Back From the Great Wide Open

I open the door of the little, rural hospital I have been tethered to for the last 96 hours.  The bright, plains sun slams into my eyes. I squint and don my sunglasses.  I haul my call bags across the small, gravel parking lot and through them into the back of my car.

My car has become quite the road warrior over the last year.  12 years old, it shows its age. The front end is largely held on with baling wire.  The body is heavily dimpled from hail damage (an eventuality if you spend much time on the High Plains).  After the fifth rock extended the windshield spider web to an unsafe degree, I finally replaced it.

Nonetheless, I hold onto it.  It is effective basic transportation.  More importantly, after fixing the struts, head gasket, oil sensor, windshield etc, I need to get a little return on my investment.  Old, decaying homesteads dot the back roads of the High Plains and remind you of the legacy of the Dust Bowl and its deprivation.

If you spend enough time here, frugality seems more of a moral duty to those who survived than a way to get ahead financially.  Ostentation seems blatantly disrespectful.

I slide into the seat, turn the key, and the engine rolls over obligingly.  Turning out of the gravel drive onto the paved two-lane highway, I feel the first change that marks the return journey to my modern City-State.

That Ribbon of Highway…

I ease down on the accelerator and little four cylinder engine slowly increases frequency until I am at cruising speed.  I pass the grain trucks grinding slowly out of town and engage cruise control.

The City is still sufficiently distant that its radio waves don’t reach me yet.  I rarely use my smartphone to listen to my music, or medical CME, or audiobooks.  I like to listen to the local radio, even though it isn’t particularly good.

I like to hear the classic country and rock songs punctuated by advertisements for farm financing, announcements about the local county fair, and today’s corn, wheat, pork, and beef prices.  The only other options are Christian praise music or Norteno corridos on the Spanish-langauge station.

Occasionally, I listen to a few corridos before I tire of the wailing of lost loves and betrayal.

I never listen to the praise channels.

I drink in the never ending sky and the limitless horizon.  If you are from the lands of big sky, nothing is more comforting and inviting than the long, distant horizon.  You revel in your smallness.  If you aren’t native to the sky, it is nothing but a barren, foreign, emotionally disconcerting country.

No matter what you call it: plains, prairie, steppe, or llano, you either love it or you don’t.  Big sky country demands an emotion.  I have never met someone who is indifferent to it.

Wrapping up a shift and sliding onto the open highway combines two great sensations: the freedom of being both off the clock and off the grid.

It is a moment bordering on intoxication.

The Interstate

An hour later, I take a left turn and merge onto the interstate.  The wet, acrid smell of the nearby feedlot invades my car.  Immediately, I am in a different world.

The large UPS truck trailers remind me of modern e-commerce and our intense, modern interconnectedness.  I navigate the huge RVs doing their seasonal migrations.  I pass turn offs for the large truck stops with chain fast-food restaurants attached.

The local radio station starts to crackle with static.  The City’s more powerful antennas have already begun to crowd out the rural stations.  I give in and switch to one of the City’s stations.  The finely polished voices badges me to consider refinancing to roll my high interest debt into a low interest mortgage.

Or, advertisements bombard me for questionable hormone replacements therapies, which will apparently making aging optional. Not to mention the not-so-subtle adds for clinics specializing in phosphodiesterase-5 inhibitors.

I have officially crossed a boundary.  I have moved from a land where suffering is accepted as an unfortunate part of life to the regions where we are promised the power to opt out of suffering entirely.

“Life should be easy,” I hear. “Just buy this product and all the struggle will disappear.  We have plenty of financing options available for you…”

I flip the channel, hear the start of an old Sheryl Crow song, and settle in for a five minute break from advertisements.  I set the cruise control 10 mph faster than it had been on the two-lane.

The Modern Travelers’ Bazaar

About an hour later, I ease off the interstate, tacking a right into the parking lot of a truck stop.  I pull up to the pump, insert my various plastic forms of identification: my rewards card, my credit card.  I push the fuel selector, remove the pump handle, slide the nozzle into the gas tank and pulled the lever.

The fuel makes soft whooshing sound as it plunges into the tank.

Again, advertisements bombard me. This time a screen on the pump rages at me. “When did these become a thing?” I wonder to myself.  The squawking from the screen is overlain by barking from a loudspeaker informing me of all the deals to be had inside.

It reminds me of an electronic version of market stalls with vendors harassing you for attention and shoving their wares in your face.  Only, I cannot politely decline with my hand across my chest, and slight bow, and say, “Maybe later.”

The onslaught continues, I am powerless to modify it.

The pump thunks, and I replace the nozzle.  I lock my car and record the receipt in my smartphone, for tax purposes.

A dizzying array of crap I don’t need greets me inside.  I rush past the racks of pseudo-cowboy regalia, t-shirts with not-so-witty sayings emblazoned on them, and canes with “Vietnam Veteran” logos on the pommels.

I make it into the bathroom, and even relieving myself, I cannot avoid the advertisements for more shit I don’t need.

A man can’t even piss without being sold something in this country any more.

The Edgelands

Back on the interstate, I see the City starting to spill out and infect the plains.  The traffic picks up, the drivers who were content to go the speed limits now need to go 15 mph faster, driven by innate feelings of competition with the increased road population. I disengage my cruise control.

