An Audience of Terminal Patients

chelanblooms1

Write as if you were dying. At the same time, assume you write for an audience consisting solely of terminal patients. That is, after all, the case.
~Annie Dillard from “Write Till You Drop”

chelanducklings5

You’re going to feel like hell if you wake up someday and you never wrote the stuff that is tugging on the sleeves of your heart: your stories, memories, visions, and songs–your truth, your version of things–in your own voice. That’s really all you have to offer us, and that’s also why you were born.

~Anne Lamott in a recent TED Talk

chelanspirea

I began to write after September 11, 2001 because that day it became obvious to me I was dying, albeit more slowly than the thousands who vanished that day in fire and ash, their voices obliterated with their bodies.   So, nearly each day since, while I still have voice and a new dawn to greet, I speak through my fingers and my camera lens to others dying around me.

My good friend, Sara, who I’ve known and loved half my life, is fighting for her life in an all day cancer surgery today, having fought a chronic disease and a totally different cancer once before and won.  She knows well the hard cost of winning even when the odds aren’t good,  yet still has a courage in her to fight once again.

That will to fight is heavy on my mind today.

We are, after all, terminal patients, some more imminent than others, some of us more prepared to move on, as if our readiness had anything to do with the timing.

Each day I too get a little closer, so I write and share photos of my world in order to hang on awhile longer.  Each day I must detach just a little bit, leaving a small trace of my voice and myself behind.  Eventually, through unmerited grace, so much of me will be left on the page there won’t be anything or anyone left to do the typing.

There is no moment or picture or word to waste.

 

chelanpoppies

 image1

 

Doc Season

duckchelan2

img_0761


It may not be rabbit season or duck season but it definitely seems to be doc season, especially as the next version of the American Health Care Act is unveiled today. This (and the Affordable Care Act which preceded it) is not about patients — it is about how to keep doctors and the health care industry under reasonable cost control and maintain some semblance of quality service.

Physicians are lined up squarely in the gun sights of the media, government agencies and legislators, as well as our employers and coworkers, not to mention our own professional organizations, our Board Certifying bodies, and our dissatisfied patients, all happily acquiring hunting licenses in order to trade off taking aim. It’s not enough any more to wear a bullet proof white coat. It’s driving doctors to hang up their stethoscope much earlier than they expected just to get out of the line of fire. Depending on who is expressing an opinion, doctors are seen as overcompensated, demanding, whiny, too uncommitted, too over-committed, uncaring, egotistical, close-minded, inflexible, and especially, and most annoyingly – perpetually late.

One of the most frequent complaints expressed about doctors is their lack of sensitivity to the demands of their patients’ schedule. Doctors do run late and patients wait. And wait. And wait some more. Patients get angry while waiting and this is reflected in patient (dis)satisfaction surveys which are becoming one of the tools the industry uses to judge the quality of a physician’s work and character as well as their salary compensation.  It is considered basic Customer Service 101.

I admit I’m one of those late doctors. I don’t share the reasons why I’m late with my patients as I enter the exam room apologizing for my tardiness. Taking time to explain takes time away from the task at hand: taking care of the person sitting or lying in front of me. At that moment, they are the most important person in the world to me. More important than the six waiting to see me, more important than the several dozen emails and calls waiting to be returned, more important than the fact I missed lunch or need to go to the bathroom, more important even than the text message from my daughter from school or the worry I carry about my dying mother.

I’m a salaried doctor, just like more and more of my primary care colleagues these days, providing more patient care with fewer resources. I don’t earn more by seeing more patients. There is a work load that I’m expected to carry and my day doesn’t end until that work is done. Some days are typically a four patient an hour schedule, but most days my colleagues and I must work in extra patients triaged to us by careful nurse screeners, and there are only so many minutes that can be squeezed out of an hour so patients end up feeling the pinch. I really want to try to go over the list of concerns some patients bring in so they don’t need to return to clinic for another appointment, and I really do try to deal with the inevitable “oh, by the way” question when my hand is on the door knob. Anytime that happens, I run later in my schedule, but I see it as my mission to provide essential caring for the “most important person in the world” at that moment.

