Adverse Childhood Experiences 13: on gratitude

I saw a meme today about gratitude. It is saying that some people look at a garden and see thorns and weeds, but others see the roses. That we need to have gratitude. I think this is simplistic and papers over the trauma and grief that some people have. If they have endured a highly traumatic childhood, who am I to say they should focus on the roses? They may have a very good reason to see if there is something like a thorn that can hurt them before enjoying the roses.

I work with many patients with high Adverse Childhood Experience scores and mine is high too. I don’t tell my patients that they should have gratitude. I tell them “You survived your childhood. You have crisis wiring. Good for you. Some of your learned crisis survival wiring may not serve you as well now as it did when you were a child.” Then we discuss whether they want to work on any aspects and the many many different approaches. One example: a man who sleeps very lightly. He said that it was lifelong. When asked about his childhood he says, “We would have to leave in the night when there was shooting in my neighborhood. It was a very dangerous area.” I said, “I am not surprised you sleep lightly. You HAD to in childhood to survive. Is this something you want to try and change?” He thought about it and decided, no. Once it was framed as learned in childhood to survive, he stopped worrying about “normal”. He was satisfied that the way he slept was “normal” for him and he wanted to wake up if he heard shooting.

I think we have to ask why a person sees thorns and weeds in a garden before we judge them. My first thought with a new and angry or hostile patient is always, oh, they have been badly hurt in the past. What happened? I don’t worry that the anger is at me. I know it’s not at me, it’s at the system or a past physician or a past event. Under the anger there are other emotions, usually fear or humiliation or grief. I have brought up Adverse Childhood Experience scores on the first visit sometimes. One person replies, “I am a 10 out of 10.” The score only goes up to 8 but I agree. He was a 10. He stated once, “The military loved me because I could go from zero to 60 in one minute.” Very very defensive and very quick to respond. The response may seem extreme and inappropriate to other people: but it may feel like the only safe way to be to my patient.

I grew up hiding any grief or fear in my family, under anger, because grief or fear would be made into a story told for laughs. In college, a boyfriend told me I was an ogre when I was angry. I started working on it then and it was difficult to tame that. The person who took the longest was my sister: she could make me explode until I was in my residency. Medical training was excellent for learning emotional control, at least, on the surface. After my mother died, I had to do the next piece of emotional work: open the Pandora’s Box of stuffed emotions, mostly fear and grief, and let them out. It was such hard work that my day where I saw the counselor for an hour was harder than my ten hour clinic day. I did the work, for two long years. Blessings on the counselors who stood by me while I worked through it.

I do not think we are ever done with that sort of work. I think, what do I need to learn next? What is this friend teaching me? Why is this behavior frustrating me and I have to look in my inner mirror. Why, why, why?

Blessing on your healing path and may you not be judged.

Link about ACE scores: https://www.cdc.gov/violenceprevention/aces/about.html

Sometimes I do feel like a fossil, now that I am middle aged. For the Ragtag Daily Prompt: fossil.

Is this a tree?

Is this a tree?

I would not call this a tree. I would call it a cone. It contains seeds. It is not a tree.

A pregnancy is called an embryo until 8 weeks after conception and then a fetus until birth. It is not a baby, any more than a seed is a tree. Here is a link to a picture of the embryo developing:

https://en.wikipedia.org/wiki/Human_embryonic_development#/media/File:HumanEmbryogenesis.svg

It’s a bit difficult to call the embryo a baby.

After 8 weeks (10 weeks from the last menstrual period) the developing pregnancy is called a fetus. It cannot survive outside the womb. A term pregnancy is 37 weeks, and the due date is at 40 weeks. The earliest survival, certainly not natural, is around 24 weeks. This takes heavy intervention and technology, a premature infant on a ventilator for months. There is risk of damage to the eyes from high oxygen and risk of spontaneous brain bleed and cerebral palsy, because the newborn can weigh half a pound. Once born, the fetus is termed a baby.

This is important from a medical standpoint and pounded into us as physicians. WHY? Because in a trauma situation, the life of the mother comes first. In Obstetrics and Family Medicine, the life of the mother comes first. In Oncology, the life of the mother comes first. My sister was diagnosed with stage IIIB ductal breast cancer at age 41. She was engaged and it turned out that she was pregnant. She wrote this essay on her blog, Butterfly Soup:

The hardest loss of breast cancer.

She had an abortion and chose chemotherapy, because it was her or the fetus. If she had chemotherapy pregnant, at that time she was told that it would probably kill the fetus or cause terrible birth defects. If she held off on chemotherapy for seven months, her oncologist thought she would die. She had a very very aggressive cancer and she already had a daughter who needed her.

