Across the Great Divide…Part 2

The High Plains are a place where people get by. No one is “hustling.” Instant gratification does not exist. Distance demands a certain level of patience. In the City I live in, Amazon offers Same-Day delivery. Of course, Amazon delivers to the High Plains, but add 1-2 more days than you would expect in any city.

To live in the small towns that dot the old rail lines of the High Plains, you have be willing to accept a ethos of “good enough and making do.” Optimization is just not really an option most of the time.

For instance, I had an patient in the hospital today who appears to have subclinical hyperthyroidism, rather unrelated to his reason for admission. So, he needs a radioactive iodine uptake scan. A Nuclear Medicine service does not exist here.

It’s the weekend, and none of the staff know where the closest place to have this done is. Obviously it is not in town, but it might be as much 2-3 hours away. It will have to wait and be arranged as outpatient. He is asymptomatic, so we can make do till then.

It’ll have to be good enough. He understands and doesn’t demand transfer to another facility or some other extremely expensive and unnecessary intervention.

World’s Apart

Going back and forth from the High Plains to the City can lead to a rather schizophrenic existence. I can have any product or food I could ever desire in the City, often within minutes. Of course, the caveat is – you have to be able to afford it.

On the High Plains, you can have meat and potatoes, and you’ll probably have to wait.

On the other hand, if you want to be able to see the stars at night, know true silence, the City can’t help you.

Being a Millennial, all my friends from before medical school are scattered about all the cities you’d expect: Seattle, Nashville, Oakland, Boston, London, etc.

Their lives, in those cities thousands of miles away, have more in common with my City life, than the lives of the people I treat, who live less than a couple of hundred miles away from me. The residents of the global city-states measure distance in hours in an airplane, not in miles of streets, fields, and people passed.

Few of them know the human and physical geography right outside their back door. They don’t the seasons of planting, the rhythm of sun, rain, and wind that marks the lives of those who live in the Great Wide Open.

Even those not involved directly in agriculture on the High Plains know those rhythms. The timing of calf sales, wheat and corn harvest, hunting season, determine the rhythms of all other economy.

Even the jobs titles and work in the City seem inexplicable. They are analysts, project managers, a few might even call themselves “influencers.” There is no tangible output to their work. Their hands don’t feel the pulse of a heart, the hum of a machine, or dampness of the soil.

They speak words, makes click on computer screens, and paychecks arrive. No goods are made, exchanged, or transported.

In the City, the idea of economics waiting on the rhythms of the natural world is laughable at best, heretical at worst. Why would a product that does not have a direct basis in the natural world hinge on it at all? We should be able to have anything we desire, yesterday.

Dangerously Simple

The City thrives on complex, interconnected system all available from the touch of the button. Understanding and commanding the complex is highly regarding in the City. In contract, simplicity is considered a virtue in much of Rural America.

People pride themselves on a simple, direct approach to life. If a machine is broken, I fix it. If my neighbor needs help, I help them. In small, close nit communities, this generally works well. It is so ingrained that people often view complex explanations with immediate suspicion.

To many on the High Plains, complexity and obfuscation are the same. In the past, the simple solution to complex situations, such as healthcare, revolved around personal trust. If a problem is too complex, I bring it to someone with knowledge whom I trust – simple.

Trust is simple, you either do or you don’t. However, as the institutions who employ the educated experts concentrate more and more cities, local communities have fewer and fewer experts to trust within them.

The decisions made in cities and state governments feel far removed and unrelated to daily struggles of life on the High Plains. Even in my life, I often have to explain to my consultants on the phone the capabilities of facility I am working in, because many cannot imagine practicing medicine where I do.

So, people on the High Plains must choose between trusting unknown people, who sound like chronic obfuscators, or finding someone who offers a simple solution to complex problems. Not surprisingly, they often choose the latter.

It is cognitively easier to believe something untrue which does not challenge the story one knows about the world than it is reorganize the world.

The Story of our Worlds

In High School, I once debated some Christian idea with a more fundamentalist minded classmate. He cited some part of the Old Testament, I stated that a different part of the Bible said the opposite. He looked at me suspiciously, then at our teacher, who said simply, “It’s true.”

“Noooo!” He literally wailed it. He was desperate as the underlying, organizing tenet of his young life shook precariously from the roots.

America is changing, somethings good, somethings bad, but very, very rapidly. It is becoming more complex, more multicultural, and the change is only accelerating, especially in cities.

