Tag Archives: life

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Dissolution

I am sorting, Beloved.

I dream that my sister has drowned
in the ocean. A sailboat went down.
There were others on board.
Two friends ready me to dive and find her.
I don’t want to scuba dive, I am not trained.
I don’t know how to use the equipment.
I am afraid I will drown too.
I see her daughter, who is four.
Her daughter knows from my face that her mother is lost.
My friends say, “You will be able to find her.
You can find your sister.”
“But she is dead,” I say.
“I don’t want to find her.”
I know that they are right, I could find her.
But I might be separated and lost, in the depths.
I don’t want to die too.

I wake up.
The dream sticks.
My friends wanting me to wear a borrowed wetsuit
and scuba gear and go down untrained.
My sister floating in the depths, dead eyes open.
But she has been dead for years, I think.
And this is the sea of dreams
my unconscious
the greater unconscious
everything.
So why isn’t my sister’s body dissolving?
Changing to a skeleton.
A skeleton coming apart over the years.

I don’t need a wetsuit
or scuba gear
to dive in the sea of dreams
I can breathe in the unconscious
I have been to the bottom of the sea
many times before.

My niece is four in the dream.
She was thirteen when her mother died.
I think she was lost to me long before that.
The dream knows.
Her mother was lost to me
when my niece was four.
Drowned.

When the dream returns
I will say yes to the dive
I love the sea and the ocean and going deep
I don’t need a wetsuit
I don’t need scuba gear
I don’t need to find my sister’s body
She is gone
Dissolved
I let my past go.

I have not dreamed of the ocean

since.

__________________________________

I really don’t know where my sister is, because of the family schism after she died. Are her ashes somewhere?

This poem wanted to be born. For the Ragtag Daily Prompt: Who knew?

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Done and undone

I am done with my third Grand Junction travel doctor assignment and packing to go home. I don’t think much of my temp company at the moment. I had to nag them for two weeks regarding the travel plans. I had to call both airlines (one hour 18 minutes and one hour 38 minutes) to be sure that taking Sol Duc on board the plane is arranged (it wasn’t). I called the hotel for the day between planes and they do not take pets. I called the company that takes me from the airport the last two hours home and they DID know about the cat. One out of four. They finally switched the hotel on Friday, the last day of work.

Then at 5:18 pm I am sent an email saying I have to vacate on the 19th. The first plane is on the 21st. It was sent by the rep who is covering me and knew the travel arrangements are for the 21st. I am glad that I pay way more attention to detail as a physician than they do to my travel and housing. They frankly suck. And I am not vacating until Monday. They may charge me at which point I will say they need to pay me for spending more than 5 hours fixing their travel screw ups.

I did say to the rep on Friday, “Well, if it’s not arranged today, I will just call the emergency travel line at 5:01 pm. They will help me.” The emergency travel folks cost them more money. That apparently caused them to do the last arrangements. I am doing the travel in two days because otherwise my cat would be in the carrier for 12 or more hours. That is not reasonable.

I am done except for travel home. Today I finish packing and cleaning.

The photograph is Sol Duc in front of our rental house yesterday. I think she will miss the heat here. She seems to quite enjoy 90+ degrees.

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For the Ragtag Daily Prompt: done.

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Taste

I am back in Colorado for another work stint.

I am in a different house.

I am in a neighborhood, of cul de sacs that don’t connect. My house is quiet in front but backs on a very busy road, an artery. The speed limit is 40 mph but people often go faster.

The house seems odd to me. There are curtains and shades on every window, all closed when I arrived. I open them, because I like light. There is a 3 by 4 foot television in the living room, another in the master bedroom and a third in a guest bedroom. There is a large kitchen with tons of shelves and cupboards, but a table only seats two, and there are two more chairs at the counter. This feels very odd to me. It seems as if the whole house is arranged to watch television.

