Category Archives: death

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There is no blame

This article came up yesterday on Facebook:

http://articles.latimes.com/2013/apr/07/opinion/la-oe-0407-silk-ring-theory-20130407

How never to say the wrong thing….

Well, now, wait. What the hell is your goal? To always comfort people? To always say the right thing? Peaceful and sweet and niceness all the time?

Why?

And isn’t it dishonest?

Isn’t a true friend that loves you the friend who says, hey, this guy you are dating sounds just like the last one, didn’t you say you weren’t going to do that again?

Even if it makes you mad. And you forgive them because damn it, they are RIGHT. You might not forgive them right away. It might take a while. You might shun them and then have to do some crawling and apologizing.

Our society is terribly afraid of emotion. Don’t say the wrong thing. Do not make someone angry, afraid, never ever hurt anyone.

Except…. I am a physician. And I’ve had my mother and then my little sister die of cancer.

With my mother, we did what she wanted. She was home for 6 weeks in hospice. My sister and I cried for two minutes after I told her the surgeon said feeding her iv would kill her faster. We took her home on iv fluid and morphine to starve. She was tough tough tough. We had over thirty visitors from as far away as London.

My partner was her doctor. She did a home visit and she cried. Afterwards my mother said, “I didn’t appreciate that.” So we did not cry.

My sister did one day when I was at work. She started crying after my mother was asleep in the hospital bed. She called me. “I started crying. And everyone left. Everyone left the room. Not one person stayed with me.”

Ouch. Now I can see that once my sister started, everyone was afraid that they would start too. So they all left.

I stopped talking. In the fifth week, family called and I was handed the phone. “How is she? Are you ok?” I just held the phone. I knew I was supposed to say reassuring things, I am ok, she is ok, but I wasn’t and she wasn’t. She was dying and I was broken, weeping inside. So I just held the phone, silent.

My mother died. We were all exhausted. And for the next two years I thought about it…. and one thing that I thought was, I wish she had let me cry. I did what she wanted. We all did. But in the end, I never got to cry with my mother and say how much I was going to miss her.

And maybe she would not have appreciated it. But I am her daughter! Don’t my feelings and wishes matter? There are two of us in this relationship!

Then my sister got breast cancer. At age 41. Stage IIIC. And this time I thought, I will be different.

I refused to do what she wanted. I told her I loved her, I told her when I was mad at her, I told her when she was hurting my feelings and when she was being wonderful. I held BOTH of us close. I held her close but I refused to let her go into the cancer bubble where no one was telling her the truth.

I was dating a man who complained. He told a couple’s counselor: “I want her to do what her sister wants or cut her off.” I explained about my mom. I explained about the cancer bubble, where people stop being honest and only do what they think you want. The counselor defended me.

And I think I did the right thing. For me. AND for my sister. Because our last day together, she thanked me and she even apologized for something… and I got to say “I love you anyhow.” I meant it to my bone marrow. People yelled at me for being grumpy, bitchy, not doing what she said…. but I was my real self with her. And she knew it. And she also knew I love her and stayed real with her.

In the hospital when someone is very sick, families fight. They argue. They get angry. The emotions are running high. The doctors, the nurses, the janitors, the desk people, we are used to it. People yell, they cry, they behave badly. But their hearts are breaking, why would we expect them or order them to behave well? Honestly, sometimes they work off some of the anger part of grief by fighting with each other.

In clinic sometimes I am handling a room: a person with cancer with a spouse and one or more children. Adult children. People handle death in different ways. Siblings fight before and after a death, “You aren’t doing right.” We are all different. The way I grieve is different from the way you grieve. There is no wrong, there is no blame.

My sister wanted to handle her cancer with grace. Grace, it’s complicated. For me, the greatest grace is honesty.

I want to die singing, crying, going to see the people I love that are gone, and honestly. The I Ching sometimes says there is no blame. Think if we could all accept each other’s honest emotions. The most beautiful harmony is sometimes the resolution of dissonance. Goodbye, goodbye, I will miss you so….and there is no blame.

 

For the Daily Prompt: harmonize. I took the photograph of my sister four days before she died.

 

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diy

The other thing that I think of with Sam is tools and do it yourself. He told me once that when he went to college, he wanted to learn everything. He had tons of both practical and esoteric knowledge. I took these pictures at Lake Matinenda… so for those of you who don’t know, what is this? Can you guess?