These rural communities feel as thought the social anchors which have held them together: church, military fraternal organizations, schools, hospitals, are under attack. Whether they are under attack or simply withering from neglect is up for debate but the result is the same.

The gulf is widening, and all I hear on the High Plains is long, wailing Nooooo…. They wail because ‘Merica is under attack. Not the United States of America, but the story of America that their parents recounted to them and that they have since recounted to their children.

And I truly believe it is. I don’t think it is a bad thing, but I do think it is.

A war of narrative is being waged over what it means to be American in the 21st Century. Rural America is losing the that battle in media, popular culture, and demographics. So, they fight harder on the front where they have an advantage, electoral politics.

I have talked before about the importance of Founding Myths, and Rural America’s binding narrative is losing.

This is an important thing to understand about Rural America, they feel under attack and fear they are losing the battle.

Maybe that is necessary, or at least inevitable, I don’t know. But like all cultures which have existed in one form and now do not, we may look back on the rituals of ‘Mericaness and pine over their passing.

A piece of fleeting human culture that is no longer.

In the meantime, Rural America continues to wail, gnash its teeth, and rend its garments in grief over an identity that seems to be disappearing.

Telling My Story

I have had a lot of time to write and think this shift. It is one of the many gifts of the work I choose to do. When I am on the clock, I have to be here and not at home. So, when things are slow, I get paid to reflect, write and be still.

Between a new baby and my wife and I returning to work, the last couple of months hasn’t had a lot of time for thinking and reflecting. It also hasn’t presented a lot of time for writing.

So, as I have gotten back into writing the blog again, I am coming at it anew. I must decide why I am doing this. I do enjoy it, sure. But I enjoy a lot of other things I have neglected – why am I not doing those?

What is the point of this blog? Why did I start writing a blog? Is it still serving the original purpose, or new one?

I Had a Story to Tell

After moving back to my wife’s home City, I felt fairly adrift in Medicine. I read a lot of other physician blogs, mainly motivated by a desire to learn how to be as effective as possible at paying off my loans.

My loans were the last thing that bound me to Medicine, which I was furious with. I found out a lot of other physicians were struggling with what medicine is. M’s story over at Reflection of a Millennial Doctor particularly resonated with me.

I began responding to posts in the comments. Eventually, I felt like I was writing so much in comments I was in danger of looking like I was trying to take it over. I must have had something to say.

I would like to say I tell my story for other people, so it might help them, or make them feel less alone. Maybe, I kid myself, it will help residents and medical students make decisions with eyes wide open. In reality, those are ancillary benefits. They give me a little bit of a warm feeling inside, but they aren’t why I started this blog.

I simply needed to write my story. I just had to get it out. My anger, grief, pain, and disillusionment, were just too much for me to bear alone. I had left my previous job without so much as exit interview, they were afraid to hear my story. So, I had to spit it all out. And, I had learned I couldn’t tell people I knew.

It was too much for most people to hold. Some people wanted to make it all better – impossible. My partners just wanted to pretend nothing had happened – the worst response. I just needed to get it out.

Vomiting Pain

The first couple weeks of the blog were just vomiting pain. I just sat at my computer and wrote and cried and seethed and cried. A few people have read this blog and some of you have said some nice things, which I acknowledge and appreciate.

Yet, the act of putting the words on the screen was all that mattered. The kind words were nice, but it was the saying of the thing. The putting it into order on a page which made the difference.

I was turning rage and pain and grief into something with a beginning, middle, and maybe, I hoped, an end. Building a narrative was the only helpful thing. When writiers say they need to write, they have to write, I get it now.

It is thing you have power over which seems to make the burden lighter.

Yet, If it Works, the Pain Ebbs

Yet, it took the loss of a newborn daughter and the chaos of a life plan destroyed to get me to that point. But, with time and counseling and a new baby, the pain is ebbing. Like a violent surf slowing into the gentle lapping of waves on a shore. The emotion is still there, but my continent is no longer being battered into the sea.

As I look back at a lot of what I wrote about in the beginning, I can see how the grief and loss gave way to the anger and pain over a medical system which fails us at every turn. The medical system hasn’t gotten any better, but I have figured out how to keep it from it swallowing me, for now.

As time has passed, I no longer need to write. Yet, I still do. Why? I like telling stories. The challenge of conveying a feeling, a place, and emotion in words is interesting.