I go for a walk in the neighborhood. There are many houses. There are beautifully trimmed lawns and there are flowers and some roses. What is missing? There are no people. Walking a mile and a half, finding the mostly hidden corridors from one cul de sac to the next, I see one man working on his lawn. Even though it is Saturday afternoon, I seen no children, no dogs, no toys. I see two garages that are open, one with a man and in the second I hear a child. Why are there beautiful lawns and no people? And many of the lawns have little flags saying, poison sprayed.

I do turn on one of the televisions after my first day of work. The living room one says that the antenna is not hooked up. The guest bedroom one works. I look on the service. Nearly every movie is about violence and conflict.

I do a little research on the internet. I go to the library and take out 8 books. One is Nonviolent Communication, by Marshall Rosenberg, PhD. Most of the others are fiction. Yet so much fiction is about conflict too. Good triumphing over evil. I am pretty good at nonviolent communication in clinic after 30 years: I want to meet each patient somewhere that is helpful. Sometimes they don’t like what I find, or don’t want to do what I recommend, but I have a deep and abiding faith that everyone can change, that they are smart, that I can make a difference and that they are capable. I think that belief helps daily in clinic.

I choose this book because I want to be better. Some of my family is estranged. I thought that was rare and horrifying at first, years ago. Now I think that it is horrifyingly common, much more common than I realized. How do we heal this? What can we change? I don’t want to be in a dark house with the shades down watching “good” triumph violently over “evil”.

There is a pond, man made, with a fence around it, half a block from my house. There are two male mallards, a female, and eight ducklings. They are fuzzy and delightful. I stop my car and watch the first time I see them, and I walk over too.

I haven’t seen anyone else there. I think we can change. I have hope. I have a deep and abiding faith that we can change.

For the Ragtag Daily Prompt: garlic.

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What to check before bringing your elder home from the hospital

I get a call from the hospital (this is over a year ago). They say, “Your friend is ready for discharge. What time can you pick her up?”

I reply, “Can she walk?”

“What?”

“She has three steps up into her house. Can she walk, because otherwise I can’t get her into her home.”

“Oh, uh, we will check.”

They call me back. “She can’t walk. She’ll have to stay another day.”

I knew that she couldn’t walk before they called. She could barely walk before the surgery and after anesthesia, surgery and a night in the hospital, her walking was worse. She had been falling 1-5 times at home and the surgeon knew that. He did not take it into account. The staff would have delivered her to my car in a wheelchair and then it would have been my problem.

She was confused by that afternoon, which is not uncommon in older people after anesthesia. She stayed in the hospital for six days and then went to rehab, because she still couldn’t walk safely.

Recently I have a patient, an elder, that I send to the emergency room for possible admission. He is admitted and discharged after two and a half days. Unfortunately he can barely walk and his wife is sick as well. The medicare rules say that he needs 72 hours in the hospital before he qualifies for rehab. We scramble in clinic to get them Home Health services, with a nurse check and physical therapy and occupational therapy, and I ask for Meals on Wheels. It turns out that Meals on Wheels will be able to deliver in two months.

The wife refuses to go to the emergency room. I tell her that if she does get sicker, that they both need to check in. The husband can barely walk and is not safe home alone. If one gets hospitalized, they both need it.

If you have a frail elder, be careful when you are called about discharge. Go look at them yourself, make sure that you see that they can get out of bed, get to the bathroom, walk up and down the hall. Can they eat? Do you have steps into your house or theirs and can they go up the steps? I got away with saying please check that my friend could walk because I am a physician, because I knew she couldn’t and because there was no one else to pick her up. Do NOT ask your elder. They may want nothing more than to go home and they may well exaggerate what they can do or be firmly in denial. You want them to be safe at home, to not fall, to not break a hip and to not be bedridden.

For an already frail elder, even two and a half days in bed contributes to weakness. And being sick makes them weaker. If they are barely walking when they are admitted, it may be worse even after just 2-3 days. I used to write for physical therapy evaluation and exercise when elder patients were admitted, to help them for discharge. Once I got a polite query from physical therapy saying, “This patient is on a ventilator. Do you still want a consult?” I reply, “Yes, please do passive range of motion, thank you!”