That summer I helped wire an outlet attached to this and helped float the raft in the correct position, which fine tuned my motor boat driving skills. I had to hold the boat in position in wind and waves, while Sam yelled over his shoulder at me and connected lines and wires and an anchor.

705matinenda&walnut 070

 

 

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play

I took this in 2005. My daughter is going after our friend Sam. She is wearing glow in the dark vampire teeth. He is going along with it and playing along. Three of us are playing because they are my glow in the dark vampire teeth. I have a strong connection with that playful inner child part and so I always have some toy in my dopp kit. Glow in the dark vampire teeth. Temporary tattoos. Glue and glitter for temporary tattoo stencils. A friend once looked in my dopp kit and was very surprised. His only contains toothpaste and toothbrush and razor and practical things.

Blessing on Sam and all the adults who play when the time is right….

dopp kit: http://shop.wingtip.com/why-is-it-called-a-dopp-kit

 

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growth

This is for photrablogger’s Mundane Monday #116. Ok, yeah, it’s Thursday. I am thrown off by four days off, my son visiting all the way from Maryland and the news of the death of an old friend, Monday.

The lower branches of the trees are dead, but are covered with growth anyhow: the hanging beautiful moss. I don’t know how the moss holds on through the dry season. Meanwhile the tree continues upwards, new branches reaching up to the light.

I took this on Mount Zion, two weeks ago.

Lake Street Dive: What I’m doing here.

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bye bye doctors

stop this healthcare bill… until there is transparency… or this will get worse.

 

I am grieving, watching doctors leave.

I have been in my rural county, 27,000 people, for 17 years.

Doctors are leaving. Wake up, United States.

The trend when I got here was that we had 14 primary care doctors and 5 midlevels. For years, we lost one primary care doctor a year. I would grieve and it would mean more work, every year. We would get a new doctor, but often there would be a gap… I made up a game to help cope with grieving. I call it “Local Doctor Survivor”. I would bet on the next doctor to leave and also on their trajectory. One of three: nice doctor, angry doctor, doctor labeled nuts. Burn out.

But…in 2015 it jumped. Suddenly we had 3 primary care doctors and two midlevels leave. Uh-uh. One was a husband and wife, doctor and nurse practitioner. One switched to being a hospitalist. Another left. And another midlevel. By then, we still had 14 primary care doctors, but the number of midlevels, nurse practitioners and physicians assistants had risen to 12. Ok, 12 plus 14 is 26. One fifth left. That is a bad trend.

In 2016 another physicians assistant retired. One of the best. I stopped counting who was leaving. Until another doctor announced they were leaving in February 2017. One of the best. That doctor said that a 20 minute visit generates 1 hour of paperwork. If one works “full time” the quota of patients is 18 per day, 72 in the four day week, and that is 32 hours four days a week of 20 minute visits. Generating 72 additional hours paperwork. That is 104 hours a week. Unsustainable.

The 2016 salary information is out for primary care. The “median” family practice physician in the US makes $168,000. Ok. But every doctor given as an example works 60-70 hours a week. Maybe that salary is not as good as you think. Because they are quitting.

Our neurologist retired, in about 2010. I was bummed. The county north of us has 75,000 people. They had two neurologists. Both left in the last two years. The county south of us has 350,000 people. They had five neurologists. Two have left, including my current favorite. For the first time in 17 years I have a neurology referral refused: and not one, but two. Send them to the big city, says one. The other just says no.

I call ENT and he bemoans that now they are down to three in the county. Another left. Three there, one on the county north of me, great, we have 4 for 450,000 people.

I get a letter from one of the two neurosurgeons in Seattle that I like best. In 2016. He is leaving to go do medical administration in another country.

Our three counties are down three dermatologists. One sent a letter. “I am quitting on October 1, 2016, unless ICD-10 is cancelled.” ICD-10 is the new manual of diagnostic codes. It was not cancelled so that dermatologist quit. We have to code every diagnosis. ICD-9 had 14,000 codes. ICD-10 has 48,000. I am memorizing the new ones. I10 is hypertension. E11.65 is type II diabetes in poor control. I used to be able to write a prescription for diabetic supplies, lancets and glucose strips. Now I have to include the ICD-10 code on the prescription and often the pharmacy cites medicare and demands that I fax proof that I have seen the patient and that the patient does indeed need the prescription. I frankly have better use for my brain than memorizing the ICD-10 codes, but whatever.