The patient who is angry about waiting for me to arrive in the exam room can’t know that I’m late because the previous patient just found out that her upset stomach was caused by an unplanned and unwanted pregnancy. Perhaps they might be more understanding if they knew that an earlier patient came in with severe self injury so deep it required repair. Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection is showing signs of a pulmonary embolism caused by oral contraceptives. Or the man with blood on the toilet paper after a bowel movement finding out he has sexually transmitted anal warts when he’s never disclosed he has sex with other men, or the woman with bloating whose examination reveals an ominous ovarian mass, or finding incidental needle tracks on arms during an evaluation for itchiness, which leads to a suspicion of undiagnosed chronic hepatitis.

Doctors running late are not being inconsiderate, selfish or insensitive to their patients’ needs. Quite the opposite. We strive to make our patients feel respected, listened to and cared for. Most days it is a challenge to do that well and stay on time. For those who say we are being greedy, so we need to see fewer patients, I respond that health care reform and salaried employment demands we see more patients in less time, not fewer patients in more time. The waiting will only get longer as more doctors hang up their stethoscopes rather than become a target of anger and resentment as every day becomes “doctor season.”

Patients need to bring a book or catch up on correspondence,  bring knitting, schedule for the first appointment of the day. They also need to bring along a dose of charitable grace when they see how crowded the waiting room is. It might help to know you are not alone in your worry and misery.

But your doctor and health care team is very alone, scrambling to do the very best healing they can in the time available.

I’m not hanging my stethoscope up anytime soon though some days I’m so weary by the end, I’m not sure my brain between the ear tips is still functioning. I don’t wear a bullet proof white coat since I refuse to be defensive. If it really is doctor season, I’ll just continue on apologizing as I walk into each exam room, my focus directed to the needs of the “most important person in the whole world.”

And that human being deserves every minute I can give them.

chelanbirches2

chelanshadows

Snake Skin

snakeskin1

 

snakeskin10

 

Pruning back the old spirea bushes
that sprawled for years in summer’s heat,
I bared the snake skin, a yard and a half long:
its naked empty length rippled in the streaming wind
lifting its ghostly coils from the dead shoots
that scraped the slough from the slithering body
that shed it in that narrow, shaded space.

I paused—who wouldn’t?—shears poised,
slipped off gray canvas gloves, extracted
the sere, striated casing from the brown stalks
that had held it, silent, hidden.

I coiled the paper-thin curling sheath with care,
delicately, eased it into a simple squatty box
for keeping, for care, for my daughters
to take to school, to show, to explain
how some sinuous body we’ve never glimpsed,
that haunts about our shrubs, our porch,
left for us this translucent, scale-scored wrapper,
this silent hint of all that moves unseen.
~Stephen Behrendt “Snakeskin”

 

snakeskin3

Cast off on a sunny spring day
onto a warm manure pile,
a wriggled-free fresh molt snakeskin,
nearly covered by my fresh load~
lay blended with old hay, horse hair, shavings,
tucked among what is already digested,
dumped and discarded.
This, an intact hollowed shadow
of a still living creature
who has moved on:
I too need to leave my old self
shrugged off onto the manure pile,
shed when it no longer fits
the ways I’ve grown hallowed,
a fitting remembrance of
who I once was,
yet left behind.
snakeskin9
snakeskin5

A Crack in Everything

brokenbarn

sunrise66172

morningbird

The birds they sang
At the break of day
Start again
I heard them say
Don’t dwell on what
Has passed away
Or what is yet to be

Ah the wars they will
Be fought again
The holy dove
She will be caught again
Bought and sold
And bought again
The dove is never free

You can add up the parts
but you won’t have the sum
You can strike up the march,
there is no drum
Every heart, every heart
to love will come
but like a refugee.

Ring the bells that still can ring
Forget your perfect offering
There is a crack, a crack in everything
That’s how the light gets in.
~Leonard Cohen from “Anthem”

sunsetsky67172

lettinggo4

Our cracks expand with age:
do they not heal as quickly
or are we more brittle than before?

I know how my eyes leak,
my heart feels more porous.
The events of the day break me open even wider.

Let the light pour in
and illuminate our wounds old and new.
Let the world know
that from the hurt comes healing.

May we become the perfect offering.

 

suzzalo

 

dandysunset6

A Deep But Dazzling Darkness

stormynight

287530_534324987764_148300158_30899579_7339161_o

There is in God, some say,
A deep but dazzling darkness, as men here
Say it is late and dusky, because they
             See not all clear.
    O for that night! where I in Him
    Might live invisible and dim!
~Henry Vaughn from “The Night”

dylansnight7

brightnight

Wandering the evening farm,
I feel the darkness rising within me,
more than see or hear
the settling of birdsong,
the clicks and whoosh of owls overhead
the rise of coyote calls.