Your elder does not have to be doing rumbustious dancing before they go home, but they need to be able to manage stairs, manage the bathroom, manage walking so that they can get stronger. Otherwise a stay in a nursing home or rehabilitation facility may be much safer for everyone.

For the Ragtag Daily Prompt: rumbustious.


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Who is there?

This is not a brilliant photograph, but it is interesting. This is taken from North Beach in 2022 with my cell phone. It was a very grey day and wet and we heard roaring. I imitate both animals and birds, so I roared back and tried to match the call. This is the response. These are sea lions and they can be enormous. The elders and biggest ones stopped and stuck their heads out, wanting to know who is there? Thankfully they did not come ashore, because the males can be 2.4 meters long (7.8 feet) and 390 kg (859 pounds). We did stop roaring, a bit intimidated. We had roared back at them other times. The sea lions are moving north, more information here.

I am trying to find time and energy to keep removing lots of old blogs and photographs to make room for the new. I could pay for more space, but then I have to keep paying for it, so I don’t want to. I have gone back and read my 2009 posts, no pictures, from the Mad As Hell Doctors trip and from writing elsewhere. I write more often with the Ragtag Daily Prompt, but the longer medical posts are intermittent.

Work has been interesting and I feel a bit off balance, because the plan is in flux and morphing. Right now I am in the same clinic Monday through Thursday, but at two different desks. I won’t be in this clinic for the rest of the assignment unless something changes. I don’t know where I will go next. Primary care has lost two providers in the six months I’ve been here, but I don’t know if that is an ongoing rate nor how many there are total.

My first job out of residency had a terrible turnover. I was fifth senior doctor out of fifteen in two years. That is a really really bad sign. By the end of the second year I was fairly sure that I would not be staying and that I could not change the culture. The three women doctors that I had joined had been trying for two years and one had already left! I was gone by the end of the third year.

And back to roaring with the sea lions. Here is Walt Kelly’s take on roaring, his poem Northern Lights.

Oh, roar a roar for Nora, for Nora in the night,
For she has seen aurora borealis burning bright.

A furore for our Nora! And applaud Aurora seen!
Where, throughout the Summer, has our borealis been?

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For the Ragtag Daily Prompt: grey.

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Tea bear

My friend C. is a bear.

People don’t know she is a bear. She carries a bear, a teddy bear. It is named S Bear, after her husband. He died of cancer a while ago. So she carries a bear named after him. The first time I met the bear, I asked if it needed a teacup too. Because people make clothes for it and I don’t know how far it all goes. No, the teddy bear did not need a teacup.

My friend C. is a bear. She writes horror stories under the name lostcauser. The writer is from Tennessee and so is C. The stories are horrid. Lostcauser is an anagram. Rearrange the letters and you get closet ursa. Closet bear. Hidden bear.

She is not my only friend who is a bear. She is aware of her bearness, her ferocity, the beast inside. Bears like honey and blueberries, too, they aren’t just monsters. My other friend dreams of a one room shack in the woods. His dead brother is at the door shouting for help. His brother is being attacked by a bear. A huge terrifying bear.

“Did you invite it in?” I ask.

“It’s a BEAR.” says my friend.

“It’s a Dream Bear.” I say, “I would ask what it wants.”

“You don’t understand bears,” says my friend.

“I understand a lot about dreams. Some think that everyone you see in a dream is a part of yourself. It can be a part that you don’t accept.”

“Bears attack. You can’t invite them in.”

“I would ask the bear in. I would ask the bear if it would like some tea.”

I tell another friend about one of my dreams. There are monsters screaming. I go towards them.

“TOWARDS them?” says my friend. “Why would you go TOWARDS them?”

I have to think about it. “Well, they are screaming. They might be hurt. They might need medical care. I have to go help them.”

My friend shakes his head. “Only you,” he says, “would go towards the screaming.”