Moreover, as I have lost and I now bear witness to the struggles and losses of others, the stories seem to hold some hope. They are how we transmute pain into meaning.

Learning how to tell them seems as much doctoring as the duoneb treatment and steroids I administered to patient having an asthma attack this morning. Chekhov did it, William Carlos Williams did it. Bulgakov did it, W. Somerset Maugham did it.

Many have gone before. The medical machine is too brutal for some of us to live our whole lives in. Before losing my daughter, I might have kept on for a few more years going full tilt. But, some wounds change us, or expose who we really were.

I have learned how to feel in a new way. I cannot bear the suffering, despair, and quixotic denial of our mortality full time. There are those of us who can only be part-time doctors.

We must find other ways to thrive and hold onto our humanity. I think writing is one way. Maybe once my loans are done, I may try and make a real go at the writing life.

Until then, the blog serves as practice, as a kind of journal of snippets of ideas, people, and places. A repository of half-baked scenes and soft-boiled emotions.

I guess it is a good enough reason to keep at it.

Across the Great Divide…Part 1

The Urban-Rural Divide, A Culture Gulf.

“You see, this is why they are wrong…” began our guide Ibrahim. My wife had just asked him to explain the difference between Shi’ites and Sunnis. He was Sunni, as are the vast majority of Moroccans.

We prepared ourselves for a very unbiased and nuanced theological discussion…

No place in the world has made me feel so “other” than Morocco. Sure, in Taipei I was an obvious Westerner, a novelty. In Moscow, I was suspicious as an American, but could blend in. In Istanbul, I was barely worth noticing.

In all these other places, I was different – a rare breed perhaps – but still recognized as part of the same species. Only in Morocco have I felt as though I was something else entirely. I came from another world, another plane.

In the mountains of High Atlas, the desert Palmaries of the Sahara, and the markets of Marrakech, my wife and I were more other than I can explain.

Increasingly, I see this dynamic playing out between Urban and Rural America. As someone who now spends two thirds of his time in one world, and one third in another, I want to talk more about it.

This will be the first post on the Urban-Rural Divide I have navigated since I was 18 and currently straddle in my professional life.

A Foot in Two Worlds

I never thought of myself as a two-culture kid, a common phrase for first generation children of immigrants. I am a white male, who grew up in an overwhelming white place. In theory, I fit in growing up.

At least some of my family have been in the US for a couple of hundred years. Some are more recent, but we don’t have any living memory of immigration from abroad. So, I can’t even claim Polish-American, Irish-American, or Italian-American as a second culture.

My father was born in the poverty of the post-Dust Bowl Northern Plains. He didn’t have running water until his family fled to California when he was nine. My mother grew up an Urban girl in the Bay Area of Northern California. Both graduated from UC Berkeley.

Somehow, I was born and raised in the middle of grass, beef, and sky country. A full days drive from a Major League Sports Team.

Where all the women are strong, all the men are goodlooking, and all the children are above average. – Garrison Keillor

I did what a lot of us curious ones did, I left. I began wandering an archipelago of institutions of higher learning. Initially, I enrolled at a highly selective liberal arts college, on scholarship.

For the first time in my life, the majority of people with which I socialized voted like my family. Difference was not an inherently suspect trait.

It was a revelation. After an entire childhood of feeling different because my family wasn’t from “here,” I finally fit in. Then, as I got to know more and more people, it became clear that I was still different.

You cannot spend your formative years in a place like the rural Northern Plains and “fit in” with the children of hyper-educated, suburban Tiger Mom’s.

A common refrain became, “You’re the first person I’ve ever met from that state.” There it was, I was again a novelty, to be wondered at.

“Well, there aren’t very many of us.” Became my standard laconic reply. I fell back on my tried and true survival technique, talk less about myself and more about events, ideas, politics, etc. People like that love to share their opinion on things they think “matter.”

The Trouble with Normal is….It Only Gets Worse – Bruce Cockburn

By the time I reached medical school, my very existence confused people. I had learned Latin in High School. I had lived in Russia and spoke Russian. I could follow a basic conversation in Spanish. I read, I mean really read. Not just because I had to.

Yet, I couldn’t shake all my ruralness. Sushi was still suspect in my book. Professional sports still seemed an alien and foreign thing to me. Traffic left me jittery.

During medical school, I often left for the mountains and spent several days alone, a tonic to counteract the volumes of people I dealt with on a daily basis.