Billboards for urgent cares, liquor stores, and music festivals start to appear by the side of the highway.  Warehouses and distribution centers pop up like weeds.  Soon, the first exurban shopping center edges into view next to the highway.  The chain restaurants, discount clothing stores, all surrounded by their own asphalt plains.  I am told these are signs of the healthy economic growth…

Growth for the sake of growth is the ideology of a cancer cell.

-Edward Abbey

I look to the horizon, now obscured by scraggly trees, buildings, and semi-trailers.  It has taken on a sickly brown hue.  It is the color of a week-old bruise.  The air, now visible, starts to obscure the sky.   Without the visual escape of the horizon, I am drawn down to the human landscape, so paltry in comparison.

The detritus of homeless camps under the overpasses or next to the channelized, polluted rivers and the irrigation canals sucking them dry greets my gaze.   I turn up the pop-indie-folk-blues-autotune whatever coming out of the speakers.  Numb out.

I slide off the interstate into a cloverleaf and slide back onto another.  I smell the exhaust of the oil refinery waft out of my cars vents.  Soon, but never soon enough, I am at my exit and gratefully leave the interstate.

I jockey into position for the lane which will allow me the smoothest turn into our neighborhood.  The aggressiveness of the other drivers sends an electric energy up through the cars tires.  I let my mind drift back to the serenity of the sky I left behind.

Artificial Eden

I take a left at the park across from our house.  It is broad and flat, colored a deep, artificially green.  European Pines, crabapples, and Elms dot the small plain.  It contrasts with the light, airy green of native grasses and winter wheat I passed on the plains.  The trees on the plains had been ash and cottonwood lining the water courses, while wild plum and chokecherry in bloom clustered slightly higher.

I stop in the alley, step out of the car and open the back gate to our rental house.  The air smells mostly of nothing, but with the faint perfume of exhaust, asphalt, and cigarette butts.  Our old hound bounds out of the back door, wagging her tail excitedly.

Shortly after, my wife comes out, our daughter in her arms, excitedly telling her “Daddy’s Home!”  At 4 months, she is not particularly understanding.  But, I move my face into her view and she smiles her big, unbridled, infant smile.  The bridge of her nose crinkles and she lifts her arms in front her face in apparent embarrassment at her excitement.

I pick her up, kiss her cheek long and hard and she laughs.

And just like that, I am home again.

 

 

 

Brene Brown and Seneca Walk into A Bar

Back in residency, I read a lot of Brene Brown.  We saw a lot of very damaged people in our residency clinic and the ideas of vulnerability, armor, and perfectionism were very helpful in understanding many of my patient’s struggles.  Also, those ideas helped me understand many of the physician personalities around me.

Since then, I have dabbled with Buddhist, Stoic, and modern psychological thought. Much of this was to help me deal with my own grief.  Most of these ideas overlap and complement each other.  However, occasionally ideas conflict.  When they do, I feel a need to resolve this conflict.

One such conflict was the idea of “Foreboding Joy” in Brene Brown’s work and “Worst Case Scenario Thinking (premeditatio malorum/premeditation of evils/negative visualization)” in Stoic thought.  The Stoics recommend the latter, whereas Brene Brown views the former as a detrimental practice.  Initially, they seemed very similar to me, so I was perplexed.

Foreboding Joy

“Joy is the most vulnerable emotion we experience, and if you cannot tolerate joy, what you do is you start dress rehearsing tragedy.”

-Brene Brown

The idea of foreboding joy is the imaging terrible things happening as a way to protect ourselves from the vulnerability of feeling joy at the prospect of something.  In protecting ourselves from vulnerability, we rob joy from our lives.  Obviously, Brene Brown argues, this is detrimental to our overall happiness and a life well lived.

How, she argues, can we live our lives fully if we won’t let ourselves experience joy?  Is the risk of pain worth removing joy from our lives?

I think we would all generally agree it isn’t.

Foreboding Joy becomes a mental trap we lay for ourselves, protectively and instinctively.  The work then, is catching ourselves laying this trap and slowly and repeatedly undoing it.

The Stoics, on the surface, seem to recommend the opposite approach.

Premeditatio Malorum

The man who has anticipated the coming of troubles takes away their power when they arrive.

-Seneca

Seneca and others actively recommended the practice of imagining the worst possible outcome of a scenario to prepare ourselves for tragedy.  They argued it strengthens us in the face of tragedy.

On the one hand, they argued we would be better prepared to combat any ill which may befall us if we had anticipated it.  On the other hand, if there was no way to combat the ill, we would be better prepared to accept it if we had anticipated.

Does this not seem like contradictory advice to Brene Brown’s?  Doesn’t imagining all the negative outcomes ahead of time rob us of our present joy?  How is it possible to both anticipate evils which may befall us and no forebode our own joy?

For weeks after reading of the practice of premeditating on evils, I struggled with how it intersected with the dangers of foreboding joy.  Like most things in life, I came to the conclusion that it depended on the execution and one’s approach to the question.

I came to this by meditating on our own great tragedy, the loss of our first daughter.

Tragedy as My Teacher

When my wife called me in the middle of a clinic day and told me she was to be induced for polyhydramnios, I immediately did a quick literature search.

I came face to face with all the terrible possibilities.

Based on a quick rule out of maternal reasons for polyhydramnios, I concluded something could be very wrong with our baby.

As the pines zoomed past me on the drive to the hospital, I though of the possibility that our child may not live.  It was a terrible possibility.  I also remember thinking, “We’ll deal that if we have to.”  There was nothing to do in the moment but have our baby.