She lived until age 49, with multiple rounds of chemotherapy, radiation, gamma knife radiation, whole brain radiation. And she lived until her daughter was 13. Without the abortion, her physicians thought she would have died when her daughter was 7.

My ethics in medicine are that patients have autonomy. I would NOT have wanted my sister to choose to refuse chemo and try to bring a baby to term while dying of breast cancer. However, it was HER CHOICE, not mine. It was private and no one else’s business and how dare people make moral judgements about another person’s medical choices. I give my patients CHOICES. They can choose not to treat cancer and go into hospice. They can choose surgery or refuse it. They can choose to treat opioid addiction or refuse. They may die of a heroin overdose and I grieve. I try to convince them to go to treatment and I give them nalaxone to try to reverse overdoses. I refuse a medication or treatment that I think will harm my patients, but my patients have autonomy and choices. That extends to women and pregnancy as well.

It is NOT a baby in the womb, however emotionally attached people are to this image. It is an embryo first and then a fetus. And in a car wreck, the woman comes first and the fetus second.

For the Ragtag Daily Prompt: explain.

hunger

It is hard to write about hunger

I am always hungry
I am always afraid
I always long for love

How can I always be hungry?
The hunger is partly for food
and partly for love

They are tied together
“You have food insecurity,”
A friend says

I want to argue and do
but I also know that he is right
I am always worried about food

My daughter has it too
she admits that even as she finishes a meal
she wants to know that there is food for the next meal

A friend tell me about running out of food
hiking in Alaska. He is ok with it.
My daughter and I agree we will never camp with him.

My mother says that pregnant
she is hungry the entire time
fantasizes about a banana split and chocolate syrup

After the baby is born
“I did not want the banana split!”
she says and laughs

Maybe it is the baby who is hungry
inside the womb, the fetus that is hungry
“The doctor yells if I gain any weight.” laughs my mother.

Hunger and love intertwined.
I don’t see my mother for nine months after birth
because she is ill.

I curl around my daughter ferociously
I want to protect her from any harm
I eat when I am hungry and feed her food and love

____________________

The photograph is me and my mother. She is getting over tuberculosis and is still very thin. I think that my grandparents took the photograph. I took the photograph of the photograph.

For the Ragtag Daily Prompt: hunger.

before the rain

I took this two days ago on an early beach walk starting at North Beach. The sky was amazing and beautiful. We had intermittent sun through the clouds and very little rain on that walk. It’s easier to see the clear agates when the sun lights them up.

I did not find any clear agates. B found one that met his criteria. There were many other beautiful rocks. This one was way too big to bring home. The rock itself is almost a rainbow.

For the Ragtag Daily Prompt: rainbow.

Achievement

My first achievement for today’s Ragtag Daily Prompt is spelling achievement. And no, I did not spell it correctly on the first try.

My daughter has finished her first two years of teaching eighth grade, during Covid-19. She taught remotely until March of 2021 and then in person. She worked on her teaching certificate the first year and finished her Masters last month. She is SOOOO amazing!

Hooray for ALL of the teachers who continued to teach during Covid-19, remotely, in person, hugs and prayers and sending love.

Volume of water

We check the tides before we go walk the beaches on the Olympic Peninsula. I am learning the patterns of the tide locally. On North Beach, the tide is about an hour later each day. However, low tide is at a different time further out the Olympic Peninsula. I had to think about that a bit.

Picture the tide a low with the Salish Sea volume down. Then the tide turns and starts flowing back in. The Salish Sea is like the roots of a tree, with a main trunk and then branches and branches and more branches. There is water coming in from the land, from streams and from rivers, but the tide rolls in from the trunk first and then spreads through all of the roots. I have a tide table for the peninsula for this year, and it has tables for multiple different sites! Most days we have two high and two low tides, but once in a while the low goes out so little that it matches both highs, and we only have two tides that day, a high and a low!

I took the photograph at Dungeness Spit this month. The tide was nearly low when we started walking and we only went 2-3 miles down the spit and turned back. It is beautiful! Check the weather, check the tides and always take something rain proof, even in July. Our water is not warm.

For the Ragtag Daily Prompt: volume.

Bird talk

A photo tale from a hike last week.

Her: “I think we should discuss our future.”

Him: “Well, um.”

Her: “Wait. Are you trying to tell me something?”

Her: “Is there someone else!!?!”

Him: “I was going to tell you!”

Her: “You lying scum.”

Him: “Wait! Oh, no, she’s GONE.”

__________________________________

For the Ragtag Daily Prompt: create.

These are Pigeon Guillemots, more here.

Photographs taken on Marrowstone Island last week.