Being Led Home

photo by Josh Scholten
photo by Josh Scholten

Nothing was helping.  Everything had been tried for a week of the most intensive critical care possible.  A twenty year old man, completely healthy only two weeks previously, was holding on to life by a mere thread and nothing and no one could stop his dying.

His battle against MRSA pneumonia precipitated by a brief influenza-like illness had been lost.   Despite aggressive hemodynamic, antibiotic and ventilator management, he was becoming more hypoxic, his lungs collapsing and his renal function deteriorating.   He had remained unresponsive during the ordeal due to intentional sedation for his time in the ICU.

The intensivist looked weary and defeated. The nurses were staring at their laps, unable to look up, their eyes tearing. The hospital chaplain reached out to hold this young man’s mother’s hands.

After almost a week of heroic effort and treatment, there was now clarity about the next step.

Two hours later, a group of family and friends gathered in the waiting room outside the ICU doors. Most were the age of their friend; they assisted each other in tying on the gowns over their clothing, helped distribute gloves and masks. Together, holding each other up, they waited for the signal to come in after the ventilator had been removed and he was barely breathing without assistance. They entered his room and gathered around his bed.

He was ravaged by this sudden illness, his strong young body beaten and giving up. His breathing was now ragged and irregular, the sedation preventing response but not necessarily preventing awareness. He was surrounded by silence as each individual who had known and loved him struggled with the knowledge that this was the final goodbye.

His father approached the head of the bed and put his hands on his boy’s forehead and cheek.  He held his son’s face tenderly, bowing in silent prayer and then murmuring words of comfort. It was okay to let go. It was okay to leave us now. We will see you again. We’ll meet again.  We’ll know where you can be found.

His mother stood alongside, rubbing her son’s arms, gazing into his face as he slowly slowly slipped away. His father began humming, indistinguishable notes initially, just low sounds coming from a deep well of anguish and loss.

As the son’s breaths spaced farther apart, his dad’s hummed song became recognizable as the hymn of praise by John Newton, Amazing Grace.  The words started to form around the notes. At first his dad was singing alone, giving this gift to his son as he passed, and then his mom joined in as well. His sisters wept and sang. His friends didn’t know all the words but tried to sing through their tears. The chaplain helped when we stumbled, not knowing if we were getting it right, not ever having done anything like this before.

Amazing Grace, how sweet the sound,
That saved a wretch like me.
I once was lost but now am found,
Was blind, but now I see.

Through many dangers, toils and snares
I have already come;
‘Tis Grace that brought me safe thus far
and Grace will lead me home.

Yea, when this flesh and heart shall fail,
And mortal life shall cease,
I shall possess within the veil,
A life of joy and peace.

When we’ve been here ten thousand years
Bright shining as the sun.
We’ve no less days to sing God’s praise
Than when we’ve first begun.

And then he left us, his flesh and heart having failed, to enter into a new life of joy and peace.

His mom hugged each sobbing person there–the young friends, the nurses, the doctors humbled by a powerful pathogen. She thanked each one for being present for his death, for their vigil kept through the week in the hospital.

This young man, stricken by a common virus followed by a devastating bacterial pneumonia, was now lost to this mortal life, having profoundly touched so many people in his dying. His parents’ grief in their loss, so gracious and giving to the young people who had never confronted death before, remains, even now a few years later,  unforgettable.

This was their promise to their son as they let him go, as he was lost to them: that he would be found, that he was deeply loved.
This was their sacred gift to us who witnessed this love in the letting go: such Grace will lead us all home.

 

Thirty Eight Years Ago

EPSON MFP image

Tonight I received a remarkable email from Bill Grueskin, Dean of Academic Affairs at the Columbia University School of Journalism.    He looked me up on the web to share a scan of an article he wrote as a intern reporter in May 1975 for the Palo Alto Times.  He had been assigned to interview me after I returned to Stanford University following the Gombe kidnapping of May 19.    He keeps his articles like any good journalist and was reminded about this interview after his wife heard my professor and mentor Dr. David Hamburg at a Grand Rounds presentation at a New York Hospital today refer to the Gombe kidnapping and subsequent rescue of the students.

I was the age that our daughter is now–twenty.  This does not feel like it happened only yesterday.  It feels like it happened in another life. Thank you to Bill for sharing his story with me after all these years.  I’d like to hope I was one of his first interviews leading to his remarkable career of journalistic achievements.

Just click on the image of the article to get it to enlarge for easier reading.

EPSON MFP imageEPSON MFP image

Cat-Like Observation

photo by Nate Gibson
photo by Nate Gibson

Even doctors must become patients eventually, and often challenging patients at that.  We know enough to be dangerous but not enough to be in charge.  We want to question everything but try not to.  We can tend to be catastrophic thinkers because that is how we are trained to be, but fear being alarmists.  We want our care providers to actually like us, when we know they inwardly cringe knowing they are dealing with another physician.  We wouldn’t want to take care of us either.

Due to intermittent changes in vision in one eye, I have recently been getting some practice at trying to be a model patient.  Unfortunately, I have become an ‘interesting’ patient, something no patient really wants to be.  That means the symptoms are not classic, the diagnostic tests not straight forward, the exam findings not clear cut, the differential diagnosis list very long.   It also usually means a visit to a tertiary care center for a visit with a sub-subspecialist to try to pick the brain of one of the handful of living physicians who thoroughly understands one aspect of complex human physiology and anatomy.  As a primary care physician who always sees an entire forest when I approach a patient, it is a unique experience to watch a colleague at work who truly concentrates on understanding one leaf on one tree.

