Let Us Go In

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Let us go in; the fog is rising…
~Emily Dickinson, her last words

 

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I have watched the dying
in their last hours:
often they see what I cannot,
listen to what is beyond my hearing,
stretch their arms overhead
as fingers touch what is beyond my reach.

I watch and wonder what it will be like
to reverse the steps that brought me here
from the fog of amnion.

The mist of living lifts
as we enter a place
unsurpassed in brilliance and clarity;
the mystery of what lies beyond is solved
simply by going in.

 

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My Heart in Hiding

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High there, how he rung upon the rein of a wimpling wing
In his ecstasy! then off, off forth on swing,
As a skate’s heel sweeps smooth on a bow-bend: the hurl and gliding
Rebuffed the big wind. My heart in hiding
Stirred for a bird, – the achieve of, the mastery of the thing.

Shine, and blue-bleak embers, ah my dear,
Fall, gall themselves, and gash gold-vermilion.

~Gerard Manley Hopkins from  “The Windhover – For Christ Our Lord”

 

 

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And did you feel it, in your heart, how it pertained to everything?
And have you too finally figured out what beauty is for?
And have you changed your life?
~Mary Oliver from “The Swan”

 

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I hold my heart in hiding, trying to protect that tender core of who I am from being pierced and shredded by the slings and arrows of every day life.

Yet to live fully as I am created to live, I must fling myself into the open, wimpling wings spread, the wind holding me up hovering.  I must change my life as the wind changes.

I take my chances, knowing the fall has come.  My wounds shall be healed, even as they bleed.

There is no wonder of it.  So stirred. So much beauty to behold.

Ah…  Ah, my dear.

 

 

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When Worry is a Terminal Disease

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Considering myself a Dr. Doolittle of sorts, always talking to the animals, I reached out to pet a stray cat sitting quietly outside our barn one evening while doing barn chores.  This is a grayish fluffy cat I see around the barns every few months or so–he doesn’t put in frequent appearances and reminds me of a kitten we raised on this farm a few years back, though his markings are a bit different,  so I know it is not our cat.

We have 6 cats to pet here who claim “us” as their home and family, so there is no lack of fur balls to love.  There are probably that many more who hang out,  now and then,  considering our farm fair game and looking for an occasional free meal.  This cat just seemed to need a reassuring pat at that moment or maybe I needed the reassurance.  Wrong.

I found myself with a cat attached to my wrist by teeth and claws.  It took a bit of an effort to shake him off and he escaped into the night. I then surveyed the damage he inflicted and immediately went to wash my wounds.  They were deep punctures near my wrist joint–not good.  Lucky for me I was up to date on my tetanus booster.

By the next day the wounds were getting inflamed and quite sore.  I know all too well the propensity of cat bites to get badly infected with Pasteurella Multocida, a “bad actor” bacteria that can penetrate deep tissues and bone if not treated with aggressive antibiotics.  After getting 6 opinions from my colleagues at clinic, all of whom stood solemnly shaking their heads at my 12 hour delay in getting medical attention,  I surrendered and called my doctor’s office.  I pleaded for a “no visit” prescription as I was up to my eyeballs in my own patients, and he obliged me.  I picked up the antibiotic prescription during a break, sat in the car ready to swallow the first one and then decided to wait a little longer before starting them, knowing they wallop the gut bacteria and cause pretty nasty side effects.  I wanted to see if my own immune system might just be sufficient.

So the bacterial infection risk was significant and real but I was prepared to deal with it.  For some reason I didn’t really think about the risk of rabies until the middle of the night when all dark and depressing thoughts seem to come real to me.

I don’t know this cat.  I doubt he has an owner and it is highly unlikely he is rabies vaccinated.  My own cats aren’t rabies vaccinated (and neither am I) though if I was a conscientious owner, they would be.  Yes, we have bats in our barns and woods and no, there has not been a rabid bat reported in our area in some time.

But what if this cat were potentially infected with the rabies virus but not yet showing symptoms?  Now my mind started to work overtime as any good neurotic will do.  Last summer a rabid kitten in North Carolina potentially exposed 10 people when it was passed around a softball tournament, no one aware it was ill until it died and was tested.  Lots of people had to have rabies shots as a result.

This cat who had bitten me was long gone–there was no finding him in the vast woods and farmland surrounding us.  He couldn’t be kept in observation for 10 days and watched for symptoms, nor could he be sacrificed to examine his neural tissue for signs of the virus.

