If the Pandemic is War, I guess My Neighbors are Vichy?

The war analogy in regards to the pandemic is a little worn out. Cable News screamed it for too long in the early days for it to resonate much now. Nonetheless, I am going to lean on it in an attempt to convey a few things.

Most of you are probably involved in healthcare and know all to well what I am about to describe. But, it is something I just need to write down. The whole point of this blog is catharsis, after all.

Morale is Low in the Trenches….

From the beginning of this pandemic, those of us working in healthcare have been told we are on the front lines of some epic battle against a deadly foe. It is as good an analogy as any other, I guess.

Like most wars with an aggressor foe, we began underprepared. It was disheartening, but not surprising. Few organizations could have been adequately prepared (though we could have certainly been much better prepared).

Either way, we could deal with the lack of PPE, staffing, etc, as a temporary setback as we struggled to adapt to fighting this new challenge. It was something that would get better, and it did.

For months, we settled into trench warfare. We threw a few salvos of recovered patients out in the world, and the world threw some different ones back. Staff got sick or exposed and had to quarantine, and we had to fight with one hand tied behind out back. It was grueling, but manageable. Most importantly, we had reinforcements, staffing agencies, PRN staff, locums, etc, could be called in.

Unfortunately, we have entered a new phase. Everywhere is surging at once, no reinforcements are available. Hell, urban hospitals are asking us to be reinforcements and surge capacity. We try.

The reality is, for the most part, this is all still manageable (at least where I am). It is stressful, but we signed up to take care of sick of people. Sometimes periods are busier, and then you get slower times to recuperate.

What is becoming unmanageable is a crisis of morale. Burnout has been taking its toll in healthcare for years, so morale wasn’t great to begin with. But now, it is reaching crisis levels.

When Your Neighbors are your Enemy’s Supply Lines

In my corner of the pandemic, I feel like I am resistance in Vichy controlled France. My countrymen, people with whom I should feel a brotherly bond, have decided to capitulate to the Enemy en masse.

When possible, they gather in groups as large as they can get away with. Fully half abhor mask wearing. Which, beyond its well-documented benefit of reducing the spread of the virus, makes me feel like the resistance fighter living among neighbors who provide succor and assistance to an enemy invader.

6 months ago, Paul Revere ran through the countryside yelling the British are coming. In the intervening months, apparently half of us have decided not only refuse to help the Minute Men, but actively feed and clothe the British.

Hell, sometimes they even seem to be setting up a nicely outfitted afternoon tea for them.

Inside the hospital, you never know if enough nurses are going to show up to staff the hospital and/or the nursing home from day to day. At any minute, the Locum Doc or Traveling Nurse you were depending on to give you break may call and say they have tested positive or been exposed and need to quarantine.

Nerves are raw.

Rural healthcare runs a shoestring in the best of the times.

If only 3 docs work in a community responsible for the ED, hospital, Nursing Home, and Primary Care, you are one person away from more than 30% of your medical staff being down.

In the best of times, you live on the brink of disaster.

Now, we are stressed at all times about whether or not we are wearing adequate PPE, our nursing staff is permanently understaffed, and there are no replacement to be found. Add to that, the communities we are supposed to serve seem to view the simple inconvenience of wearing a mask as too steep a price to pay to let us know they have our backs.

We hear the message loud and clear: We are on our own.

The post-modern consumer-patient tells us, “Well, its your job, they pay you, what is it to me?”

Already, I am having to wait half a day to get a person with a Hemoglobin of <4 transferred to somewhere with endoscopy capabilities. That might be you tomorrow, or two weeks from now. It might not, you might be lucky.

At this point, I don’t even care if you don’t think wearing a mask is effective at slowing the spread of the virus.

If you could just do it to send us the message that you have our backs, that you aren’t feeding the Enemy.

Ask the Vichy, capitulation never ages well.

I am not here writing this to descend into politics, culture war, or even evidence based arguments. I am just a tired Doc in a small town asking you to wear a mask to let us know we aren’t alone out here, that someone gives a shit.

Photo: WW2 US Government Propaganda.

