problem like Maria?
How do you catch a cloud and pin it down?
How do you find a word that means Maria?”

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These lyrics from one of my favorite movies are on rewind in my head, the incongruent cheerful riff at odds with the churning emotions inside.  I am in contact still with some of the incredible people I met and worked side-by-side with in Puerto Rico.  I’ve shared some of their eloquence to give friends and family who ask a small glimmer of what it was like, but it feels a little like borrowed elegance, a little like cowardice to hold back what I’ve turned over and over in my mind like a many-faceted gem, and a whole lot like the type of pressure I feel always to paint the picture right the first time. I kept biding my time, waiting for the perfect words to come.

Then recently while at dinner in Phoenix, I had a sudden sharp pain in my L eye.  It felt like a torn contact lens, the sharp edges drawing across my sclera. I thought nothing of it, and driving to dinner with another friend, I noted a larger than usual amount of blood in the centrolateral aspect of my L eye from a subconjunctival hemorrhage.  Confirming this with my fellow PAs (really what better place for a curbside consult than at a leadership conference for PAs?), I knew it required no specific medical care.  On my 7 hour drive home from the conference, I mentioned that this had been the 4th one in less than a year or perhaps 6 months to my good friend, who happens to be an acupuncturist.  She gently reminded me that after travelling to Columbus for the National Girl Scout convention with Daughter #2, two weeks working nearly nonstop in Manatí, a short week home, then another nearly week-long conference in Phoenix, I might consider that I need rest.  Apparently the sclerology chart she sent to me indicates that the area of my eye affected points to a possible problem of the heart.

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As a former cardiology PA, I know there is nothing wrong with my heart. I also know that when I think about Puerto Rico, I feel a pressure in my chest that has nothing to do with a myocardial infarction, and everything to do with another type of blockage, the kind that comes from feeling something so strongly, and being unable to talk about it in any kind of coherent way. I get updates from DEMPS personnel who replaced us there about patients I took care of, and it makes me wonder.  How is it possible to love being home with my family and wanting so badly to be back in Manatí, in a place where I don’t speak the language, but where I understand perfectly what my purpose is?  How can it be that everything here goes on as normal, commuters driving badly to work, kids struggling with slope and y-intercept homework, and at the FMS Manatí, patients whom I cared for still have no home to go to and still have no power for basic needs? How can it be that my patients are dying, and I can’t do anymore about it now then I could then?

I struggled with these thoughts, overthinking perhaps that by talking about it, I might be exploiting the prurient aspects of seeing a disaster up-close versus the need to show people what it is really like there in this era of “fake news.” And then today, a NY Times article about the mental health crisis affecting Puerto Rico was featured, and the trolls online could not type fast enough about how we are wasting money on an island that isn’t even a real part of the US, and I told myself it was time to tell the story. The 2 questions I’ve been asked most frequently: “Is it really as bad over there as they say it is?” and “What was it really like over there?” The short answers: Yes, and terrible, but wonderful.

The long answer, well, that’s harder. That’s going to take more than 1 blog post to answer.  And I promise you, it will not be any semblance of a perfectly presented answer to the question of how to solve the problem of Maria and it’s effect on the people of Puerto Rico.  It will be my truth about the privilege of being a PA serving as one small part of the federal medical response to Hurricane Maria with fellow VA employees in the DEMPS program, DMAT, DoD, USPHS, ICE, and volunteers from New York Presbyterian Hospital.  Stay tuned–there won’t be any nuns breaking into song, but there will be cake, clowns, and cops with rhythm.  There will also be stories about patients that will make you rethink what you know about love and devotion. It was my privilege to witness all of it.

Special thanks to my husband, my mother, and my friends who took over mom duties at home so that I could go and serve. I could not have done this without their support.  I love all of you more than I can say.

If you’d like to help the people of Puerto Rico:  https://www.fema.gov/news-release/2017/09/22/how-help-after-hurricane-maria

This is the main page for up-to-date resources and information on the federal response to Hurricane Maria:  https://www.fema.gov/hurricane-maria

This link will take you directly to the statistics for Puerto Rico: https://www.fema.gov/disaster/4339

The NY Times article about the mental health crisis in Puerto Rico that finally broke the dam holding in the words:

 

 

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Hello September


via Daily Prompt: Critical

“Mama, I’m so sad for her.”  My sensitive daughter, as awkward socially as I was at her age, has a big heart.  She has had friends battling big demons, problems that I hope my children and your children will never have to deal with, and comes to me with questions on how to help them.  She wants to know why her friends who are so sad, can’t see that she wants to help them, to be a shoulder to cry on, and a listening ear, and can’t understand why that is not enough to fix their problems.  These friends thankfully have loving parents who are getting them the help they need. My children have been lucky enough to grow up with plenty, a mother and father who love them and each other fiercely, a family bonded across miles by real affection and goofy humor with both sets of grandparents, aunts, uncles and innumerable cousins, friends who are steady and enough of a tribe to create a blanket of security. But even having all of the above doesn’t make you immune to trouble.  Having to confront the turmoil of the teenage years so early definitely feels like summer is over.

September

It’s September, which for most people bring to mind crisp, cool evenings and pumpkin-flavored everything (to my husband’s chagrin).  Fall is my favorite time of year and the smell of school supplies makes my nerd-heart want to dance.  But September also stands for something very real and very critical.

September 1 kicks off National Suicide Prevention Month.  I remember the first (and unfortunately, not the last) time suicide touched my life. I was 13, the same age as my daughter now, and a boy from my school whom I did not know had taken his life over the weekend.  I saw girls crying in the hallways.  Many of them talked about the last time they had seen him, their last words with him, or memories they had shared.    The question overwhelmingly asked is the same question my daughter asks me now. Why?

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For those who have never felt this way, it can seem incomprehensible.  Many of my veterans struggle with this, as well as many first-responders, but we can’t forget that even kids can feel this way, and don’t have the maturity to think through the very real consequences to actions that can be heart-breaking.

I tried to explain to my daughter what I think it is like when you are so depressed and full of despair that you think life cannot get better.  I told her that even though her friends know that she cares deeply for them, it is like being at the bottom of a hole so deep and so dark, that even though you know the way out is up there, it feels so far away that you cannot even see the light, or if you do, you’re not sure if it’s just your eyes playing tricks on you.  And you feel so tired that trying to get to that light is hard, and curling up in yourself feels so much easier.