In no other moment in my life have I been so present as during the labor and birth of our first daughter.  Knowing what I knew about the future and my powerlessness to affect it drove me deeply into the present, beside my wife.

I sat next to her as she breathed through contractions. I supported her as she swayed and moaned around the room as Latin music played softly in the background.  For 6 hours, I knew no past or future.

The world reduced to my wife and I and the electronically registered heartbeat of our baby.

Foreboding Joy or Premeditating on Evils?

A year or more later, as I wrestled with the concepts of foreboding joy and negative visualization, I thought back to these moments.  Had I not visualized the worst possible outcome?

Yet, it had not destroyed the joy in being present with my wife during her labor.  It may not have intensified the joy of the birth, but it did intensify my immersion in the experience.  My imagining of future ills had not, in fact, robbed me of my present and its joys.

I thought of another moment of intense emotion: when we decided to try for another child.  We were still grieving, our loss was less than 1 year old.  And here we were, sitting in another state, planning to start down the path again.

Knowing better than most the possible tragedies which could befall us, we jointly made the decision to start our journey.  We both knew we could lose a second child.  We could not ignore it.  We were terrified, yet also knew we had survived it – even as painful as it was.

We did visualize losing this new person we would attempt to bring into the world. We did not dance around it, we faced it head on.  We decided it was worth the risk.

Courage is the Difference

Courage is not the absence of fear, but rather the judgment that something else is more important than one’s fear.

-Ambrose Redmoon (James Neil Hollingsworth)

I believe the apparent conflict of foreboding joy and premeditation of evils can be resolved by understanding the problems of uncertainty, fear, and courage.  It all depends on how one practices the premeditation of evils.

If we practice negative visualization as a way to wall ourselves off from possible harm and disappointment, it is a form a foreboding joy.  It is an attempt to emotionally shield ourselves from vulnerability.

On the other hand, we can choose to use negative visualization to better understand our fears, worries, and possible consequences.  Instead of walling off vulnerability by imagining terrible things, we consciously accept them as possible.

Then, we must decide it is worth the risk.  If, knowing the risks, we move forward, not rashly, but deliberately; we are being more intentionally and, I dare say, courageously, vulnerable.

It would not have been courageous to ignore losing our second child was not an option.  Naming and knowing our fears, letting ourselves feel them in a conscious way, and deciding something else is more important, is a courageously vulnerable action.

Knowing our Fears

I believe the ideas of foreboding joy and premeditation of evils are not opposed.  However, their dangers and benefits depends on our approach to them.  Are we practicing negative visualization intentionally? Or, are we succumbing to unintentional, unfelt fears and pulling back, hiding from risk and loss?

Naming and letting ourselves feel our fears can be used to help us live more courageous and vulnerable lives.  However, if we run from them and only know them in short blips of foreboding, which we then try and scrub from our memory, we are hiding from life.  We are letting our intolerance for uncertainty, risk, and loss control us, not embracing of life and its complexities.

 

 

 

 

 

The Psychology of My Debt

My debt weighs on me, both financially and psychologically. Interestingly, this was not the case in medical school or residency. Then, about 3 months into my first job its specter began to grow, even though the actual number started declining for the first time in 7 years.

Overtime, the psychological importance of my debt balooned in inverse proportion to the speed at which I was paying it off. I would spend hours per month tracking it, trying to find ways to pay it off faster.

I stared at the screen, as if by sheer will I could reverse the nature of compound interest. This did not work.

This was always going to be a bad thing for me, psychologically. Money has never motivated me. Having more money has never made feel better about life or myself. It felt unnatural to be so concerned about numbers on a screen. It just wasn’t me – but I couldn’t stop.

Turns out, having lots of money won’t make you happy, but owing lots to someone else can make you miserable.

My wife tells me sometimes our marriage feels like a terrible love triangle between me, her, and my debt. Yet, after leaving my first job, the problem did not improve. It actually worsened.

We took a significant hit in income and any hope at loan repayment went away with transitioning to 1099 work. I felt the pressure of paying off the debt land squarely and intensely on my shoulders. I focused all the energy I had previously given to medical training onto paying down my debt.

It had become my white whale.

Obsession is Never Healthy

At first, I had assumed my debt weighed on me because I hated my first job. I had jumped from the cloistered, privileged, insincere nobility of academic medicine into the cauldron of RVUs and the greed driven Hospital-Pharmaceutical Complex. The disillusionment was scalding.

More disturbingly, my partners were lining up at the trough to eat the unethical slop. The system was playing them like fiddles, and they were happy to oblige. Never mind the fact they were actually miserable.

Yet, they played the part of selfless, caring physicians – even if all we ever talked about at meetings was how much money they could make. I felt tainted by association. The guilt gnawed at me.

That guilt did not immediately go away upon changing to my current locum tenens work, it morphed into a different kind of guilt. I felt guilty for abandoning the noble aim of continuity of care and my former dream of being the “local doc.”

So, my obsession grew, despite changing my work situation.

Kids Change Everything

Having our second daughter gave me a chance to refocus. Having a family has changed the relationship I have with medicine again. I have slowly been able to let go of some of the anger I had at the way my partners and health system treated me.

I had directed a good deal of that anger at the institution of medicine. I have since come to realize it isn’t particularly helpful to hold an amorphous profession accountable. I will never be able to have closure with a profession.

