trauma bunnies

We can work it out, the song says. But no, maybe not, not always.

Trauma bunnies together. Walking. Why would you walk with me, I am so down? Oh, you are a trauma bunny too. Walking on the beach, slowing down, looking at rocks. The walks get longer and longer. You bring FOOD and tell me I have food insecurity. I laugh. But it is true.

Comparing notes about childhood. You say yours was worse. Yours was terrifying. You ran away over and over and over, but came home. Small children need food and shelter. You get older. A neighbor says if you run away now, you will never stop running. You do not run away permanently. But you still run.

My childhood has no bruises to the skin. But the bruises to the heart are a nightmare. You finally say that I win, my childhood was worse. But I was not trying to win, I want to say. I was just telling you as you’ve told me.

We have both survived damage and coped. I have the resource of a grandmother with money who paid for medical school. I apply without telling my parents, after my mother says, “You don’t want to be a doctor. It’s too much work.” I am a poet, a writer, being a doctor so I can study people and have children and be certain there is food. Job security. And food security, true. With a husband or without.

You fight school all the way, but when you are told that you will be a failure or in jail, you decide that you will prove them wrong. You are still proving it. You won’t tell how you make your money, not to the locals, but the new car every two years tells them you have money. And it’s the wrong kind of car: a liberal car for a professed conservative. It stands out.

We start playing trauma bunnies after six months. You want me to come to dinner and I turn New Yorker and direct: is this a date? You are surprised. I set the boundaries and you think about it. And say yes.

But trauma bunnies is not as much fun as the beach. We get close and intimate and then you run. When you run, I run too: the other way. I don’t chase you. You haven’t experienced that before. You keep coming back. Why aren’t I chasing you? Because I too am a trauma bunny, remember?

Back and forth: close and far, together and apart. All holidays become times when you run, so that I will not be part of the family. I announce that I am now your mistress and you can’t be with my family either. Back and forth. Closer and then you refuse to come to my son’s wedding. Far again.

You say the summer will be very busy. You say your focus is music. You say we can go to one beach. One beach? For the whole summer? I run to europe and you are surprised. I ask, are you too busy to have me around? No, you say. But when I return, you have a friend staying with you. Intimacy disappears.

I am tired of it. My daughter is here.

At last I bring up sex: are we done with that?

No, you say. We have visitors.

Wouldn’t stop me, I say.

You say, sex is still on the table. Then you hem and haw. You say sex is not important, you can take or leave it. The friendship is more important. Well, the friendship is most important, but sex IS important to me and hello, it’s damn insulting of you to say you can take or leave it. Leave. This is all triggered by your yearly family get together. You need me at a distance so you won’t be tempted to invite me. You don’t want me there so I am distanced again.

And I am done, done, done. I dream of a small child, a wild woman, a woman doctor and someone new: a quiet woman. I think about the quiet woman and I ask the other three. Yes, they say.

The quiet woman is the adult. Not the mask of the professional, not the wild defense fighter, not the small child. The small child has healed. She is the connection to the Beloved, to the source of the poems. She blesses the others. The quiet woman takes over.

The quiet woman takes over. She says goodbye, farewell, Beloved keep you and bless you, you may contact me any time.

You are in your cave alone and do not answer.

You may end up there, alone, alone, alone. You want freedom most of all, you say. Another song: freedom is another word.

Yes it is. People can change and grow. But some want to and some don’t and sometimes we don’t grow at the same time.

Yes, says the quiet woman. Sometimes we don’t grow at the same time.

Fade to quiet.

______________________________

I took the photograph from a canoe at Lake Matinenda in Ontario, Canada.

Caduceus Hair

A physician says to me, “You might have had more friends and been more successful in your career if you had been put on medication a long time ago.”

I think, “You f—ing bitch.” Nothing shows on my face. The doctor face is pleasant on the surface and the stone face that guards my feelings is deeper. I could show you the snakes and you would turn to stone but I would go to jail.

Your words don’t go away. They fester, a deep deep wound. I ask my other doctor, “If my only symptom of pneumonia is my mood, no white count, no fever, how would I know if I had pneumonia if I were medicated?”

I think back. Age twenty five with belly pain, emergency room, CT scan and then a sigmoidoscopy. I couldn’t eat, it hurt so bad. The emergency room offers me valium. “No,” I say, “my father is an alcoholic. I won’t take that.” I am sent to counseling. The counselor, smug, blonde, polished, wants to send me to her husband, a psychiatrist, for drugs. “No,” I say, “my father is an alcoholic. I want talk therapy not drugs.” I am very very afraid.