I called the health department to ask what their recommendation was in a case like this.  Do they recommend rabies immune globulin injection which should have been done as soon as possible after the bite?   I talked with a nurse who read from a prepared script for neurotic people like me.  Feral cats in our area have not been reported to have rabies nor have skunks or raccoons.  Only local bats have been reported to have rabies but not recently.  This cat would have had to have been bitten by a rabid bat to be rabid.  This was considered a “provoked” attack as I had reached out to pet the cat.  This was not a cat acting unusually other than having wrapped itself around my arm.  No, the Health Dept would not recommend rabies immune globulin in this situation but I was free to contact my own doctor to have it done at my own expense if I wished to have the series of 5 vaccination shots over the next month at a cost of about $3000.   Yes, there would be a degree of uncertainty about this and I’d have to live with that uncertainty but she reassured me this was considered a very low risk incident.

I knew this was exactly what I would be told and I would have counseled any patient with the same words.  Somehow it is always more personal when the risk of being wrong has such dire consequences.  I could see the headlines “Local Doctor Dies From Rabid Cat Bite”.

This is not how I want to be remembered.

Rabies is one of the worst possible ways to die.  The cases I’ve read about are among the most frightening I’ve ever seen in the medical literature. Not only is it painful and horrific but it puts family and care providers at risk as well.  It also has an unpredictable incubation period of a up to a month or two, even being reported as long as a year after an exposure.  What a long time to wait in uncertainty.  It also has a prodrome of several days of very nonspecific symptoms of headache, fever and general malaise, like any other viral infection before the encephalitis and other bad stuff hits.  I was going to think about it any time I had a little headache or chill.  This was assuredly going to be a real test of my dubious ability to stifle my tendency for 4-dimensional worries.

I decided to live with the low risk uncertainty and forego the vaccination series.  It was a pragmatic decision based on the odds.  My wounds slowly healed without needing antibiotics.  For ten days I watched for my attacker cat whenever I went to the barn, but he didn’t put in an appearance.  I put out extra food and hoped to lure him in.  It would have been just be so nice to see his healthy face and not have to think about this gray cloud hanging over me for the next few months, as I wondered about every stray symptom.  No gray kitty to be seen.

Almost a month has gone by now and he finally showed up last night.  I could have grabbed him and hugged him but I know better now. No more Dr. Doolittle.

He is perfectly fine and now so am I, cured of a terminal case of worry and hypochondria which is not nearly as deadly as rabies but can be debilitating and life shortening none the less.

From now on, I’ll be contented to just “talk to the animals” like any good Dr. Doolittle.  I don’t need to cuddle them.

 

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photo by Nate Gibson

Foggy and Fine Days Within Me

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And so you have a life that you are living only now,
now and now and now,
gone before you can speak of it,
and you must be thankful for living day by day,
moment by moment …
a life in the breath and pulse and living light of the present…

~Wendell Berry from Hannah Coulter

 

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~Lustravit lampade terras~
(He has illumined the world with a lamp)
The weather and my mood have little connection.
I have my foggy and my fine days within me;
my prosperity or misfortune has little to do with the matter.
– Blaise Pascal from “Miscellaneous Writings”

 

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photo by Nate Gibson

 

Is my gloom, after all,
Shade of His hand,
outstretched caressingly?

~Francis Thompson from “The Hound of Heaven”

 

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My days are filled with anxious and sad patients, one after another after another.  They sit at the edge of their seat, struggling to hold back the flood from brimming eyes, fingers gripping the arms of the chair.   Each moment, each breath, each heart beat overwhelmed by questions:  will there be another breath?  must there be another breath?   Must life go on like this in fear of what the next moment will bring?

The only thing more frightening than the unknown is the knowledge that the next moment will be just like the last or perhaps worse.  There is no recognition of a moment just passed that can never be retrieved and relived.   There is only fear of the next and the next so that the now and now and now is lost forever.

Worry and sorrow and angst are contagious as the flu.
I mask up and wash my hands of it throughout the day.
I wish we could be vaccinated to protect us all from these unnamed fears.

I want to say to them and myself:
Stop this moment in time. Stop and stop and stop.
Stop expecting someone or some thing must fix this feeling.
Stop wanting to be numb to all discomfort.
Stop resenting the gift of each breath.
Just stop.
Instead, simply be.

I want to say:
this moment, foggy or fine, is yours alone,
this moment of weeping and sharing
and breath and pulse and light.
Shout for joy in it.
Celebrate it.
Be thankful for tears that can flow over grateful lips
and stop holding them back.

Stop me before I write,
out of my own anxiety,
yet another prescription
you don’t really need.

Just be–
and be blessed–
in the now and now and now.