I have also released myself of my burden of accountability to the profession. If the profession is not accountable to me, I am not accountable to it. This has greatly improved my relationship with work.

I have managed to lower my bar for satisfaction drastically. My relationship with medicine has evolved from complete devotion, to resentful hatred, to a simple acceptance.

This evolution has allowed me to see how much power I was giving my debt over my life.

We Give Things Power over Us

Most people seem to have the problem of not realizing how detrimental debt is to their financial health. I had the opposite problem, I gave my debt complete control over my enjoyment of life.

I had made eliminating my debt into the dreaded “next step.” That next accomplishment I had to reach before I could be happy. Even though I knew that trap all too well, it had caught me again.

Debt had become a binary state. I was either in it or I wasn’t, progress did not exist. And, as long as I was in debt, I was beholden to medicine. And that pissed me off.

Eventually, I realized it had gone too far…

Around tax time, I was able to throw a huge amount of money at my debt. As this was the first year I have been paid substantially as a 1099 sole proprietor I apparently had over-saved substantially for my tax bill. In one fell swoop, I eliminated over 15% of my remaining debt burden.

But, I was not pleased. Instead of congratulating myself on making large progress in eliminating debt, I was emboldened to try and move up the timeline on making myself debt free.

I felt the need to pay more faster because I had made so much progress so quickly. I knew this was not a reasonable reaction.

I was chasing the dragon…

I had something to decide. I could continue to be angry and resentful for 2-3 more years and hope it got better when I paid off my loans (the go to doctor coping mechanism). Or, I could actually wrestle with my emotions and try to find a way to happier in the present.

Perspective Change

So, instead of continuing to think of my loans in binary terms of being chained to or free from medicine. I asked myself a bigger question.

“If I had already paid off my loans, what would I do differently?”

Turns out, probably not much.

I would probably work a little bit less. We would travel more(I hope), probably buy a house. But, most importantly, I wouldn’t quit medicine and try a different career.

This was hugely freeing.

The emotional benefit of being debt free is the idea you could walk way if you wanted to. So, realizing I would not walk away took away a lot of the power of the loans.

Doing The Math

Once I deflated the emotional power of my debt, I could look at it a bit more rationally. I had made a lot of progress. I decided to run some scenarios.

I ran various amortization schedules based on refinancing vs not and at different time intervals (2-5 more years). Instead of the shackles vs. freedom emotional response to debt, I tried to give myself more of a dollars and cents view.

Turns out, depending on various scenarios, my debt will likely cost me another $10,000-$25,000 in interest. Also, it turns out I should probably refinance my student loans.

So, those numbers are not nothing. However, it allows for a more rational conversation about my loan debt. Instead of a binary choice for happiness, I can ask:

“How many more months am I willing to be in debt to enjoy my life more for the net 2-4 years?

Since I am not going to go out and buy a Tesla or mega-house or anything like that, it is mostly about how gentle am I going to be with myself about how choosing to work a little less so I can spend more time hiking, fishing, traveling, etc.

Turns out, I am probably willing to spend up to 6 months more in debt to have more time doing other things I enjoy.

I am tired of waiting for the next thing, I am living right now. 2 years of living a happier, more balanced life seems worth a few more months of debt.

At the Bottom of a Hole

I startle in the windowless sleep room.  My call phone summons me awake.  In the darkness, I reach for and immediately find it.  From week to week, the counties, hospitals, and staff all change, but the phone is permanent. 

It is always there, it has become an appendage.  My brain seems to have proprioceptively grafted the location of the phone onto its neural circuitry.  It has become a permanent part of me in this floating life.

A voice on the end relays the message. “Dr. HP, we have an ambulance coming with a Mrs. Z, complaint of altered mental status, possible seizure.  She’s been in here three times for the same complaint in the last 2 months.”

“Ok, I’ll be there.” a disoriented groan.

Patient Arrived Altered…

I walk into the trauma bay. Family is crowded about their her. She lays in a crumpled pile on the gurney.  Her GCS is 11, so she avoids an intubation.  Nonetheless, she is minimally responsive, completely disoriented, unable to provide any meaningful history. 

From the family, the story unfolds like a jumbled ballad of confused pain and suffering. I hear the frustration about the repeated hospitalizations, the perceived lack of answers, the desperation to help her, etc.  

“She was here three weeks ago with the same thing. She went home for a few days, and then was in the other hospital in county 10 days later, and now she’s back. We don’t get no answers every time we come in.”

“That must be so frustrating and scary.” I reflexively parrot their emotions back to them as I look up and down Mrs. Z’s body.

“They just say it was another bout of seizure activity and increase her meds, but it seems to be gettin’ worse, not better. We just can’t keep doing this…”

“Jane!” I call her name and her eyes pop open. They fix on me in a wild confusion. She looks straight at me, but I get the feeling she registers nothing.

“Where are you?”

“The hospital…” comes the groggy reply. She meets any further questions with drooping eyelids and a nodding head. The nod.

“Squeeze my hands.” I command her. She faintly squeezes.

The verses of the songs are different, yet we all know the melody by heart and the chorus rarely has much variation.  Her life and medical care has become a tilt-a-whirl ride gone awry.  No one seems to know where to find the exit as she whirls about, up and down, in and out of hospitals.

She is trapped in a swirling confusing mess of tests and medications, no one really sure what they are treating. But by God, they will treat something. 