It is in the horizon’s firelight,
the slowing of my pulse,
and the depth of my breaths.

I let it come over me,
the deep descent,
this most dazzling dusk.

sunset521152

sunset521151

Your Very Flesh

noblesseeye1

 

birchbay6917

 

This is what you shall do:
Love the earth and sun and the animals,
despise riches,
give alms to everyone that asks,
devote your income and labor to others,
hate tyrants,
argue not concerning God,
have patience and indulgence toward the people,
and your very flesh shall be a great poem,
and have the richest fluency, not only in its words,
but in the silent lines of its lips and face,
and between the lashes of your eyes,
and in every motion and joint of your body.
~Walt Whitman from his preface to “Leaves of Grass”

 

19029765_733549410424_7985210921303375709_n

 

Time lurches ahead in imprecisely measured chunks and today is the start of another summer season of relative rest, of another transition for several thousand college students moving on to another phase of life with advice of all sorts ringing in their ears.

Commencement is best suited to start in a season that itself is a poem.  Summer simply stands on its own in all its extravagant abundance of light and warmth and growth and color stretching deep within the rising and setting horizons. Each long day can feel like it must last forever, never ending, yet, like the length of our fleshy days on earth, it eventually winds down, spins itself out, darkening gradually into shadow.

In a few short months we will let go with reluctance as if no summer like it could ever come again.

Yet another will, somehow, somewhere, someday. Our very flesh can depend on it.

Surely such a never-ending summer is what heaven itself will be.

 

marshmallowlunde

sisters5:17

 

Middle-Aged Gals Should Stick Together

noblessesunset

 

noblesseeye1

 

haflingermares

 

I’m almost sixty three, deep into my middle age and some days I’m reminded how deep more than others. Though I’m well past the hot flashes of the last decade, I still compare notes with the aging mares on our farm and watch how well they cope with their advancing years.

For instance:

These mares still have a lot of life left. They run like the wind when turned loose, their hair flies in the wind and they can buck, kick and fart with the best of them.

These mares know who they are. There is no identity crisis here. They are mothers who have finished their mothering years, and are well into the grandmothering years. Even so, they still like to flirt and haven’t given up on the idea that they can attract attention from a certain fella in the neighboring field.

These mares know their jobs very well, sometimes too well and anticipate what is being asked before it is requested. They can go for long periods without work but once saddled or harnessed up and pointed in the right direction, it is like they’ve been doing their job every day for years. No need for a steep learning curve, or reminder lessons. No funny business or messing around. There is pride in their work. They can be a bit out of shape though, with a tendency toward the fluffy side of fitness, so they need a moment to catch their breath once in awhile. Their muscles sometimes hurt the next day. They break out in sweat easily.  They appreciate a break for a mid-day nap.

These mares are opinionated. There is no question they know their own minds, what they want and how they are going to get it and keep no one around them guessing.

These mares are stubborn. Once they’ve decided something, it takes more than soft sweet persuasion, like a whack on the behind, to change course. Once they’ve decided they don’t like another horse, the only way to change that opinion is for the other horse to adopt an attitude of complete servitude and submission, giving way whenever approached and grooming the boss mare whenever asked.

These mares are hungry. Always. See “fluffy” above.

These mares don’t sleep all that much, but wish they could sleep more.  Even though they might look like they are napping (see “mid-day nap” above), they are actually meditating, with their eyes closed, on the next plan of action.

These mares are not as fussy about their appearance as they used to be. The four foot manes have been rubbed down to two foot manes and may have a few more tangles in them. Their tails may have stains (don’t ask why). They stride through mud puddles without a second thought to where the dirt flies, whereas when they were younger, there was no way one hoof was going to set foot in such mucky stuff.

These mares don’t keep as tidy a bedroom as they used to. Why bother? Life is too short for tidiness.

These mares know how to make best friends and keep them. If their best forever friend is not turned out with them in the field, they will stand at the gate, and call nonstop for an hour asking where she is.

These mares know how to give great kisses and hugs. Especially if you are hiding a carrot on your person, you’ll be mugged.

Yes, we deep-in-middle age gals, human and equine, do seem to have a lot in common. Nice to know we can always stick together, through thick and …well, thick.

 

eveningrun

 

spaday2

briarcroftponies

 

wally617