She said hopefully, “I could climb down in the hole and pull her out. I’m pretty strong, even though everyone calls me skinny.”

Man, I love this kid so much.  So I hugged her, even though at 13, she’s not always into hugs no matter how much I tell her everyone needs a minimum number of hugs a day to stay healthy. https://www.scientificamerican.com/article/a-hug-a-day-keeps-the-doctor-away/

And I told her that being a kid, it would be too hard to climb down in that hole, because it’s her friend’s pit, and even adults sometimes can’t climb down there, but that she could keep trying to extend a hand to her friend by being the best friend to her she can be and telling her that she cares about her so she knows which direction is out, but that no matter how far down she reaches into that deep, dark hole, her friend has to climb up far enough to grab on, because no one else can climb those walls but the person who is at the bottom of the hole.  And hopefully with help, they can do that, but it takes work and time, and never giving up. And being with someone who is trying to do that can make you feel helpless.

We aren’t helpless though.  What we can do is to recognize that those we love may be at the bottom of that pit of despair even if it doesn’t seem like it to everyone else.  We can shine a light to show the way out, share words of encouragement and provide nourishment for the soul with kind words for the hard journey, but no one can travel that road for them, though we can walk with them.  It is a hard thing to say to a child of 13, and a harder one for an adult who sees others suffering to know, but the hardest task is figuring out who is in need and trying to help them before it is too late.

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My attempt to capture the eclipse

I’m sharing this because you can never know what lies in the heart of another.  Please be kind to one another. Be that light for someone. We never know what demons others are battling, with bright smiles and shining eyes, Facebook posts filled with kids starting school and Labor Day plans.  It starts with awareness.  And a good heart, whether you are a confused 13-year-old with skinny arms or a mom who wishes she were better at these kinds of talks.

Swallow It


As I sit here with an ice pack and foot propped up, it occurs to me that the old adage that doctors make the worst patients should be amended to include all medical providers.  In my work, on a daily basis I dispense medical advice that I frequently ignore.  Not because I think I’m ten foot tall and bullet-proof, but because I’m busy running around taking care of other things before I realize that I haven’t had a single thing to drink all day (hence the three kidney stones), or busy running around and not watching where I’m going (hence the three sprained ankles in three years).  Is it any wonder my mother is always admonishing me to slow down?

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I am a firm believer in the mind-body connection.  Since I started practicing medicine, I’ve seen what stress can do to our bodies.  Like most women I know, I carry all of my stress in my neck and shoulders, the non-ergonomic office chair and computer set-up, of course, contributing to the problems.  My husband, on the other hand, feels his stress in his stomach, having difficulty eating when he feels stressed out (I wish I had that problem!).  The brain is the most powerful organ in our body with its ability to effect changes which may seem magical to those not confronted with these cases every day.

Though both branches of my family have survived wars and strife, my recognition of PTSD has grown by leaps and bounds through my work with veterans.  Time after time, I am struck by the stories my patients tell of how ill-equipped they were psychologically to deal with what they saw and did.  Many veterans came back from Vietnam or Korea, and stated that they had no problems with “shell-shock” like other veterans they knew, raising families and working steadily at jobs that built this country, until they retired.  Then suddenly, they find themselves experiencing palpitations and sweaty hands in crowds, nightmares/vivid dreams of people and places they have not thought of for years.  They come in genuinely confused, some of them undergoing cardiac testing for these symptoms which make no sense to them.  After years of looking forward and striving for the next thing, retirement affords them space and time to look backwards, and they find their past is catching up with them.

One veteran told me that shortly after he arrived in Vietnam, he spoke to his supervising officer about his doubts that he could deal with all of the death he was seeing.  This was a man whom he respected, a grizzled veteran of many military maneuvers, and so he took the man’s advice to heart.  “Swallow it,” the young soldier was told.  “If you don’t, it will eat you alive, so swallow it, because we don’t have time for it now, and your job is to stay alive.  Just stay alive.”  I am not a psychologist or expert on PTSD, but I found it interesting that the veteran’s main complaint was debilitating stomach pain with extensive gastrointestinal testing over many years which has been negative.

I’ve had other patients come in with complaints of dizziness.  In medicine, a complaint of dizziness needs to be further clarified in order to narrow the differential diagnosis.  My question to patients with dizziness or lightheadedness is usually asking them if they have a sensation of feeling woozy like they are about to pass out, a spinning sensation either of the world spinning or of themselves spinning, or a feeling of being off-balance.  I’ve learned that besides trying to figure out all of the medical reasons for a patient’s symptoms, it is important to ask questions about how the rest of their life is going as this will have an effect on their symptoms.  It never surprises me that the patients who will share that they are feeling lost or confused, will also describe their dizziness as a feeling of being off-balance, often times associated with blurry vision or tunnel vision.  Is it any wonder that those who most feel out of control emotionally have symptoms that mimic having lost sight of where they are going or where the ground is? Some have literally used the words, “I don’t know which way is up.”

The words that people use when describing their symptoms and telling their stories can be revealing.  Perhaps because I love words so much, I think they are important and I try to pay attention to how people describe their pain.  In our training as PAs, we are asked to be very specific in how we document pain.  Some patients will laugh a little at my question, ‘Would you describe the pain as sharp, stabbing, squeezing, pressure, aching, burning or something else?’ but it helps people to find the word that best describes their pain.  As medical providers, we have a lot of experience dealing with pain, and though I cannot truly “feel” their pain, I always feel that if I can help them name it, it will have less power over them.

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One method frequently used to help patients categorize their sensation of pain.

As medical providers, sometimes we can be so focused on the disorder, we forget that mind-body connection.  No matter how many times we read the study about how pretending to smile actually improves a person’s mood, we point the arrow from body to mind, and forgot the power the mind has over the body.  One of my most memorable patients during my psych rotation was a woman who had been diagnosed with somatization disorder (which in the DSM-5 has now been replaced with the broader category of somatic symptom disorder in order to “remove the mind-body separation that is implied in DSM-IV”). She reported paralysis and loss of feeling from the waist down, though all testing and imaging was normal, and there was no report or sign of injury or external trauma. She had been there for weeks undergoing test after test before she was moved to the psychiatric ward. Other patients have reported blindness, others deafness. She would speak cheerfully of everything but the broken engagement that had occurred just prior to her hospitalization, that event a black hole into which all memory had vanished. Was it chance that this woman had lost half of her body, her better half perhaps? Or that she was numb, and paralyzed to the point that she could not move forward or backward?