A public academic training institution’s subspecialty care outpatient clinic is a fascinating place to spend a few hours.  The waiting room was packed to capacity with people from all walks of life sharing our afternoon together because of a shared concern about one small but crucial part of our bodies — our retinas.  We were all told the average time spent in clinic could be three hours or more and we all knew it was worth the wait so didn’t mind a bit.   Despite the long wait, not one of us would have thought to object when a couple of sheriff deputies accompanying a shackled county jail inmate dressed in his orange jumpsuit were escorted right into an exam room, rather than taking the only empty seats in the waiting room next to several elderly ladies.   We figured he was more than welcome to jump to the head of the line.

Finally my turn came to be seen first by a technician, and then a resident physician, then more testing with more technicians, and finally by the subspecialist attending physician himself.  I appreciated his gracious greeting acknowledging me as a colleague, but also his unhesitating willingness to be my doctor so I could be his patient.  His assessment after his exam  and review of everything that had been done:  there was no clear cause for my symptoms,  so my diagnosis would carry an “undifferentiated” label rather than the currently less preferred “idiopathic” label.   In other words, he didn’t know for sure what was up with my retina and as an expert he didn’t like to admit that, but there it was.

He then smiled and said “so for now we’ll treat you with MICCO.”

MICCO?  I knew there are many new unique pharmaceutical names that I have not been able to keep up with, but this was a brand new one to me that I figured only a sub-subspecialist would know about and be able to prescribe.

So he explained: Masterful Inactivity Coupled with Cat-like Observation.

In other words, do nothing for the moment but keep a close eye on it and be ready to pounce the minute something changes. Watchful waiting.

I am relieved to only be under watchful surveillance for now even though my diagnosis, its etiology and prognosis is unclear.  I realize it is a treatment strategy I need to use more in my own clinical practice.    It helps solidify that doctor/patient partnership, especially when the patient is a doctor;  I am content to do nothing but watch for now,  knowing I’m being watched.

It was an afternoon well spent in the sub-subspecialty world, as I come away with a commonsense piece of advice very appropriate for some patients in my own primary care practice:

Right now it might appear I’m doing nothing, but doing nothing makes the most sense and is the least risky option.  I’m keeping my unblinking eye on you, ready to spring into action if warranted.

Treatment plan: MICCO prn

photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson

The Bleeding Heart of Sunset

photo by Nate Gibson
photo by Nate Gibson

Very still and mild it was, wrapped in a great, white, brooding silence — a silence which was yet threaded through with many little silvery sounds which you could hear if you hearkened as much with your soul as your ears. The girls wandered down a long pineland aisle that seemed to lead right out into the heart of a deep-red, overflowing winter sunset.”
~ L.M. Montgomery from Anne of the Island

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chocosun

If I can put one touch of rosy sunset into the life of any man or woman, I shall feel that I have worked with God.
~G. K. Chesterton

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photo by Nate Gibson
I wonder at a northwest sunset
evolving from gray haze to warm into golds,
then pinks and oranges to bleeding red. 
So too my heart overflows,
pulsing out the love
poured into me
from God’s endless grace.

I too,
once graying at the end of the day,
will be covered with roses.

Reconciled Trembling

photo by Josh Scholten
photo by Josh Scholten

I am the rest between two notes,
which are somehow always in discord
because Death’s note wants to climb over—
but in the dark interval, reconciled,
they stay there trembling.
And the song goes on, beautiful.”
Rainer Maria Rilke from “My Life is Not This Steeply Sloping Hour”

On Mondays I often feel I’m the spot in the middle between discordant notes. There is on one side of me the pressure of catch-up from what was left undone through the weekend and on the other side is the anticipated demand of the coming week. Before I arrive to work, I’m uneasily in dead center, immobilized by the unknown ahead and the known behind.

This moment of rest in the present, between the trembling past and future, is my moment of reconciliation, my Sabbath extended. This morning I allow myself an instant of silence and reflection before I surge ahead into the week, knowing that on my journey I’ll inevitably hit wrong notes, but it can be beautiful nevertheless.

Even the least harmonious notes find reconciliation within the next chord. I now move from the rest of my Sabbath back into the rhythm of my life.

Trembling, still trembling.

Good Enough

photo by Lea Gibson
photo by Lea Gibson

“and there was once, oh wonderful,
a new horse in the pasture,
a tall, slim being–a neighbor was keeping her there–
and she put her face against my face,
put her muzzle, her nostrils, soft as violets,
against my mouth and my nose, and breathed me,
to see who I was,
a long quiet minute–minutes–
then she stamped her feet and whisked tail
and danced deliciously into the grass away, and came back.
She was saying, so plainly, that I was good, or good enough.”
~Mary Oliver from “The Poet Goes to Indiana”

Our farm has had many muzzles over the years–

Pink noses,
gray noses,
nondescript not-sure-what-color noses,
noses that have white stripes, diamonds,  triangles,
or absolutely no marks at all.

Hot breath that exudes warm grassy fragrance
better than any pricey perfume,
lips softer than the most elegant velvet.

Noses that reach out in greeting,
blow,
sniff,
nuzzle,
caress,
push,
search,

to smudge faces and
shower snot.

Because we’re just good enough
to warrant
such a baptism.

Austere Love

photo by Josh Scholten
photo by Josh Scholten

“Sundays too my father got up early
And put his clothes on in the blueback cold,
then with cracked hands that ached
from labor in the weekday weather made
banked fires blaze. No one ever thanked him.

I’d wake and hear the cold splintering, breaking.
When the rooms were warm, he’d call,
and slowly I would rise and dress,
fearing the chronic angers of that house,

Speaking indifferently to him,
who had driven out the cold
and polished my good shoes as well.
What did I know, what did I know
of love’s austere and lonely offices?”
–  Robert HaydenThose Winter Sundays