…She was Arousable to Voice…

The old cowboy saying goes something like this: “The first thing to do when you find yourself at the bottom of a hole is to stop digging.”

This is should be the first tenet of treating the chronically ill. 

We all know them, the professional patients.  The people perpetually entangled in the Hospital-Pharmaceutical Complex. 

Invariably, clinicians know these patients better than any others. We’d rather not, though. We cringe when we see their names.  

In clinic, we fear looking at our Monday schedule before leaving work for the weekend. Their name in an appointment slot can cast a pall over the whole weekend.

As hospitalists, our hearts never sink as low as when our pager goes off and we’re told, “Mr. T has bounced back, you admitted him last time.  Same problem.”  Walking into the room, we sit down in the hole.   

We hate sitting in their darkness with them. Because, when we sit with them, we can’t see the way out either. Their presence smacks us with our own impotence.

First, stop digging…

…Only Oriented to Place, but Able to Follow Commands…

Our teachers trained us with cute acronyms for developing differential diagnoses of chief complaints. VINDICATE, VITAMIN C. With the chronically ill, the first three letters should be “I.”

In the mnemonics, “I” stands for Idiopathic/Iatrogenic. Idiopathic – we don’t know why. Iatrogenic – we did this. I find this juxtaposition amusing. The implication of iatrogenesis being close to idiopathic is commonly upheld in clinical practice.

Otherwise brilliant physicians seem to struggle to identify when the cause of patient’s problems are the medical system itself. It seems a kind of heresy to admit our church’s complicity in their suffering.

Yet, when you lean in, comb their histories and medication lists, our fingerprints are always there. The half-hearted attempts at treatment. Another medication added to end a depressing clinic visit, another test to “rule out” some strange disorder before discharging from the hospital.

…In reviewing her med list, I found a great number of sedating medications….

She is definitely altered, but nothing about her looks like a seizure. I review her medications and tick off the likely offenders: gabapentin, baclofen, phenytoin, and, of course, hydromorphone.

“The one that starts with a D.”

She is on a total of 50 morphine milli-equivalents with less than perfect kidneys. She is on this for arm and wrist fractures which occurred several months ago. Well past the acute phase of treatment.

We admit her, she is too altered to swallow medications, we start IV fluids and let her rest, withholding all medications. The medications begin to wash out of her system. Initially, she responds slowly. Once we refuse to give her narcotics unless she requests them, she comes back to life within 12 hours.

None of the nurses, nor myself are surprised.

Encephalopathy Secondary to Polypharmacy

The chronically ill, the products of the Hospital-Pharmaceutical Complex need a different approach. The old mnemonics and work ups start with a faulty assumption. They start with the assumption of originality of complaint, of something new, of a previously healthy person.

The chronically ill meet none of these stipulations. The first questions should be, “What have we done to this person?” followed quickly by “What can I undo?”

After she has returned from pharmaceutical zombie state, I go in to discharge her.

“You’ve been scarce around here. I have seen you since I have been in here.” She stares accusingly.

“I am not surprised you don’t remember me, you were pretty out of it for a couple of days.” I don’t get defensive. Those newly returned to consciousness are rarely polite.

I recommend an aggressive reduction in many of her sedating medications, including her narcotics. Strangely, she doesn’t argue, it seems to make a kind of sense to her.

Mrs. Z goes home. I am not sure she will follow my instructions.

Nonetheless, they seem thankful for a more a logical explanation to her problems than a confusing seizure disorder that seems to get worse despite “appropriate” treatment. For a minute, we stopped digging and the light stopped receding.

Sometimes, a pause in the chronic deterioration seems like an improvement.

Wherever I Go, I am a Stranger

Spring is the best time on High Plains, especially on the Northern High Plains. The snow has melted. If the springs rains came, then the grass has greened and the winter wheat is growing in the fields. Verdancy is everywhere.

The birds have returned and their sounds can be deafening. The mourning doves and prairie meadowlarks fill the evening with their calls.

The wind brings the scent of sweet clover and moisture. Later, in July, it will feel like a dusty blast furnace. But now everything is pleasantly fresh and new. It is a good time to get out of the City. The sense of possibility and abundance surround you as you walk down dirt streets.

Towns on the plains are of two camps, clod hopper towns or shit kicker towns. This roughly divides them between towns that rely on farming and those that rely on ranching, respectively.

Farming requires more machinery, more labor, and is more lucrative. As such, these towns have a more robust tax base and generally more funds for services. They tend to have greener lawns and more orderly, well-kept homes.

I am on shift in one such town today. School has ended for the year, children run feral throughout the town, down lanes of arts and crafts homes and mid-century ranches. It reminds me of my childhood.

Upon going out into the world, I found out that even in the 1980’s and 1990’s, I was living a childhood out of a different time. Now, these children are having an experience downright foreign in comparison to their urban and suburban counterparts.

In this little pocket of America, the end of school year does not simply mean a transition from one overly-scheduled, hectic routine to a different overly-scheduled, hectic routine.

It means the freedom to roam, make mistakes, get hurt, and learn and grow. Freedoms now so rarely afforded children in our society.

I sit in the well-manicured park next to the baseball diamond and let myself dream of a simple life in a little world like this. Where my daughter could roam the streets in relative safety.