Things get better.  I tell the counselor thank you. “You can’t stop now,” she says, “You must continue the counseling. Or you will have problems later on.” I go once more. She says I must keep coming. I speak to a family friend, a PhD psychologist, who encourages me to say no. I cancel. No regrets.

I am not an alcoholic. I don’t smoke. I don’t use pot nor CBD. I never tried cocaine or meth or opioids or crack. I can tell an addict by their charm: the sick people are not charming nor the people in for maintenance. The moment a person tries to charm me I wonder what they want.

The physician is wrong and cruel besides. Valium is addictive and is still overused. I could have taken the path of psychiatric medicine but I chose not to.

I will find another doctor who is less stupid and cruel. They do exist. I know, because I am one.

____________________________

Four myths about death

Currently I see myths about death and dying in the United States. These myths are very strong and lead to a disconnect between medical personnel and non-medical. The medical personnel talk about end of life and want the answers to certain questions. But we often fail to address the persons deep fears and concerns because medicine sees them as myths, and so there is a disconnect between what the patient and the medical person see as important about the discussion of death.

Here are the four questions and fears:

1. How can I avoid being kept alive on a machine?
2. How can I avoid dying in pain?
3. How can I avoid having too much done, too many resources used, and dying in a hospital?
4. How can I avoid dying of starvation or thirst?

1. How can I avoid being kept alive on a machine?

The myth here is that we can keep someone alive on a machine. We almost never can. Comas are extremely rare. There are a very few people who survive a high spinal cord injury, like Christopher Reeves, and can be kept alive for a period on a ventilator. Or people with a disease that leads to the failure of the breathing muscles: Steven Hawkings with ALS has outlived all predictions.

But for the most part we can’t. I have tried: I have had two patients in 25 years with brain death who had signed organ donor cards. When brain death is established, an organ donor team will fly in to a rural area. Meanwhile, I was to attempt to keep the patient’s body alive. One lived long enough and the other did not. I could not stop the death with machines or drugs and that person was already on a ventilator.

Part of this myth is fear relating to hospital settings. ICUs, intensive care units, frighten people. There are alarms going off and machines with blinking lights and it is brightly lit and quiet and alien. Why? If a person is on a ventilator, they are sedated. Otherwise they will automatically pull the breathing tube out or the urinary catheter or the iv or all of them. It is instinctive. They are sick, may be delirious or injured, they are not in their right minds, they are not logical. So they are sedated. Most of the alarms are rightly ignored by the nurses: most alarms are going off because the patient has moved and the machine is not picking up. The nurses learn to filter automatically which alarms are trivial and which alarms do need attention and are an emergency.

I wanted to see an elderly aunt. When I arrived, my cousin said I couldn’t because she was in the emergency room. I said that I am pretty comfortable in emergency rooms and thought I could talk my way back to see her, since I am a physician. We had to wait in the lobby for a couple of hours, but then they let me back.

Part of the drama and horror that shows up in ICUs is the family’s feelings. Family members may feel guilty or angry or afraid and they often lash out at each other. Families are both at their best and their absolute worst when someone is critically ill. I have a friend who still doesn’t speak to a sibling after their father died in hospice three years ago, because they disagreed so strongly on how he should be cared for. The hospital staff and nurses and doctors and maintenance people and laundry people and dietitians are used to families crying or arguing or even yelling at each other. We try to support the patient and the family. But we cannot make them agree and don’t try.

We will return to the “in hospital” death later.

2. How can I avoid dying in pain?

Wear your seatbelt, wear helmets, don’t drive in blizzards, change the batteries in your smoke alarm, don’t text while driving….

That seems like a joke, but not really. Accidents are in the top ten causes of death in the United States currently. People do die in pain if shot, in car accidents, in falls. If we can’t get to them and get pain medicine on board in time.

When death is coming, the fear is that we will die in pain from, for example, cancer. However, most people that I have seen dying of cancer DECREASE the pain medicine rather than increase. There are at least two reasons. One is that they want to be awake. As the kidneys fail, the pain medicine lasts longer. They may not need as much. If they are in hospice and have family present, my experience has been that they say “Turn it down. I don’t want it. I don’t need it.” They want to be awake with their family.

The second reason is that it really may hurt much less. When people stop eating and go into ketosis, some pain receptors are turned off. This is very interesting. I have been using it in clinic: my patients with osteoarthritis who try a ketotic diet say that the joint stops hurting when they become ketotic. One patient said that when her right hip stopped hurting entirely, she realized that the muscles from the left hip were very sore from limping. “After two weeks, I tried one piece of bread,” she said, “And the right hip joint pain came right back.” So a person with end stage cancer or end stage dementia, who does not want to eat, may have little pain or different pain.