One time in my neighborhood, I hear horrible screaming. I get up. It is 1 am. I go out and try to find the screamer. I don’t find anyone. A few days later, I read that someone nearly severed their arm somehow, in my neighborhood. A policeman saves his life with a tourniquet. It was three blocks from my house, at the grade school. The grade school is where I went. I think the person was knifed, but I don’t know. My neighborhood does not get a lot of that sort of thing, at least, not a lot of screaming that wakes me up.

I wonder about my friend that is attacked by a dream bear. A bear that is much bigger than his dream self and his dream brother self. There must be a lot of darkness in that bear. It is angry about being ignored.

My friend C. is a bear. She knows she is a bear. Reading her stories, I do not think she likes being a bear.

I don’t mind if she is a bear. I wonder if we will have tea again some day.

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For the Ragtag Daily Prompt: fan. Why? Maybe I am a fan of bears. Or maybe fans make me think of hats and gloves and tea parties. And bears.

This is based on speculation and some true events.

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Soldier on

Older
bolder
golder
told yer
moulder
soldier on

What is older? Anything and anyone older than me? At one point I have 5 women who are over 100 years old as patients. Two are 104. One is local indigenous tribe and tells me about white women moving to another pew if she sat down near them in church, back when she is in her twenties. I am apologetic at that visit because it is hospital week. Our pacific northwest hospital has chosen cowboys as the theme so being a bit oppositional defiant, I have braids with one feather hanging down. I swear that EVERY ONE of my indigenous patients comes in, including the 104 year old. I apologize, but they mostly seem amused by my rebellion.

They also influence me. Now when a 72 year old complains about being OLD, I say, “You are not old in my practice.” They look confused. I say, “I’ve had five people over 100 all at once, so you don’t get to complain about being old until you are 90.” People laugh, but they also usually look pleased. Over 100 is a LOT older than 72. When someone is over 100, I don’t really doctor them much. I might say, “This is what the book says we should do.” “I’m not doing that,” says my 101 year old. “Ok, cool.” I say. It’s hard to argue with.

And the joke about the centurian? What do you like best about turning 100? “No peer pressure.” Um, yes. I want them to tell ME what they’ve done to reach 100. The one thing that they all have in common is that they are all stubborn. I don’t know if stubbornness is what gets them there or if we just get more stubborn as we get older. Both, perhaps.

By stubborn, I don’t mean that they don’t learn and do new things. I had a woman in her upper 70s who I diagnosed with diabetes. At the next visit she said cheerfully, “I found these five apps for my phone. This one tells me the carbohydrates, this keeps track of the distance I walk, this one tracks my blood sugar.” I don’t remember what the other two did. This was a decade ago. She was retired from Microsoft. I wanted her to teach a class for me and all of my other diabetic patients.

My grandmother took classes in her 80s in lip-reading. She was going quite deaf and her hearing aides were not terribly helpful. She had videotapes and a rather shy teacher who would come to the house. She would glare at him and the videotapes. She attacked learning it like a piranha and was furious that she couldn’t learn it faster. I am like that too and my son learned some patience from the violin. He couldn’t play well immediately and found that practice works.

At what age is someone old? I think that’s moving target and the older we get, the older we think it is. I do think 104 is a lot older than 72. When does your culture think that people are old? My fierce grandmother said that she would look out her window. “I see little old ladies across the street and think, oh, poor things, they are so old. But then I think, OH, I am older then they are!” She died at age 93, fierce until the end and curious about death too. Her last words to my father were, “Look, Mac, I’m dying.” He said, “I’m looking,” and she stopped breathing. She was always curious and funny and could tease quite terribly and she and my mother butted heads and loved each other. She loved my father too, and me.

The photograph is my maternal grandmother, Katherine White Burling and it’s one I took.

For the Ragtag Daily Prompt: older.

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You can have some of the things some of the time

My father’s name is Malcolm Kenyon Ottaway. He went by Mac. He died in 2013. I miss him and I still follow Mac’s Rule.

Mac’s Rule is simple: You can get one third of the things that you think you can get done in a day.