Forever the Rolling Stone

Freedom so often means that one isn’t needed anywhere. Here you are an individual, you have a background of your own, you would be missed. But off there in the cities there are thousands of rolling stones like me. We are all alike; we have no ties, we know nobody, we own nothing. When one of us dies, they scarcely know where to bury him… We have no house, no place, no people of our own. We live in the streets, in the parks, in the theatres. We sit in restaurants and concert halls and look about at the hundreds of our own kind and shudder.

Willa Cather, O Pioneers.

It is a silly little fantasy. I am a stranger here. I always will be. Even if we moved in and I set up shop as the town doctor, I would always be an outsider. I would be a little suspect, I wouldn’t really “understand” the town. That is the way it is.

As long as I am temporary, the staff and patients treat me well. They treat me like a guest. They are very kind and obliging. On the other hand, I know cultures which place the most importance on hospitality towards guests are also often the most closed.

As long you are a guest, you have no rights in community decisions. You are otherized and compartmentalized into a nonthreatening entity, ever so politely.

So, I roam, continually a guest, an outsider, an observer. Nonetheless, the dream of simple little corner of Americana is a seductive one…

To Dream a Little Dream

When I discuss these little flights of fantasy with my wife, she sighs and rolls her eyes. She knows why a simple, pleasant, little life for us is only a dream. We are not simple, pleasant, little people – and I am likely the worse of the two.

I don’t know if we dream of bigger things, but we do not fit into molds well. We are not terribly pliable people. We have not melded back into the city well, either. The self-indulgence, easy conveniences, greed, commercialized spirituality, and glorification of self have rubbed us raw.

I often wish I could be satisfied with a simpler version of what life was about. I wish I could still believe working in healthcare is about helping people.

But some things cannot be unseen, some hurts cannot be unfelt.

Simplicity is Complicated, Too

The funny thing is, my life actually is much simpler now that I travel for work. I roll in, do my work, and I roll out. Back at home, I live a life with plenty of unstructured time spent with my wife and daughter.

Work is far less draining. I don’t go to meetings to be harangued about productivity, my life is not held hostage to a call schedule. Yet, I am perpetually a stranger at work, and in the City.

It turns out, after a certain age, most of the people in our lives we meet through work. And most people don’t have 10-20 days a month free to spend as they like – they are at work.

It is an odd paradox, my life is honestly much simpler than it has been in years. Yet, that simplicity has not necessarily made it richer.

Without the demands of Medicine following me day and night, I have had to let myself be a human again. To let myself do nothing, without guilt, which has been the hardest part, by far.

After 9 years of being fashioned into a bow and strung tight, always ready to react to some new crisis, it is hard to unstring oneself. Sometimes, I force myself to remember I was a whole person before Medicine, and will continue to be so if I were to leave it.

The Stranger, only Human

So, this is the trade-off. I am perpetually the stranger, but much more human. I am not defined my role and relationship to my career and coworkers. Now, two thirds of the time I am simply me, not Doctor HighPlains, but just a guy with a family.

I also remember grief and disillusionment have led me here. They have forever changed my relationship to the world. Initially, it is all destruction and chaos. That is the painful part.

The world expected the pain after we lost our first daughter, it expected me to hurt. But then, as the pain transmuted from a gaping, burning wound to an ember of love and sadness, the next part came.

The awkwardness of building of a new self and a new world. This struggle is harder for people to see and relate to. It is a constant tension. I make progress and lose it all within seconds.

And really, even though we are 18 months removed from the loss of our daughter, only now has the pall of crisis started to lift from our lives. We lost our daughter, quickly moved states, set up new lives in new jobs. Then, we had survive the stress and anticipation of another pregnancy.

We had the normal stress of a newborn baby, mixed with the guilt of feeling the pain of losing our first fade. Only now, has our breathing seemed to slow to a normal pace.

Without crisis and loss and disillusionment, who am I? The Stranger, forever it seems now, the Stranger. I have become, it seems sometimes, a stranger to everyone including myself.

So, I accept this task. The awkward, slow task of getting to know this new me in this new world. I am bad at it, but I am doing it.

Lockjaw Still Lives Underground

“Alright doc, I have a 6 year old who fell in her back yard in the dirt and cut her right palm.” Bill, the ED paramedic gave me his report.

“Do you think it’ll need stitches?”

“Probably”

“Grab a suture tray, 1% lidocaine with epi, and 5-0 prolene. I’ll numb it up, wash it out, and we’ll get her home.”

I walked into the room, introduced myself and took a look at the wound. 4-5 stitches would likely do the job. It was a clean, straight cut – the easy kind to close.

“This should be quick'” I think to myself.

I love lacerations, they are the closest thing to actually fixing something I get to do in my practice. Someone comes in with an injury, they leave put back together. It usually isn’t terribly hard, but it is a discrete problem with a discrete solution.

It is a nice break from the parade of our health system’s failures I usually see.

Isn’t there always a catch?

I numbed the wound and irrigated it. It was straight, clean, and pink in her hand. About 2 inches long. I quickly placed 5 simple, interrupted sutures and it came back together nicely.

I told Bill the kind of dressing to place on it, inverted my gloves, and threw them in the trash.

Offhandedly, I asked her mother, “And she’s had all her vaccinations?”

“No, we don’t vaccinate.” Her mother responded, as if it were an integral part of her moral compass.

“Goddamnit.” I think to myself. “This was supposed to be a simple lac.”

I turn around, sit down on the stool and look seriously at the mother.