 

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People of Your Light

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On Epiphany day,
     we are still the people walking.
     We are still people in the dark,
          and the darkness looms large around us,
          beset as we are by fear,
                                        anxiety,
                                        brutality,
                                        violence,
                                        loss —
          a dozen alienations that we cannot manage.

We are — we could be — people of your light.
     So we pray for the light of your glorious presence
          as we wait for your appearing;
     we pray for the light of your wondrous grace
          as we exhaust our coping capacity;
     we pray for your gift of newness that
          will override our weariness;
     we pray that we may see and know and hear and trust
          in your good rule.

That we may have energy, courage, and freedom to enact
         your rule through the demands of this day.
         We submit our day to you and to your rule, with deep joy and high hope.
~Walter Brueggemann from  Prayers for a Privileged People 

 

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Unclench your fists
Hold out your hands.
Take mine.
Let us hold each other.
Thus is his Glory Manifest.
~Madeleine L’Engle “Epiphany”

 

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Today is celebrated the Feast of Epiphany (His Glory revealed and made manifest in all lives).

Even as weak and crumbling vessels, God is made manifest within us. It is not the easy path to say yes to God: it means sacrifice, abandoning our will for His will so His glory is illuminated by His Light, not ours.

And so, we, like Mary, shall say yes.
His Seed shall take root in our hearts.

 

“Like Mary, we have no way of knowing…
We can ask for courage, however,
and trust that God has not led us into this new land
only to abandon us there.”

~Kathleen Norris from God With Us

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A Stretching Light

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Did you too see it, drifting, all night, on the black river?
Did you see it in the morning, rising into the silvery air –
An armful of white blossoms,
A perfect commotion of silk and linen as it leaned
into the bondage of its wings; a snowbank, a bank of lilies,
Biting the air with its black beak?
Did you hear it, fluting and whistling
A shrill dark music – like the rain pelting the trees – like a waterfall
Knifing down the black ledges?
And did you see it, finally, just under the clouds –
A white cross Streaming across the sky, its feet
Like black leaves, its wings Like the stretching light of the river?
And did you feel it, in your heart, how it pertained to everything?
And have you too finally figured out what beauty is for?
And have you changed your life?
~Mary Oliver from “Swan”

 

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This laboring of ours with all that remains undone,
as if still bound to it,
is like the lumbering gait of the swan.

And then our dying—releasing ourselves
from the very ground on which we stood—
is like the way he hesitantly lowers himself

into the water. It gently receives him,
and, gladly yielding, flows back beneath him,
as wave follows wave,
while he, now wholly serene and sure,
with regal composure,
allows himself to glide.
~Rainer Maria Rilke, “The Swan”

 

And could it be that I too,
awkward and lumbering through my days
may glide and soar when afloat or aloft.Could it be there is beauty hidden away and within
until I change how I look at life,
how I move in the air that I’m given to breathe
and how I am stretched by the Light that illuminates me?
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But now they drift on the still water,   
Mysterious, beautiful;   
Among what rushes will they build,
By what lake’s edge or pool
Delight men’s eyes when I awake some day   
To find they have flown away?
~William Butler Years from “The Wild Swans at Coole”
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Be Obscure Clearly

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A wind has blown the rain away
and blown the sky away
and all the leaves away,
and the trees stand.
I think, I too,
have known autumn too long.
~e.e. cummings

 

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Be obscure clearly.
~E. B. White

 

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As a family doctor in the autumn of a forty year career, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation.  That is hard work for my patients, especially when they are depressed and anxious on top of whatever they are experiencing physically.

There is still much unknown and difficult to understand about psychology, physiology and anatomy.  Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem.  Sometimes the solution is very muddy, not pristine and clear.

Let’s face the lack of facts.  A physician’s clinical work is obscure even on the best of days when everything goes well.  We hope our patients can communicate their concerns as clearly as possible, reflecting accurately what is happening with their health.  In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study.   Our footing is quicksand much of the time even though our patients trust we are giving them rock-solid advice based on a foundation of truth learned over years of education and training.   Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.

Forty years of doctoring in the midst of the mystery of medicine: learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with a little silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients.  What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for.  Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm.  The complex reality of health care reform may dictate something quite different.

The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records.  The pitfall of not knowing what work up was previously done can be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The time has come for the patient to share responsibility for maintenance of their medical records and assist the diagnostic process by providing online symptom and outcomes follow up documentation.

The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops,  reflecting a relationship able to transcend the unknowns.

So we can be obscure with clarity.  Our lives depend on it.

 

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