I played with this on my days off for quite a while. I would write a list of all the things I wanted or needed to get done. Once I write the full list, it looks silly. Soon it is clear that he is correct.

When I am working full time in Family Medicine and have a five year old and a new baby, I think about getting something done on the weekend. Clear my desk, organize photographs, that sort of thing. After a while I realize that the weekend was more like this: Meals. Get kids clean and dressed. Laundry for the next week. Clean the house a bit. Do some fun family things! Read to kids and put them to bed! My list changed and instead of the ambitious “organize photographs”, I would think of something very small. Perhaps take one roll of developed photographs, pick some of the duplicates, send them to the grandparents. That was it for the entire weekend.

If I apply Mac’s Rule to my life and list all the things I want to do, which third will I pick? For years I write lists for a day off and then pick the top third that I want to get done. If something is added to the list, a friend calls to go to coffee, I take something else off. I make sure that the list always has something that I need to do on it (and often don’t want to: start taxes, pay bills, clean a bathroom, whatever). And something fun.

I don’t try to do it all. It’s very satisfying to get that 1/3 done on the list. And I feel like superwoman if I get an extra thing done! I get to choose which third to do and think about it. And the stuff that I don’t want to do slowly gets done over time. It isn’t that awful to do one of those duty jobs, thank you letters, tax information, dental appointment, mammogram, every day and then it gets DONE.

I am working with someone who puts RUSH at the start of every single email subject line. I have to say that it makes me want to dig my feet in and not even read the email. What kind of rash haste are they working under and why would I pay any attention to the RUSH by the ninth email? It is annoying and ludicrous. I move those emails to the next day list and don’t read them on the day of arrival. No pressure, so there.

Blessings on my father, for Mac’s Rule.

For the Ragtag Daily Prompt: rash.

The photograph had to be taken before May 2000, because my mother died on May 15 and she is on the boat. I don’t know who took it, another group sailing. Both my kids are there, my father with the tiller, and I am tucked behind the friend facing the camera. Why haven’t we pulled the motor up? This is Sun Tui, the boat currently in my driveway on a trailer.

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Peace Plague

If I can be anything I want to be
today let me be a peace plague.

Let me be a peace plague, airborne,
spread fast in the air
just a breath of wind
two neighbors who are angry stand at a fence
one drops a rake, the other a hose
they stare at each other. “Come to tea,”
says one, and the other comes.
Someone stops writing a letter of complaint
and gathers blankets for the warming center instead.
A policeman aims at a kid with a gun
shouts “Freeze.” and then he freezes too
on an intaken breath, and the kid drops the gun
hands up, breathing my plague.
And in a war zone, one side chokes on the air
and stops firing. The other aims and stops as well.
Both fall to their knees and weep. After time,
some get up and start gathering the wounded. Others
tear sheets into bandages and yet others start moving the rubble
finding the bodies. The bodies must be found and buried
in holy ground before rebuilding. My cousin
opens her mouth to gossip again and inhales and chokes
and stops. She says something other than she had planned.
Peace spreads like a wave, like a plague, and everyone
looks for someone to help.

If I can be anything I want to be
today I want to be a plague of peace.

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Elder Care: Goals

I really enjoy elder care in Family Medicine. Mostly. Even some of the very difficult or very complicated people.

One thing I would try to figure out is what is the person’s goal? This can be quite funny at times.

“Can we talk about what you would want if you got really sick? If you were too sick to talk to us?”

“I don’t want to talk about death.” Ok, this person is in their 90s.

“That is fine, but if we don’t talk about it, your daughter and I have to guess what you want. And we tend to do more when we don’t know.”

That person glares at me. “Oh, all right.”

Sometimes a person says, “I don’t want to die of cancer.”

It turns out that this is an opening. “Ok, what DO you want to die of?”

“I don’t want to die!”