I start in calmly but firmly, “Tetanus is a soil microbe. It is everywhere. There is real risk she has been exposed because of where she cut her hand open in the dirt. Now we cleaned it out as best we could, it is very unlikely she would contract tetanus, but if she did it would be a life threatening illness. What would you like to do?”

I had to breath slowly and calmly through the silence until she answered. “We didn’t have to be here having this conversation,” I think to myself. “She chose this.” I fumed internally.

Love, Fear, and Distant Demons

I saw her expression change from defiance to honest concern. I had seen that face before. My annoyance softened, I know most parents who don’t vaccinate honestly think they are doing what is safest for their children. They love their children like I love mine, they want to keep them safe.

The world is a big, scary place, full of things capable bringing harm to our children and our families. We assess these emotionally. The more fear they generate in us, the more threatening they appear. In the end, as human beings, we worry most about the dangers we feel to be closest to our families.

The face she made was the face I have seen other parents make when a danger once felt to be theoretical becomes real. I saw that face when I had told an expectant mother she was not Rubella immune (because her mother had decided she didn’t need any vaccinations).

I explained if she were to get rubella it could cause damage to her unborn child.

The knowledge that she could not undue her mother’s decision until after the pregnancy only made the fear more real. I looked into the mother’s face of the child with the laceration now and saw that same look.

It is the look of previously dismissed dangers made manifest. Of looking at a real and present threat, not weighing theoreticals and philosophical “freedoms.” It is the look of talking about the possible illness and death of your child.

It is a look I didn’t have to see that day.

Cursing Our Impotence in the Face of Death

Soldier Dying from Tetanus – Charles Bell (1808)

When I think about vaccine preventable illness, it is hard to communicate the despair and sadness doctors and nurses feel about them.

I think of a 5 month old baby I once cared for as a resident in the PICU. I think of watching his tiny body convulse in status epilepticus. He was unvaccinated and had streptococcus pneumoniae meningitis.

His mother just hadn’t gotten around to vaccinating him, she had no moral objections. Things just got in the way. To this day, I am not sure which is worse, but the “why” didn’t matter to him.

As we loaded him with ativan, then keppra, then phenobarbitol his seizures eventually abated. I remember the PICU attending looking at us during rounds and saying softly under his breath, “This will not be a good outcome, he will not have a good outcome.”

He, like all of us, were looking for ways to distance ourselves from tragedy. Using the language of peer-review and metrics he isolated himself from the picture he saw in his head of this child’s future.

He had been previously healthy, on a path to a normal life. That future was now gone. He would have permanent brain damage – probably a crippling seizure disorder for the rest of his life. He would become one of the “chronic kids.” Who are in and out of PICUs their entire lives.

He survived that hospital stay, but his life was forever altered. It is so painful to watch these things because society places its hopes and dreams in children. As adults we glory in their blanks slates, their possibilities.

We put on them the hope of correcting the failures of current generations. It is a lot to bear, being a child, being the symbol of hope and the future for a whole society.

As physicians and nurses, we watch this suffering and know it was not random chance, something simple could have prevented it. We seethe with rage, because accepting and living through the sadness would be too much to bear. It is easier to be angry, to blame.

We are furious someone has taken that future, has destroyed a receptacle for our dreams. Yet, anger gets us nowhere. Sure, we feel righteous, but it changes nothing. Its only real purpose is to insulate us from feeling the true depth of tragedy.

Our rage is for us, not for the child who lies attached to a ventilator. My anger certainly did that boy no good.

A Pound of Cure

Back in the ED, the mother and I discuss options. Being a struggling, rural hospital, we don’t have tetanus toxoid on hand. The nurse manager tells me they can have it by tomorrow, otherwise they will have to go to the City to a facility that can administer it. Either today or tomorrow.

We do have vaccinations. Hesitantly, the child’s mother agrees to a vaccination. She balks at the compound vaccine that also protects against pertussis.

“Do you have just the Td? Without the pertussis part?” She asks.

I mentally roll my eyes. Apparently, only tetanus now seems real. She is willing to have her child inoculated with the human blood product of the toxoid, but is only willing to have the minimum amount of “vaccine.”

I don’t go into long explanations about deaths from whooping cough, how it is not eradicated, how it is a real disease. I have already had too much magical thinking for one day.

We give her daughter the Td, and make arrangements for her to go to the City to get the tetanus toxoid. It seems like such a farce. So, much unnecessary effort and risk for something that could be so simply prevented.

I watch them walk out of the ED, it is hard to let the anger go with them.

It Feels Personal

As people who regularly battle death and provide comfort and care for the suffering, the rejection of vaccines feels like a personal affront. So much suffering and premature death occur in this world over which we have no power.

The idea of choosing to increase the risk, of adding more suffering unnecessarily, cuts us to the quick. We know these old disease, the previously forgotten harbingers of death. As physicians and nurses, we see the rare case that sneaks through modern defenses. They are still real to us.

We keep their secrets, we still study the demons who live underground. We know in other countries they still kill people by the thousands. Those monsters are still real to us, they keep us up at night.

We go home and kiss our children and thank God there is at least one threat in this big, dangerous world from which we can easily protect them.

This is why we respond with so much anger and vitriol sometimes. It is because vaccine preventable disease hurts us so deeply. We bear witness to so much suffering, because this is out job.

But to have suffering added to our plate, to have it piled on unnecessarily – this can be too much to bear.

Deep down, I know people love their children and are trying to protect them as best they know how. I only wish I knew how to make them feel the fear of those long-forgotten demons who still live underground.