People like me weren’t suppose to come from places like mine. My being in medical school challenged their assumptions about places and people they didn’t think mattered or were worth knowing.

I was aberration, a statistical outlier, noted and then discarded so as not to skew the data.

What Rural People Know

Shortly after I graduated medical school, my medical school started to count people of “Rural Origin” in their diversity statistics. It was a shallow ploy to make their overwhelming white, suburban, upper middle class cohort look more diverse.

Nonetheless, the logic was reasonably sound. Those of us who grow up in Rural, or even Frontier counties face significant health and educational disparities. The geography of suicide is decidedly rural.

In nearly all the indicators which the Left uses to identify historically disadvantaged or marginalized groups, Rural Americans meet the definition. Yet, we don’t make those lists.

And we think we know why. We have all heard what Urban America thinks of us. No one wears “rural origin” visibly. Because when we leave, we learn to blend in. There is no definite marker of being culturally “rural.”

So, we hear what Urban America has to say about us, our families, our communities – in classrooms, conference rooms, at happy hours. That doesn’t mean all of Urban America disdains Rural America.

Nonetheless, it is the strongest narrative Rural America has about how Urban America feels about Rural America.

What is She, from Kansas or Something?

Medical School was where I truly came to know this disdain, it slipped out accidentally, but often. Usually without malice, but with an odiferous smugness.

Once, when discussing a formula for estimating height in a medical school workshop, the professor asked the class if it didn’t apply to anyone. My friend, Steve, a first generation Chinese-American, raised his hand.

The professor, who knew nothing of Steve’s personal background, said, “Well, it doesn’t apply as well to immigrants or children of immigrants.” She assumed, based on his Asian appearance, he was an immigrant.

Later, over beers, he vented. It had clearly touched a wound.

“How the hell does she get off just assuming I’m an immigrant?” He fumed. “She’s faculty for god’s sake. You’d think she’s from…Kansas!”

It never dawned on him he had just made the same transgression he was fuming about. Kansans – coastal code for Rural Americans – apparently weren’t deserving of the same level of consideration he demanded for himself.

Mutant Towns

Another evening, I was sitting having beers with a classmate and her significant other. Both had transplanted from some Coastal megalopolis and we were discussing travel around the state.

In discussing regions of the state, her significant other stopped and said, “Oh, I don’t go there, those are mutant towns.”

“Mutant Towns?” I asked.

“You know, there are some towns in this state that are just full of people who kind of look like mutants. Fat, unkempt, ugly.” I don’t go to those places. He laughed.

I stared in silence and disbelief.

In other words, poor rural people. He thought he was sincerely funny. He also thought he was worldly and cultured. He thought he knew things.

This is what Rural America feels.

Sure there are nice, decent people everywhere, but we don’t remember those people. We remember the people who made us feel like nothing.

Can I get a Witness?

Urban America paid no mind while Rural America stewed in its hurts, limited opportunity, declining population, closing schools, and disparate health outcomes. Rural America doesn’t matter after all, it isn’t wealthy, mass culture is not produced there, fortune 500 companies don’t put their headquarters there.

“Why don’t they just move somewhat nice?”

But, Rural America votes. ‘Merica is religion on the High Plains and many other redoubts of Rural America. And the Religion of ‘Merica demands voting. And, Rural America is the only human community of in this country who has their Affirmative Action enshrined in the constitution – the Electoral College.

Rural America was tired of being ignored and forgotten. So, when a huckster who shits on a golden toilet showed up and made them feel heard, they showed up in return. That is how important it is to people to feel heard, to feel counted.

People want their suffering heard, and will sacrifice a great many other of their values to feel heard.

I hope these posts will help you get to know Fly-Over Country a little better.

You don’t have to like Rural America. I certainly know its flaws better than most. Nonetheless, it is cold and smug to deny its hurts and foolhardy to ignore the power it has to make itself heard.

A Shift as Death’s Attendant

“When was the last dose of epinephrine?” I ask the Tara, the recorder.

Her blood is everywhere. My gloved fingers are tacky with it.  I see it dripping off the edge of the bed, smeared across the floor, oozing from the open fracture of her right leg.

Her foot, connected to her leg only by skin and tendon, was still in a shoe. This struck me as an obscenity.

I watch blood pulse back forth in the tube draining her chest with the same rhythm as the chest compressions.

Tara’s reply makes its way through the commotion, “3 minutes ago.”