At the time, though, I was in my first rotation in my second year of PA school. My job was only to learn everything I could about somatization disorder which was thought to be very rare in order to prepare a presentation for the rest of those in our consult service, round on this patient every morning, as well as attending to any new consults that came in that day. My job wasn’t to diagnose this woman with heartbreak, though I thought most likely it was true.

As a PA working in cardiology many years later, I would learn about Takotsubo cardiomyopathy aka stress cardiomyopathy or broken heart syndrome, in which the heart muscle function is dramatically affected in approximately 85% of cases by an emotionally or physically stressful event. Patients normally arrive at the hospital with symptoms mimicking a heart attack, including chest pain and difficulty breathing. Actual visualization of the coronary arteries usually reveals no evidence of significant atherosclerotic plaque to explain the dramatic change in the heart’s ability to pump efficiently or the change in the actual shape of the heart muscle itself.  In most instances, the heart muscle function returns to normal by the time of the patient’s discharge (usually within a week).

Figure 2.

Called Takotsubo after a Japanese ceramic pot used to trap octupi, this is a dramatic change in the normal shape of the heart (Credit: Circulation 2011; 124)

The more we learn though, the greater distance we put between ourselves and our patients.  We think we learn enough to make a difference, gaining the tools and knowledge to ease suffering and effect cures.  We gather information, nod sympathetically, lay hands on our patients, and dispense knowledge and prescriptions with impunity, doing our best with what we know. Our patients get better, mostly, but sometimes they do not, and we blame ourselves. We want that distance because we want to believe that we can help our patients. We want to believe we do know enough to make a difference. We forget though, we are ourselves human as well. It is a bitter pill to swallow–“Cure thyself!” we are told and tell ourselves, though we no more listen to our own advice than our patients might. We stumble, and curse the ground, and forget that perhaps,  our mind wants us to listen, and slow down. We learn again, what bruising, pain, and heartbreak can do, and in doing so, close the gap between us all again.

 

 

In Which Several Unusual Events Occur


The day began innocuously enough, pushed to a small sliver of the bed by an exceptionally warm little boy who had shown up at my bedside late last night or early morning depending on if you see the glass half-empty or half-full. He has not crept into my bed in months, but his tear-streaked little round face in the moonlight tugged at my heartstrings, and I could not send him back to his room. Little did I know the surprises the day would bring.

In which a patient faints and technology intervenes:

My patients were not unusual, kind and full of stories of living overseas, but one of my colleagues had the opportunity to use a new device we were just briefed on recently when his patient felt dizzy then lost his balance. The premise of this device is stunning in its simplicity.  As no one in our facility is allowed to lift anything or anyone greater than 30 lbs, it uses a small portable battery-operated generator that allows what looks like several stacked air mattresses to fill sequentially, until the patient is raised to a height that makes it easier to transfer to a gurney or hospital bed.

In which a snowstorm appears suddenly in the desert:

Leaving work, though as always I am grateful for rain in a state that has been drought-stricken for so long, the chill and ongoing downpour had me planning for a quiet day of snuggling in front of the fire watching movies with my husband.  The rain quickly turned into snow as I drove home, which in this high desert place is not usually seen until November 30th, making roads slick and visibility poor, but turning the landscape into a winter wonderland in minutes.

In which a sleeping man surprises me:

Walking into the house, it was unusually quiet, and I found him sleeping on the couch. He is not one who usually naps, preferring to stay on a normal sleeping schedule when home, however, I knew he’d had 8 calls after midnight, the last a structure fire at 6:30 am, so I was glad to see him getting some rest.

In which a tree decides it has taken all it can take:

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As we prepared dinner, we noticed that one of our trees in the backyard had cracked beneath the weight of the heavy wet snow. It fell over as quietly as if it had just suddenly decided to lay down and rest without a noise.

In which the children try exotic tropical fruit:

My littlest ones have a habit of asking to try all manner of fruits and vegetables in the grocery store, and though I love that they love fruits and vegetables, the practical side of me is unwilling to pay $5 for 1 piece of fruit, especially when we have no idea if it will taste terrible. In the produce section of our grocery store, there is a section in which they sell very ripe fruit that needs to be eaten quickly for 99 cents/bag. Today, one of the bags contained both 2 dragon fruits and several star fruit.  While I cooked dinner, they looked up how to cut them up, and everyone got to try dragonfruit and starfruit appetizers.  Verdict?  Dragonfruit have a beautiful magenta color on the outside, but the interior is black and white, with a refreshing sweet taste and seeds similar to a kiwi.  Definitely delicious!  Starfruit when exceedingly ripe is NOT delicious with a consistency and texture like a cucumber without the seeds.

In which we have turkey cutlets, sweet potatoes, and cranberry sauce, although it is not Thanksgiving yet:

While at the grocery store, I also saw turkey cutlets on sale, so decided to try a new recipe, or more accurately, I decided to take a few different recipes and then combine them together, add my own combination of spices, and throw them on a bed of kale and spinach.  wpid-20151116_184720-1.jpg

In which we all enjoy a moonlight romp in the snow, especially the dog:

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Today’s accumulation was between 3-5 inches depending on which side of town you lived on.  Numerous snowballs were thrown, a snowman was resurrected, then lost his head, and much rolling around across the front lawn occurred.

In which we all made wishes, and watched them sail into the night sky: 

My husband had been given 2 paper lanterns at the lantern festival where he and his crew were staged to make sure no fire-bearing paper bombs started any forest fires.  He brought them home for us to experience the magic. We watched them drift upward until they were indistinguishable from the stars, as we made silent wishes.

In which we all go for a moonlit snow hike despite it being very close to bedtime:

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Hiking down to the store to return movies was more fun secondary to the slip and slide factor, and the children enjoyed the opportunity to be outside so close to bedtime.