Another clinic closed in the county north of us and our county. Then the main clinic closed in the county south of us. Within two weeks. 3500 patients needing primary care providers and refills and we can’t get old records because the rumor mill says it was a “hostile takeover”. That is, the person who owned the clinics quit paying the bills, so the electronic medical company won’t release the records. Great.

I have been absorbing about one new patient per day worked since March, but I am getting tired and will have to back off.

Meanwhile, our county hospital has been hiring specialists. Gynecology, new orthopedists, dermatology. Great, right? But currently most specialists won’t take a new patient without the patient having a primary care doctor. Why? Well, one of the new trends is that the specialist says the patient needs something but that I should order it. Yep. Had one of those yesterday. The specialist says I should order it. It’s a veteran. So I get to fill out the VA authorization paperwork with the ICD-10 codes and the CPT code for the study, fax that to the VA, call the patient and remind him to call triwest, because if the patient doesn’t call then triwest throws the authorization paperwork out. And the specialist makes more than 5 times the amount I do. Maybe I should retrain. I am a specialist: family practice, three year residency, board certified, board eligible. But….. I have little value in the United States.

We are seeing Veterans in spite of the extra paperwork. Triwest is sending us 5 from Whidby Island. They have to take a ferry to see me. Because no one on Whidby is taking veterans. My receptionist complains to triwest about all the doctors leaving the Olympic Peninsula.

“No,” says the triwest person. “Not just the Olympic Peninsula. The whole west coast of the US.”

 

http://www.aafp.org/news/government-medicine/20170620senatespeakout.html

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Dream log: June 20, 2017

I am with my father and my sister. My mother is not around. I am not sure if she’s gone or dead. Dead, I think.

My father has gone off. My sister is 3 or 4 and I am 6 or 7. I am taking care of her. We are at a park and I am trying to get food. It is Thanksgiving. It is not cold, it’s warm. There are large family groups at picnic tables.

My technique is to move in on a family group. We play near them and I listen for adult names. We play close enough that I can hear but not close enough to impinge on the group. When they start to clean up and take things to the cars, I am ready. I slip in and hold my hands out for a bowl. The adult looks at me. “Aunt Norma’s.” I say confidently, because I know which bowl belongs to each adult. And which bowl I want. The adult hands me the bowl. They can’t remember which kid I am, but I know Aunt Norma’s name….I head confidently with the bowl towards the cars and quickly slide it under my loose sweatshirt. I bypass the cars and head around to my sister.

Now the game changes a little. We have a couple bowls so she guards them. I work the next table alone and score a left over turkey.

The problem now is that we cannot carry it all to the car in one trip. I debate about safety. We are living in the car. I tell my sister to stay with the rest of the food and I leave her, carrying the turkey. It’s still light and there are still a lot of people around. She is sitting on the curb, bowls behind her, between two family groups. I will get the turkey to the car and then run back to her. The two of us can carry the rest of the food in one trip. Then we will have food for a while. She should be safe.

I wake up.

I took the photograph within the last month. What and where is it?

 

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cabin door

Another door, this taken by my daughter,Β  of me and a door. We stayed in a cousin’s cabin because our most functional and least ghost occupied cabin was set for a new roof. My cousin kindly let me use their cabin.

My parents helped my aunt and uncle build this cabin. My father talked about it. I have been going to the lake since I was a baby. Now I go about every other year: too far for yearly.

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screen door

For Thursday doors. This is one of the cabins that my family owns at Lake Matinenda. I don’t think anyone has stayed in it since my sister died in 2012. That summer my daughter and I went and tried to clean some. There were too many things that were out where the mice could get them. We bought plastic containers and crated things up. We took all the beer bottles in the boat to the car and 17 miles to town to recycle them. We took loads of mouse nested clothes and shoes to the dump. We took a guitar that belonged to my sister home to my niece.

We were too raw to make decisions, to take the clothes and wash them and give them to a charity. It is time to do that.

A door into memory and how much my daughter helped, with no complaint.

 

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portal cup

If this cup is a portal,Β  where does it take you?

I took the photograph at the Renwick. I asked the guard if I could take photographs. He smiled and said, “We encourage it.” And it’s part of the Smithsonian….free. I could not take my tea inside, and that seems entirely fair….but, free, that is, paid for by the citizens of the United States with our taxes and welcoming people from all over the world to step in and see what is there…..

…..and where does this cup take each of us?

…..and does this fit the Daily Prompt?