Lastly, the most important pain when there is not a sudden violent death, is emotional pain. We may not want people to feel it, but it is better if we can stay present and let them. Stay present, stay kind, listen, do not shut them off. If we shut them off, it is because of our OWN fears.

3. How can I avoid having too much done, too many resources used, and dying in a hospital?

First, fill out a POLST form: Physician orders for life sustaining treatment. The first question is the one medical people want you to answer: if your heart and lungs STOP, and you are dead, do you want us to try to revive you? If someone is over 80, I don’t want to do CPR. I will break their ribs and if we DO get them back, they WILL have damage. People often say, “Bring me back if I will be ok.” I joke that we don’t have the little turkey pop up that says “Too late. Done.” But it is minutes until brain death. If you want to be revived, your best bet is to die in the emergency room in front of the emergency room staff. They can move very fast. The security guards in Las Vegas are also very very good at putting AEDs on people who drop dead from a big win or a big loss.

Living wills are better than nothing, but they often say “If two doctors agree that I am terminal within six months, no extraordinary measures.” This is entirely too vague. What do YOU mean by an extraordinary measure? A ventilator? Aspirin? An iv? No one has ever defined what an extraordinary measure is.

The other questions on a POLST form ask specifically about resources. Hopefully the medical person will explain a little: what is a ventilator, when would we use it, would oxygen be ok, are antibiotics ok, have you talked to your family about this? The POLST form can’t cover everything but it does give us an idea of what someone wants when they can’t talk to us. And it takes some of the burden off the family: father DID say what he wanted and it is in writing and he talked to his doctor about it. If you are the family, how are you going to decide what an extraordinary measure is?

Now: dying in a hospital. Our culture currently pays lip service to dying at home. Sort of. A survey of Veterans revealed THREE DIFFERENT IDEAL DEATHS. One: the Hallmark death, in hospice, at home, surrounded with friends and family making peace with the world. Two: Sudden death, no warning, no attention. Three: fight to the death. This person won’t go, will fight, a miracle is possible and they are NOT at acceptance. Do EVERYTHING.

And dying in a hospital. In residency in Portland I had two patients dying on my medicine rotation. One was a young man in his 20s, surrounded by family and friends, of HIV. He was in the hospital because that is where he felt comfortable and safe and could get immediate help. The friends asked if our team was tired of wading through a crowd to check on him each day. I replied, “No. I am so glad you are here. I have another person dying, and he has no one, an elderly man. He is alone except for me and the staff.” So we, the hospital staff, are the ones who try to comfort the elderly alcoholic dying, the cancer patient estranged from her family, the lost and depressed and solitary and addicted. And we don’t care what they did to get there, the sins committed, the regrets, the mistakes. We try to help as much as we can. I do addiction medicine in part because I felt so sad watching people with addiction die alone. So dying in the hospital is NOT a failure. Sometimes it is where the person feels safest or they don’t have anyone. And not having anyone is a failure of our culture, not of medicine.

4. How can I avoid dying of starvation or thirst?

When someone is dying of cancer or dementia or another slow disorder, they want to stop eating at some point. Sometimes the family gets them to continue eating and the patient will do so out of love for their family. They have no hunger or thirst. Renal failure sets in and the rising creatinine takes them into a gentle coma and then into the great mystery. This looks like a kind death to me: the brain is quietly sedated and put to sleep by the body, by the rising creatinine. Let them go. We will offer food and drink to anyone, but sometimes they are letting go….let them.

And here is a book I want and haven’t read yet: http://www.tc.umn.edu/~parkx032/AD-OUT-NET.html

Cindy gets real and skips the ball

We had a lovely dinner with family and friends. I look at the tablecloths and napkins that I have inherited and I am glad that I live in a time where I can work as a female physician and am not embroidering elaborate tablecloths and napkins. Some of the ones that I have WERE done by female relatives. Amazing and work that is currently not very valued.

So my centerpiece was an acknowledgement of the changes: Cindy is not going to ride in the coach. She has a canoe and paddles and a backpack, sleeping bag, stove, water bottle and GPS. She is going to find her own way and paddle her own canoe.

Augean stable

Here I am
what a load of shit I know heracles did it
with brute strength in the allotted day I too
am assigned a day but I am just a girl you see
and small to boot I lean on the shovel and contemplate
the work what a load of shit has been produced and I
know what I have to do clean and sparkling by morning
I know the goddess to pray to and she shows up with all
her nymphs armed the bows aren’t so useful for shoveling
shit but they can shift it fast we are done long before
morning and all I have to do is pledge myself to her
to virginity like a virgin

all I have to do

my photo is from the 2009 US National Junior Synchronized Swimming Olympics