I turn to the team.  “Get ready to give another dose of epinephrine. Pete, take over chest compressions at the rhythm check.”

“Still in asystole.”

“Resume compressions, give the epinephrine.”  My voice has so little emotion. It seems to simply echo the recordings of the ACLS trainings I just completed the week before. Good timing, I think to myself.

On the Banks of the Styx

This is the second time in 48 hours I have stood at the foot of the bed, directing our modern dance with death. 

36 hours ago, it was all for show. We surmised he was dead well before his family found him. But EMS started CPR in the field, so we continued it. We invited the family in, to see us try and bring him back to life. We showed them all we could do.

We added artificial adrenaline to his veins. Then, when the lab-made adrenaline did nothing, we gave him our own – in the form of chest compressions, bagged breaths, and sweat-beaded brows. We danced with him, this newly dead man. We danced for his family.

We danced so they would know the drama and pain of the moment when we had done all we could.

He gave his body to those he left behind. He allowed us his body as salve to the grief of those who would miss him.

Dance of Death, replica of 15th century fresco; National Gallery of Slovenia

He sacrificed his body to lighten the burden of guilt of those he left. He didn’t make that choice, we and his family made it for him. I don’t know if he would have wanted it, but I found the gesture noble.

Now, 36 hours later, I am back in the same position. But this woman, she came in alive. Now, she was dead.

Only by standing at the threshold do you see how thin the veil really is.

Despite the intubation, the fluid, the pressors, the chest tube, her heart had stopped.

A code can actually have a lot of down time, especially once chest compressions have been going on for 20+ minutes.  I take a moment to let my mind slide out of the algorithm.

I look at the woman on the bed.  She is elderly.  I can hear the crunching of her multiple rib fractures with each compression.  Dying in a car crash after you have lived so long.  Such a violent death, so unexpected at that age.

“Doc, I have the family on the phone, can you talk to them?”

“Yes.” I grab the phone.  “This is Dr. HighPlains.  How are you related to Gladys?”

“I am her son, what is going on?”

“What have they told you so far?”

“Only that she’s been in a bad car accident.”

“Yes, she has. When she came in she was having difficulty breathing and had severe fractures in her legsand ribs. We had to put a tube into her lung to drain blood that was keeping her from breathing and put her on a ventilator. “

He sighed audibly in the phone.

“We started giving her blood as she was bleeding internally. Despite all of this, her heart has stopped and we are now doing CPR to try and restart her heart….I am so sorry.”

“We are currently doing everything we can do. However, in my experience, given her injuries, it is unlikely we’ll be able to get her heart restarted.”


“Do you know what would your mother have wanted us to so in this situation?”

He regained his voice. “Well, I am her Power of Attorney. How long have you been doing CPR?”

“About 25 minutes.”

With a tired, tremble in his voice, “I need to get my head around this, Would you keep trying for 10 minutes, and then, if nothing changes, you can stop.”

So, the music continued. And again, we danced. And Gladys too, sacrificed her body for those who will grieve her. We all tried not to focus on the grating of the ends of her ribs past each other.

It is such violent dance, these days.

Time of Death, 18:00

12 minutes later, I made a phone call.

“Sir, this is Dr. HighPlains again. Unfortunately, we were unable to get your mother’s heart restarted…”

“Thank you for everything you’ve done…”

We share a few more words, and I hang up the phone.

The Strange Calm

The routine of operationalized death begins. I sit back and watch. I slowly peel off my trauma gown. The ball is over, no point keeping up the dress code.

I watch the nurses. They cover the body first. It is a body now, no longer a person, at least medico-legally. Staff has already notified the coroner. The transfer of care is in process. I no longer have a patient.

The nurses start gathering the detritus up and throwing it away. I help feebly. We draw the curtain in the trauma bay. It is customary to the give the dead their privacy.

But, whose sensitivities are we really protecting?

Breath, Light Awareness

I sit down at the computer. Documentation is impatient. I pause before I start typing. I sit and feel. I notice my breath, and my pulse.

Luxuries, I suppose.

I can feel the heaviness of death. I do not feel guilt, I do not feel shame. I did everything I could. Could we have used dopamine instead of levophed, sure. Could we have tried externally pacing when her heart rate started to drop, sure.

Nonetheless, I do not second guess. Death sits next to me in heavy silence. I do not shy away, nor do I linger in fascination. I allow my body and breath to relax in acceptance. All our paths end here.


“Patient arrived by EMS transport in extremis….”