In which we end the day in front of the fire finally: 

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No hot cocoa as requested by the chocolate lover, but we did all warm our frozen feet by the fireplace, then upstairs for bedtime prayers and getting tucked into bed, cozy after the snowy adventure.

Tonight I’m grateful for days filled with the ordinary and the unusual.  I’m thankful to live in a place full of surprises. I pray for days like this for all of you, spent with loved ones in simple pleasures.

 

 

 

Hello darkness, my old friend


Steve Inskeep woke me up way too early this morning.  No, I haven’t thrown over my husband for someone new.  For those of you who aren’t familiar with him, he sounds way too chipper to have been up for hours as the host of Morning Edition on NPR. With Daylight Savings Time this weekend, theoretically, we all got 1 more hour of sleep last night, but in reality, I spent 1 more hour awake, and started yawning as soon as darkness fell.  Now it really feels like autumn has arrived, and winter is coming ;-).

Hello darkness, my old friend

Hello darkness, my old friend.

The news is filled at this time of year with the same stories from last year about whether or not we should continue with Daylight Savings Time. As we are among those who have eschewed cable TV for streaming services and the local evening news is filled with hype-filled emptiness, I like to get my news as I get ready for the work day and on my drive in to the hospital. This morning, the words “in Detroit” made my head snap towards the radio.  Having trained in Detroit, and grown up driving “Downtown” to the RenCen and Hart Plaza, I miss my old city. I never knew it in its glory day.  The Detroit I knew was already worn around the edges.  The grand architecture which makes it an attraction for photographers, film makers, and crazy tiger owners, is crumbling and the infrastructure which has been neglected for so long is struggling to take care of the residents of my former city.

A live tiger got loose in the old Packard plant during a photo shoot. (Photo: Andy Didorosi)

A live tiger got loose in the old Packard plant during a photo shoot. (Photo: Andy Didorosi)

What I heard today though wasn’t yet another mock-sad exploitation of the dark days of Detroit.  Instead it celebrated the success of a program implemented to bring suicide levels to 0%.  No, that is not a typo.  The goal of the program was actually to prevent suicides and thus bring the suicide rate down to 0.  Now anyone who’s every been at a meeting, no matter where it is, whether for work or the PTO or your local library guild, can imagine the silence that most likely followed that proposal. The thinking among a lot of health care workers and psychologists is that it is impossible to prevent every suicide.  This is a growing problem among veterans all over the country, and one that has been highlighted in the media as an example of how the VA is failing our wounded warriors.  As one of those left behind to question why, any reduction in the suicide rate is a miracle.

This is the first I’ve heard of any success stories, and this is truly a success, and has been for many years.  After embracing the idea, which must have taken a complete paradigm shift, the Henry Ford Health System, the same one that took care of my family for years, was able to achieve their goal for at least 2 years.  In 2009, the suicide rate among the high-risk mental health population was zero. Even now, it is 80% lower than before the start of the program.  And this was during the heart of the recession, when there were plenty of factors to make anyone depressed, plenty of reasons that someone might look into the heart of darkness, and decide the pain and shadows are too much to bear any longer.

Today on All Souls' Day, residents of New Orleans must show iID to be allowed to come to the historic St. Louis Cemetery No. 1 to pay their respects to those who have died, following a new directive by the Archdiocese of New Orleans, prior to my visit there.

Today on All Souls’ Day residents of New Orleans (another city that has seen it’s share of darkness) must show ID to be allowed to come to the historic St. Louis Cemetery No. 1 to pay their respects to those who have died, following a new directive by the Archdiocese of New Orleans (prior to my visit there).

How did this happen?  Henry Ford Health system is not situated in a rich community filled with deep pocket books.  When I trained there, most patients were on Medicaid or some type of assistance. Though the people I worked with were all hard-working, dedicated professionals, they are no different from health care providers here, or anywhere I believe. The answer, I think, lies in turning upside down the presumption that nothing can be done, and aiming for complete eradication of the problem of suicide.  And though a complete analysis of this phenomenon hasn’t occurred yet, all signs point to the possibility that the extensive work put into achieving these results has actually saved this medical system money.  While we have politicians spouting sound bites about how broken our health care system is, in Detroit, a symbol of decay and decline, some big dreamers actually are making a difference in patients’ lives, and managing not to make the bottom line worse.

Why isn’t this story all over the news at night instead of Donald Trump’s unnatural hair do?  I think it is because we have a tendency to focus on the negative and the darkness. In optical illusions, we have to train our eyes to see beyond the negative spaces.  To see what is right there in front of us waiting to be revealed, we need to let go of our preconceived notions, and be open to a new perspective.

What do you see first? The beautiful curves of the chalice, or two faces about to kiss?

What do you see first? The beautiful curves of the chalice, or two faces about to kiss?

What can we do on this Feast of All Souls, to turn away from our old familiar friend darkness and negativity? For me, I’ll start with welcoming the light of morning, instead of mourning the darkness that comes too soon.  I’m thankful today for all those in Detroit working hard to make the impossible possible, for news that manages to highlight positive stories, and for the blessing of warm covers on chilly mornings.

Waiting for Patience


My office door is always closed and locked, remnants of a day when an angry man stood over me and yelled words filled with hurt, anger, and frustration, flinging his arms out as if to grab me and shake the understanding into me.

“Why are my dreams so vivid?” they ask me.

“Why does it still feel like I’m there, fighting all over again, when it happened so many years ago?”

“Why am I still here?”

The brain never forgets, unless the insult is so severe that the parenchyma itself is damaged then dies off, or if we don’t feed it the oxygen it needs. Hypoxia we call it, but those memories don’t just need oxygen.  They need light in all its forms.  The soft rays of sunlight that come in the early dawn of a dreamless night.  The probing surgical intensity that exposes every forgotten detail of curved hair on bloodied arms. The incandescent glow of the faces of loved ones holding back the shadows.

Some injuries to life and limb are obvious. Every day when I walk into this hospital, I see veterans in wheelchairs, leaning on canes or walkers, arms and legs in braces or scarred, but the hurt that comes from post-traumatic stress disorder is not so apparent.  We are confronted with stories on the internet of people leaving nasty notes on the windshields of people using handicapped parking spots whom they judge to be unworthy of the designation and of what they consider a privilege.  Though I’m sure there are those who abuse these “privileges”, for every one of them, there are countless others who would gladly give back the parking placard for pain-free days and nights.  And for those for whom the wounds are invisible, there is no parking placard.