“Well, me either, but I can’t fix that. There are at least three “ideal” deaths that the Veterans Administration talks to people about. Maybe we could go over them. You could put your request in with your higher power.” I have written about the three here: https://drkottaway.com/2023/10/06/an-ideal-death/. The “Hallmark” or hospice death, sudden death and fight it all the way.

But, other than not dying, what is the goal? To stay in one’s home? To move to a retirement organization that has a nursing home and care until death? Home care insurance to stay home? I do have people imply that they will go into the woods or crash their car or something if they get very sick, but not very often. They are usually aware that I have to respond to any suicide threat. How much care do they want? People often say, “I wouldn’t want to be disabled,” but it turns out that life is often worth living even when very challenging. Most people want to be treated for cancer, for heart disease, for congestive heart failure, to go on.

Sometimes death comes from a cumulative load of chronic problems. We had a gentleman in his 80s in the hospital ICU many years ago. He had pneumonia, congestive heart failure and bad kidneys as well as a host of other problems. I sat down with him. “We are treating you, but when we give you enough medicine to help you breathe, your kidneys are getting worse. This is a small rural hospital. I could transfer you to the Seattle hospital, 2 hours away. You would have a cardiologist, a kidney doctor, a lung doctor. Here you just have me and the nurses. Either way, I do not know if you will live through this. What do you want to do?”

He chose to stay. “My family can visit me here.” His family was visiting daily. “I do not want a breathing tube. I do not want dialysis. If my kidneys go, let me go.” We discussed this with the family.

Four days later it was clear that without dialysis, he was dying. Dialysis might have slowed it, but he may still have died. He was no longer waking up. We withdrew the antibiotics and removed most of the monitoring and switched him to hospice. His family continued to visit and he died a few days later.

He did die in the hospital, and yes, we used some machines up until care was withdrawn, but this still seems like he got to make choices and his family understood. It can be much harder with memory loss when the person really can’t make choices any more.

He was complicated. To keep him breathing well without a machine, we had to give him diuretics, that were eventually too much for his kidneys. A bad heart, lungs with emphysema and pneumonia, and bad kidneys. Sometimes the liver is not working either, and then what is there left to work with? Nearly all drugs are broken down by either the liver or kidneys. Simethicone is not absorbed, so that’s the exception.

Sometimes people get along until too many things accumulate and then they end up in the hospital and on multiple new medicines. It can be very confusing. Regular maintenance is a good idea.

Sometimes the family wants something different from the patient. Or there is an elder parent and three adult children, who all disagree. My job is advocate for the patient. But this is Family Medicine, so I have a responsibility to the patient but also to the family. The person, the family, the community, how is it all fitting together? Sometimes functional, sometimes not.

I had one person who called me when he had been flown to a Seattle hospital. “I have to get home.” he says, “Can you release me? I have to take care of my wife!” I panicked for a moment. “Is your wife bedridden? Where is she? Why are you in the hospital?” She was not bedridden and she was fine. He was being more and more behaviorally squirrelly. He could no longer drive, but drove anyhow. His wife disabled the car, because he would disappear. I sent him to a neurologist for memory testing. The neurologist said, “Hmmm.” and sent him for neuropsych testing. The neuropsych report said dryly that his memory was fine, but he had certain long standing behaviors related to past heavy alcohol use. Oh. He was quite proud of not drinking and going to AA, but he also triangulated with his family and me. I sat him down and said, “Ok, I am not going to talk to a different one of your five children every time you see me in the clinic, because you’ve said, “Don’t tell mom I called you.” Pick ONE person for me to talk to and now you have to have a family member with you when you come to clinic.” He grinned and chose his wife. He had certainly fooled me about his memory, because he blamed his behavior on his memory. The neurologist was not quite fooled. The family calmed down and he did not drive any more, thank goodness. He was not an easy patient, but he was entertaining and educational too. And I felt that I had helped both him and the family.

Sometimes families fight. Sometimes a dysfunctional family will get way worse when someone is sick or dies. Sometimes families go on fighting. Other families are so kind and so good to each other and their elders. Every family is different.

For the Ragtag Daily Prompt: concentration.