If they were to live with the fear we know, I don’t think we would even be having these conversations.

Across the Great Divide….Part 3

It is Memorial Day on the High Plains. The small, well tended town cemetery is full of flowers. People mill among the headstones. I often walk by this cemetery while I am on call and this is the first time I have seen anyone else.

On the other side of town, the town pool is being prepared for summer and children play baseball in the town park. American flags line main street. It looks like Normal Rockwell threw up all over this little town.

These are all small little rituals that maintain an identity of Americanness for people in small towns across America. There is no Walmart parking lot to negotiate, no traffic to fight. Simply the rituals family, country, and community. It is seductive, in a way.

Twentieth century White America needed all these rituals to form a cohesive identity. Many of the adults were children of European immigrants. On the High Plains alone Irish, German, Germans from Russia, Czech, Polish, Italian, Scandinavian, and Latino immigrants mixed in communities.

So, people got together in these rituals of Americanness in public. Even if in their own homes they cooked their old foods, read their old prayers, and told their own stories.

But, in public, it was all about being American. It was a communal effort to support the idea of being one people, bound together by location and a national ideology. Even if they did not share a historical culture, language, religion, or history, they could share a hot dog, a beer, and a baseball diamond.

America is a Fragile Idea

People tripped over themselves trying to be publicly American. Assimilation was all the rage. My father’s mother spoke German. After WW1 and WW2, his father discouraged her from teaching the children any German because of anti-German sentiment.

In the Southern High Plains, school teachers and classmates mocked and punished Latino children for speaking Spanish. I won’t even delve into the brutality and cultural genocide of the Indian Boarding Schools.

People paid the price of this cultural loss to assimilate and be “American.” Only the oldest resident’s of the High Plains have memories of their European immigrant ancestors speaking the Old Language and practicing their Old Ways.

The modern generations only know that their parents and grandparents did assimilate. They don’t realize it took decades or 1 or 2 generations for their ancestors to assimilate into “Americanness.” Nor, do they acknowledge the change their assimilation brought to American culture as a whole.

Immigration did not bypass Fly-Over County, then or now. The first Arab-American Senator in this country was Lebanese Maronite Christian from a small farm southern South Dakota – James Abourezk.

Fort Morgan, Colorado made news a few years ago. Somali immigrants working in industrial agriculture sued under religious freedom grounds for breaks at work to pray the requisite number of times per day.

What I hear and see when people on the High Plains talk about new immigrants is a feeling that the rules have changed. Their ancestors bartered one culture for another. Now, in the Cities and even in their own communities, they feel new immigrants are not forced to make those same concessions. I don’t know if this is true, but it is what they feel.

I doubt any of this is conscious. Much of it comes out as simple nativist, scapegoating for the pain of being in a world that is changing rapidly and leaving them behind. Nonetheless, I wonder if deep down, there is a jealousy. A sense of “Why did my parents and grandparents have to forget their culture and these new people don’t?”

Rituals of Americanness

Of course, new immigrants are assimilating, but it doesn’t happen overnight. Whereas their presence can change the fabric of a community or neighborhood in what feels like overnight. And, as they assimilate, they change the fabric of America.

Americanness is an identity based around ideas. These ideas have ebbed and flowed over time. Their relative significance has changed as well. Periods of time when these ideas were under debate have always been the times of great discord in American society.

The 1910s and 1920s saw race riots and a swell in anti-immigrant fervor. The debate over slavery that lead to the Civil War was a time of arguing over what it means to be American and who got to participate in the idea of America.

When your national identity is based on ideas, it is so very fragile. You cannot rely on history immemorial to bind you together. Every 3-4 generations we as a country must decide that we still want to be a nation together.

Group rituals are what bind a people together. In many cultures, the communities commitment to a given ritual is necessary to keep the world moving. The planting and harvest rituals are essential to the world continuing to function as it should.

Similarly, in a Russian Orthodox Easter service, Christ ritually dies and is resurrected every year. The community re-enacts it, together, to bind them in a sense of history, purpose, and collective emotion.

The Rituals of Rural White America: the baseball games, the laying of flowers on headstones on Memorial Day, the fireworks and backyard barbecues of the Fourth of July – they are held dear because in their completion, the idea of a certain kind of America is reborn, reformed, and confirmed.

The fragile existence of an American identity is solidified, if only for another year. When White Rural America perceives the mockery and dismissal of these traditions, they feel their identity, their nation is literally under attack. Because, at least ritually, it is.

Stories are what bind us together. From the vantage point of Rural America, the polyglot, postmodernist, multicultural milieu of Urban America is not a force of creative disruption. It is simply disruptive, even destructive.

I live in the City, and even there, I don’t hear anyone offering a new American story, I only hear them railing against the old story. Which is understandable, the old story was exclusionary.

Many in Urban America cannot see themselves in the old story. White, male, Christian Americans jealously guarded membership in the old story and its benefits.

You cannot simply be against something, you must be for something as well. If a large portion of the country, especially one with significant electoral power, cannot see themselves in that story, they will fight it with all their might.

I like the idea of a big, messy, diverse country striving together to make itself and the world better, safer, healthier. So, I am asking Urban America to remember to offer a New Story in return for subsuming the Old Story.

Rural America has its faults, but it is still part of the multiculturalism of this country that you purport to love and admire. So, tell them a story that includes them, don’t just shit on their story.