PTSD is real. The patients who seem to have the best grip on this have good support networks–spouses willing to tough it out, family open to seeing it, or friends willing to listen.  When my husband calls me in the middle of the day, it’s frequently to talk about a tough case or to hash out the best way to have handled a patient or incident. Because I don’t know anything about being a paramedic or firefighter, most of the time, I’m just listening or offering a “That’s terrible.” I know it is a way of debriefing for him, just like what he does when he first gets home, and what I do when I’ve had a bad case. He has people he can talk to at his firehouse, but I’m glad he chooses to talk to me, too.  This week was his first shift on call as a SWAT medic.  Luckily, he did not get called in, but every time his phone rang or he received a text, I could see him tense up.  I understand his reasons for wanting to do this work.  How could I not? But I also know that my job as his wife is to look for the signs that he needs help.  We have an increased awareness now about PTSD with social media and trending tweets, and the focus on our military has helped to bring the issue to the forefront, but still too many first responders and veterans are dying off the battlefield, and after the trauma, from suicide and the effects of substance abuse.  It can be difficult for these men and women who are held up as heroes to admit they are struggling.

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All of us need to recognize the concept of sonder, which in my mind should rhyme with wonder.  It means the realization that each random passerby is living a life as vivid and complex as your own. If you have been lucky enough to escape sorrow, tragedy, hurt, and pain in the years that make up your time on this earth, count yourself among the lucky few.  We all have been through the fire at some point.  The trick is looking past our own wounds to see the scars that everyone carries after the flames have passed, and recognizing those who are struggling to carry on.

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June is National PTSD Awareness month, and June 27 has been designated National PTSD Awareness Day.  In the days before we knew better, they called it by a variety of names: shellshock, nervousness, hysteria. Those who have served in our military, first-responders, and survivors of any catastrophe from rape to hurricanes are at risk for developing this. It affects men, women and children.  Know the risks, learn the signs and triggers, and most of all, please try to develop the patience with humanity that comes from sonder. Today as we honor those veterans who gave everything on the beaches of Normandy, let us not forget those who came home with invisible burdens that had not yet been given names, or forget those who risk their lives every day.

http://www.frsn.org/Resources/web-links

http://www.nctsn.org/resources/public-awareness/national-ptsd-awareness-day

Liberation


Forty years ago today, Saigon fell.  It is a date engraved upon the hearts of many Vietnamese people, as well as many veterans. If you were old enough to remember, the images of helicopters, crying people with outreached hands, and flames are forever linked to this date. It is thought of as a symbol of leaving, of endings, and for some, of failure.  It has been called Black April and rebranded by those in power in Vietnam as National Liberation Day or Reunification Day. My veterans express regret and sorrow about leaving Vietnam like this, mixed with the relief of being able to go home. Some remain haunted by the images of those left behind, bound by the ghosts of the past, while the diaspora are reconciling the Vietnam they left in 1975 with the changes time, politics and money has wrought.

I am too young to remember leaving my birth country. I was a baby in my mother’s arms when we hurriedly boarded the C-130 that would take us to the refugee camps in the Philippines and Guam.  As with all immigrant stories,  ours is both the same and different from the thousands of other Vietnamese families that came to the US.  The date our family left Vietnam was actually April 26, 1975. My parents, grandmother, aunts and I were blessed to leave on an airplane, compared to so many others at the mercy of the seas who fled on boats, though this airplane had been stripped of all of its seats in order to fit as many people on board as possible.

My baby boy descending the ramp of a C-130.

My baby boy descending the ramp of a C-130.

When we finally arrived in the US, my parents set about making a life for all of us, though they had little resources.  My father’s first jobs were working for RCA as a repairman, and for a steel mill where he worked until he retired in his late 70s.  Because they had only 1 vehicle, my father would drop her off before the bakery opened before the sun rose, recalling today how hard it was to leave her there in the cold darkness alone so that he could make it to his 2 jobs.  She made so many pies, that to this day she refuses to make pies from scratch.

A pie made by me, and not my mother.

A pie made by me, and not my mother.

She then did back-breaking work in a nursing home, enormously pregnant with my little brother, lifting and bathing patients.  Under the watchful eyes of my grandmother and my mother’s two younger sisters, I learned English from watching Shirley Temple movies and Underdog cartoons, and reading Little Golden Books about Cinderella.

Eventually, our family saved enough money to bring my mother’s two brothers and their families here to the US, but not until almost 20 years later, after reeducation camps and deprivation at the hands of the Communists.  I had the advantage of growing up in America, with the constant reminder that I had cousins in Vietnam who were not as lucky, and so I, like so many other Generation 1.5 children, was pushed to succeed though hard work and education by my parents, who had left all they knew and loved behind with the hope for a better future for their children. Exactly 22 years later, surrounded by the entire reunited family, I was married on April 26, the date my wedding was changed to through a series of unplanned and unexpected events.  Now 40 years later, as a physician assistant, I am serving some of those same veterans without whom I would not have existed.  If not for the war in Vietnam, there would have been no need for a Korean firefighter to come to Vietnam.  If not for the American army base where my parents worked and met, there would not have been any seats for us on a C-130 to fly us all away from Vietnam.

Today, as we look back on this date, I was struck by the photos of this baby miraculously unearthed from the rubble of the earthquake in Nepal.  Pictures of helicopters, outreached hands, and flames are featured on news stories across the internet. Thousands of families have been separated, lost loved ones and their homes, and the date of the earthquake will forever separate their lives into before and after. And in the midst of all of this tragedy, we focus on the life of one small baby, liberated from the dust and ashes, surviving despite the tremendous odds against it.

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Nepalbabyrescue2

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http://www.cnn.com/2015/04/25/world/gallery/nepal-earthquake/?sr=fb042915nepalbaby1030aGalPhotos

We rejoice in this story of life arising from the rubble and ruins because we all share stories of liberation, some more dramatic than others, but no less important in the way that they link us all–from the ashes of a fallen city, to a road not taken, a life left behind, and still we learn to build again.  True healing begins with that first turning towards the light of home, which is wherever we make it. This then is the true meaning of liberation, not that spun by those who would have us forget the struggles and the sacrifices of those who reached down and pulled us from darkness to true freedom.

Today I am grateful for my parents’ bravery and courage in the face of overwhelming chaos and tremendous odds.  I would not be who I am or where I am if not for all of their sacrifices. I am thankful for all of my family and for the astonishing grace of not having lost a single family member to the war.  And I pray for all those in Nepal, that someday, they will look back on these days, and be able to say they are stronger for having survived.

Please pray for the many medical and relief workers as they work tirelessly for all those affected by the earthquake, as well as the family members of Marisa Eve Girawong, a physician assistant who was killed there.  If you would like to donate, check out the Better Business Bureau’s website which has a list of charities providing aid to Nepal that meet the BBB’s standards of accountability, as well as InterAction Nepal’s website which can allow you to direct your donations to specific needs, such as medicine, food, or shelter.

Triskaidekaphobia


The first time I was truly afraid of a patient, I was standing in an outpatient family practice clinic in Detroit.  If you’ve ever felt mind-numbing fear, you know that it creates a dividing line between that moment and the next. Strange details imprint on your brain, like the heft of the chart in your suddenly damp hands, and the musty smell of an exam room suddenly grown tinier.  Grown men have told me that part of the attraction for going to war is learning if they have what it takes when confronted with the fear that is part and parcel of combat.  When we watch movie characters stumble into bad situations, we have the prescience that comes with being an observer, and tell ourselves that we would never, ever go into the dark house after the psycho or get in the car with the charming serial killer.  In actuality, how often do we do dangerous things and not realize how close we stand to the precipice?  As my childhood friends will tell you, I had what I considered a charming unawareness for these types of situations (until, of course, I became a mother), and perhaps it came from my innate belief that all people are good.  When I was younger, I traipsed into places and talked to people that now I would never let my children associate with, but again, I really didn’t think anyone wanted to hurt me, and I trusted that I would know it if they did, but perhaps that was hubris or plain dumb luck that I never got hurt.

This time though, the analytical, writer part of my brain was coolly noting that, for once, I was actually not only assessing the situation accurately, but also responding in what I thought was a very calm and non-threatening manner, though the other animal instincts in my brain that had made the fine hairs on the backs of my hands prickle within the first 2 minutes of meeting this patient, were screaming “Run! Get out of there, right now! Do not pass go, do not stop! Get out!”  It was like, and I kid you not, the good buddy in movies, you know, the sensible one like Velma, or actually more like the hyper-panicky one Shaggy, tapping on my shoulder and whispering “I don’t think this is a good idea.”

Shaggy_scooby

Having grown up in the suburbs of Detroit, in a town where everyone looked so familiar I would have trouble placing the face as being someone I knew from church, the gas station, school, or work, going to PA school in “the city” was exciting to me.  I knew I’d be exposed to situations I’d never experienced, and like my combat veterans, wondered if I’d have what it took. I wasn’t afraid of the crack addicts or gang-bangers. I was afraid that I wouldn’t know how to react, wouldn’t have what it took in the face of an emergency to do what had to be done–chest compressions, suturing, bandaging, reading EKGs accurately. I thought I’d be most afraid in the ER at Henry Ford Main, or during my psychiatry rotation where I was on the inpatient consult service for Detroit Receiving and Sinai Grace, because of the out of my control aspect of those situations.  In an outpatient clinic, I naively thought, at least you could kind of predict what kind of day you were going to have.  Appointments are scheduled, and you can predict what kind of patients you will see, unlike in the ER, when you can have a heart attack, gunshot wound to the hand, and head cold all walk in at the same time.  It was a controlled environment, I thought, and control of my environment is key.

All of us desire control. It begins when we’re learning how to talk and walk.  This is where the terrible twos (and threes and fours for some of us) get their name.  The desire to exercise our will on the environment is innate.  We want to be able to choose our path. We want to believe that we have control, though in reality, we have very little. Today is Friday the 13th, a day many fear, though most of us find it superstitious.  We scoff at people who would have “silly fears” of things like the number 13, but in reality, don’t we all pause for just half a second, if we have an interview or date that gets set for Friday the 13th or we’re placed in hotel room #13? It doesn’t stop us from continuing on with our lives, but given the choice, just to be on the safe side, wouldn’t we change the date or room number, if we could?

As children, many of the sayings that we grew up with enforce those beliefs: Step on a crack, you’ll break your mother’s back–so we avoid walking on the cracks, just in case. It’s part of the mistaken belief, these superstitions, that we can control our destiny. We believe that by following all the rules, we can control our circumstances.  As children we pray, if I promise to do all my homework next time, please let me pass this test. As adults we pray, if I promise to be a better mother, please let her be OK.  Fear is irrational, it compromises our illusion of control, because it shows us how little power we actually have.  When we see through the eyes of fear, nothing is in our control, and that is the most frightening thing.

The unkempt woman in the musty exam room looked right through me.  All of us want to be seen, truly seen for who we are, and when others do not see, it can be frustrating, and make us doubt ourselves.  When she did not respond to me, I wondered for a brief second, did I not speak loudly enough? I had read her chart before coming in the room. It was supposed to be a routine follow-up for her annual gynecological exam.  Her list of medications gave me clues to what was missing in the 1 sentence description of why she was there.

“Have you been taking your Clozaril?” I asked.

“My mother has blue hair. Do you see them? People walk on buses,” she said.

Being alone in a room with a schizophrenic patient off her medications is not a place for a green PA student.  My very first rotation was psychiatry on the inpatient wards. Ingrained in us were several rules: Make sure to always be between the patient and the exit.  Make sure that someone knows where you are at all times.  Make sure that you wear long hair pulled back so a patient cannot grab you.  I had seen schizophrenic patients on their medications, discharged them home to the loving care of family or friends, after seeing them admitted off their medications, when they could not distinguish between their reality and ours.  Most were not violent, but what was frightening was their inability to see us. To them, I could have been a 300 lb body builder threatening to take away their most prized possessions, and as anyone who’s ever been threatened knows, fear will make us strike out to protect ourselves.

Fear will take a perfectly reasonable person, and turn them into a knife-wielding, gun-toting, hate-speech throwing part of a mob like those we’ve seen on the news.  It turns off the reasonable, logical parts of our brains, and takes us back to the child we all were once, vulnerable and at the mercy of others.  When we point our fingers at others, tsk at the behaviors that we, of course, would never engage in, scoff at superstitions and phobias, we forget to look at what prompts them.  We forget to look deeper. We forget to ask ourselves what are they really afraid of–and what am I afraid of that I am too blind to see them for who they really are.

“You know what? I think I left your bloodwork outside. I’ll be right back,” I lied, and briskly walked out of the room, straight to my preceptor’s office, and explained the situation to him.  I never saw that woman again, but I’ll never forget her eyes or the trembling of my hands afterward.  Have you ever been truly afraid? Do you have any phobias or fears that may seem irrational to others? I’d love to hear about them. I discovered an irrational fear of heights when I climbed up on a ladder to explore an old B52 bomber, and could not make my legs work to climb back down the ladder I had just ascended 10 minutes prior.

Today I am grateful for reminders that all of us have fears that lie behind the facade of control we all cling to. I am thankful for the friends who kept me from making irrevocable mistakes in my innocence when I didn’t have enough fear, and hope my children will have such good friends as they make their way through a world filled with too many choices.

And because I’m a giant nerd who loves words:   Triskaidekaphobia is derived from treiskaideka, the Greek word for thirteen + phobia, fear of = a fear of thirteen.Pi

Holding Hands


My father has hands like bricks, reddened and hard, fired through years of tilling Michigan clay, lifting dirty tires in February winds on the narrow shoulders of freeways, and sanding smooth the doorways of the house in which he has lived since 1977. I never thought much about his hands, except as a kid when I’d done something wrong and feared his wrath. In the days before time-outs and worrying about self-esteem, my father’s hands were scarier than a belt or a “wisdom stick”. My grandmother and mother used switches we had to pick ourselves from the two oak trees in the front yard, but my father’s hands were tough enough to make us think twice. Punishment meted was swift and painful which we earned often enough between the four of us, mischievous and curious as we were. We didn’t view it as abuse, given the nature of corporal punishment at the time, in fact, preferring a swat on the behind to being grounded or other non-corporal punishments.

My hands look more like my mother’s, slim with longish fingers for the small hands that I have. I always wanted bigger hands with longer fingers, thinking them elegant and more agile for things like playing piano or building things. Having small hands can be advantageous though, as I discovered the first time I participated in an exploratory abdominal surgery. Surgeons will frequently talk and joke during surgery, but during this one, as I stood very still trying not to contaminate the sterile field while holding retractors, one of them asked who had the smallest hands in the room. Surgical gloves are sized from 5.5 to 9 and specific to right and left. OR techs and nurses know what size and type a surgeon prefers to wear and everything is set out prior to the procedure. If you are new, they will ask you what size glove you wear, then help you to put them on to maintain sterile fields. I wear a 5.5 or 6 depending on what is available, and so the nurses pointed to me. Because I had the smallest hands, they asked me to insert my hands into the patient’s abdominal cavity to break up adhesions around the liver. The feeling of sliding my hand around someone’s liver was incredible, smooth and strangely slick, and thrilling to me.

I never thought much about anyone’s hands until the day my future husband asked to hold mine. When I was young and dreamed about the man I might someday marry, I never thought much about what he would look like, let alone what his hands would look like. As little girls, my next door friend Amy and I would hum the marriage song as we processed across the family room, holding a worn bunch of plastic flowers. The husbands we married were incidental, a necessary part of the process to get to the next step which was stuffing a baby doll up our shirts to pretend we were going to be mothers. This would be followed by pretending to be Princess Leia or Lady Jane from GI Joe. Our summers were filled with acting out fanciful scenarios of heroines and heroes with our brothers. I never pretended to hold hands with anyone though, never realizing what a lovely part of being with someone that it is.

In romance novels, a lot of the descriptions center on kisses between the main characters. Rarely do they talk about the sweetness of holding hands.  It is said that the handshake evolved from the ancient custom of a showing of hands empty of weapons. I think the knowledge ascertained from holding another’s hand in yours can be greater than just knowing they do not hold weapons. In my present work, I check hand-grip strength on patients regularly. It is a part of our diagnostic tool set, telling us if there is weakness or tremor, but patients will look at my hands, concerned that they will squeeze too hard.  I’m learning not only about grip strength though when I hold their hands. I can tell what kind of work or hobbies they do, if there are lesions that haven’t healed, if they bite their fingernails, or if nerve damage is present, among other things.

When I held hands with my husband for the first time, I was struck by the similarities between his hands and those of my father’s.  Though we were largely strangers to one another, his hands were familiar to me.  I understood instinctively what kind of person he was, though I could not have put it into words at that moment as young as I was.  Once while we were dating, he apologized for the state of his hands, rough from the work he had been doing.  I told him what I still believe today, that there is no shame in hard work.  His hands are never raised in anger to our little ones, though they are just as mischievous as I ever was.

The church in which we worship holds hands during the Lord’s Prayer, an act which always makes my children a little wary.  They don’t want to hold hands with someone who is not part of our family, and I never force them to, but they are frequently rewarded with a smile from an elderly person who might be sitting near our less-than-angelic children.  Some might call this practice unhygienic, and in fact, there are times when they are ill or someone else is that we don’t hold hands, but in that there is still a lesson about how we care for others in the community by respectfully declining.   They are learning too what it is to be connected, to know the feel of someone else’s hand, to be gentle in the way they grip arthritic fingers, and not to fear the unknown.

There is something powerful in the act of holding hands. It is an act that literally and figuratively connects us. As mothers we have known the secret feeling of children dancing within our wombs, like stars slowly spinning within the nebulae of our own personal gravity, but for our men, it is the grip of their baby’s tiny hand around their finger which shifts time and space.  As I watch my children grip their grandfather’s hand walking with him on a mountain hike, his other hand gripping the walking stick shaped with loving care by my husband’s hands, it occurs to me that I stopped holding my father’s hands after childhood, when I no longer needed his help to walk.  I remember the feeling of my hand in the crook of his arm as he walked me down the aisle of our church and the way it felt when he put my hand in my husband’s, like a blessing and an absence all at once, and I know it is too soon to let go.

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My little guy hanging onto his grandpa.

Today I am thankful for all the hands that shaped my life along the way. I am grateful for silly internet pictures of otters holding hands to remind us that we are all connected, and pray for the strength to hold on, for as long as we are blessed to have those we love in our lives.  I’m wishing my father a blessed 80th birthday, and praying for many more birthdays like this.

The Opposite of Tenebrific


A career in medicine is one that has many lures–the ability to touch lives,  fascinating medical phenomena, and the knowledge of the complexity that comprises the human body, among other things.  Yesterday, every single one of my patients reminded me again of why I became a PA.  One patient asked my advice on what to do about a lost love connection spanning over 20 years.  Another had such an intricate medical history, it had me stretching my brain for information I’d learned long ago in school.  One funny patient and I talked about our love of words, and I shared with him an app on my phone which gives me a new word to learn every morning. Every patient thanked me for being easy to talk to, and I was loathe to walk each of them to my door because I had enjoyed our visit so much.  It was a day sorely needed. Last week, the last patient of my day made me cry.

As anyone who knows me will tell you, making me cry is not actually difficult. I confess to a small sob while watching the movie Aladdin (which is a cartoon I know, but that Genie gets me every time).  aladdin genie

Someone else crying causes me to tear up.  Even writing a sentence about crying will cause what my son calls my “shiny eyes.” I’ve cried with patients numerous times, with a touching story or in shared grief. But this time, it was different.  I was crying tears of anger.  I am cursed with full-on waterworks if I’m extremely angry, which I would love to be able to control. It’s hard to be taken seriously if you’re wiping away tears while trying to make a point, and even harder to carry on a patient evaluation when you are doing everything you can to remain professional in the face of hostility.

This patient began our encounter angry before he had even met me because his appointment had been rescheduled with another provider. Where I work, I’m used to dealing with angry patients on an almost daily basis.  To some of them, solely on the basis of where I work, I am the face of all of the bureaucratic bean-counting, soul-sucking paper-shuffling nonsense that prevented them from seeking care in the first place. I am part of the system that denied them benefits, told them PTSD did not exist, and denied their right to be seen as a person, and not a number. So I understand the frustration and the anger that comes as part of the baggage of just getting to the appointment.  I understand that part of my job is to lift that burden of frustration, and make them feel like they are seen, and heard.

As patients, we come to our appointments carrying the invisible baggage of our history–the memory of an aunt who died on the operating table, medication reactions, a fear of bad news-“What if it’s cancer?” As providers, we know this, and try our best to gauge those worries and try to alleviate them if possible.   Sometimes though, the actions brought about by those fears and worries are inappropriate, and other times, even criminal.  Fears have been running high in our department because one of our sister facilities suffered a tragic shooting.  A patient shot and killed one of the providers at the hospital in El Paso.  He worked in the same type of department in which I work.   Meetings about safety measures, active shooter scenarios, and how to deal with violence in the workplace have been laced with tension-filled voices.  One of our police officers tried to help us dial back the emotions.  “Let’s not call it a panic button. I prefer the name duress alarm. We don’t want to have panic,” she said.  I’m not sure that changing the name makes a difference, though I do advocate for the power of words.

But the words I mean are those we use when dealing with patients.  As peace-loving as I try to be, I am not immune to the effects of violence. I trained in the city of Detroit and saw the ravages of drugs and violence on the faces and bodies of our patients, treated gunshot wounds and stab wounds, and saw families ripped apart by random acts of killing.   People argue that our patient population is more dangerous because as veterans,  our patients have all been trained on how to use weapons.  I argue that if anything, that makes us safer, because they were also trained in how to defend those in need, in how to stand and fight for those who could not or will not because of an oath to heal or religious convictions or even conscience alone.  I will defend our veterans as patients just as worthy of our compassion as any other patients, if not more, and not to be considered a source of fear.

Last Friday though, I was afraid, and if I were a superstitious type, might have seen the word of the day, “tenebrific,” as a portent, as it means producing darkness. My patient arrived upset, out of control, and angry with me and everyone else in his vicinity.  I stand a whopping 5 foot nothing, and so to me, everyone is tall.  This man though, stood a good foot taller than me, and weighed over 2 times what I weigh.  I tried every tactic I had ever used to deal with a difficult patient, but I could not connect with him.  The power of words failed me.  He kept standing up while I was attempting to gather his history, and the sight of this very large man gesticulating wildly between me and the door gave me a qualm every time he stood up.  Between his wife and I, we tried to calm him down, but nothing seemed to work.  He alternated between insulting me and denigrating the system, and I bit my tongue and tried to smile pleasantly until it reached the point that he started to use expletives.  I firmly told him that this kind of language was unnecessary.  At this point he demanded to see someone else because he thought I was “belligerent and argumentative.”

My hands shook and my heart was pounding as I escorted him to the appointment desk to be rescheduled, and then I returned to my office and promptly burst into tears. I was angry and upset, mostly at my inability to control the situation and at the fact that I had not been able to get him to see beyond me as the face of an organization, to see me as someone who cared about his well-being, and at myself for feeling intimidated by a patient.

I believe strongly that all patients deserve good health care, the best that I can provide if possible.  To come to a point where I could not do so, made me realize that as providers we also have the right to be treated with dignity.  When we in good conscience have done all we can to do right by our patient, we also deserve to be seen and heard. We deserve, as our patients do, to work in a place where we should not fear for our lives for doing our jobs.  My heart goes out to those in El Paso, and especially the family of the man who was killed trying his best to help others.

Today I am thankful for work which allows me to be present in the lives of others in the midst of their pain and suffering. I pray for the strength to continue to be the opposite of tenebrific as much as possible.  And I am grateful for all of the wonderful patients I’ve met along this journey.

I would love to hear any of your stories of how you’ve either dealt with a difficult person or tactics on how to keep the tears from flowing when you don’t want them to.  I hope and pray that you have someone taking care of you with whom you can laugh and cry. Let them know you appreciate them if you do.  They might really need to hear it today.