Humility is Never Far Away…

Call shifts in our little hospital work slightly differently than in larger institutions.

Generally, I run a same-day clinic of urgent care type complaints and am also on call for the Emergency Department should anyone come in during the day. In addition to that, the call person is also the point person for any acute issues from the nursing home or inpatients whose attending doctors are not working that day.

It is rarely truly busy by any larger institution’s standards, but it can get a little chaotic shifting to and from such varied treatment settings multiple times a day.

On such a day, I walked into a clinic exam room to see an 83 year old complaining of blood in stool.

Harold, in clinic.

After reviewing his vitals to make sure we didn’t need to send him directly to the ED. I entered the room and greeted him.

“Hi, Harold. What brings you in today?”

“Well, Doc.” (I have come to envy the ability of patient to address me intimately, yet respectfully, without having to actually remember my name). “I noticed my poop was dark red when I went to the bathroom this morning.”

He looked well. He wasn’t pale, he was resting comfortably. I let myself shift from Emergency Department mindset to outpatient mindset. “Okay, tell me more about that.”

“This has happened before – a couple of years ago, and since I am on that blood thinner, I had to go to the city to have something done where they looked for why I was bleeding and tried to stop it, I don’t want to have go anywhere else if I don’t have to. I was hoping we might be able to nip this in the bud before it gets to that point.”

“Well, we’ll see what we can do, let me ask you a few questions.” I ran through the standard list of questions for symptomatic anemia.

“Have you been light headed or dizzy?”

“Maybe, not worse than normal, Doc.”

I listened to his heart and lungs, looked at his mucous membranes for palor. All pretty normal.

“Any chest pain, shortness of breath, fatigue?”


Any change in urination, color, belly pain?


“Well, I am going to have to do a rectal exam to test your stool for blood.”

“I figured we’d get to this, Doc. But I’m not looking forward to it.” He rolled over and slid his pants down.

“You know, It’s not my favorite part either.”

He chuckled, “Well, I suppose it probably isn’t.”

After withdrawing my finger, I used the little balsa-wood applicator to apply the stool samples to the testing kit and applied the solution. Sure enough, the blue rapid ran across the test kit paper as the solution spread.

“Well, Harold, you definitely have blood in your stool, we’re gonna have to send you over the ED for more testing to see where your blood counts and INR are sitting and we’ll decide from there what we can do.”

To the ED

I walked out of the room, told my nurse to wheel him across the parking lot to the ED. I called the RN at the ED, explained who was coming over and rattled off my list of order, start an IV, start fluids, and give him 80mg of protonix and send a type and screen, CMP, CBC, INR, etc.

Now, we don’t have the ability to do acute endoscopy. We have a general surgeon endoscopist who comes twice per month, so I walked over to the clinic manage to figure out when he would be coming. Turns out, he would be in town 5 days from then.

A plan started to form. Most of the time, even in large institutions, doctors observe GI bleeds, treat them medically, and set up an outpatient endoscopy afterwards. It is however, very nice to know the option of an urgent or emergent endoscopy is available, so most of the time, I send people with GI bleeds to larger centers.

However, Harold had been very clear that he did not want me to transfer him out of town if I could avoid it.

So, I thought, he is clearly stable, if his counts don’t drop too badly and he stays stable, we might be able to observe him locally, and set him up for any outpatient endoscopy a couple of days after discharge.

I was starting to have fun. I like creative problem solving, but with the shift to evidence based medicine and treatment algorithms (which, In general, I think are a good thing as long as they are not treated dogmatically), creativity is increasingly absent from medical care.

Again, this is probably a good thing. But, it can take some of the joy out of practicing medicine for me.

The Plan

Harold’s labs came back. His INR was therapeutic, and we gave him some Vitamin K to drop it quickly. His Hgb was in the normal range and only 2 points down from a couple of months ago. Everything else looked good.

I run the plan through with Harold at his bedside.

“Okay Harold, If things stay stable and you don’t need a lot of blood transfusions or your hemoglobin doesn’t drop too fast, we could reasonably safely keep you here and have your endoscopies done on Tuesday. “

“That sounds great, Doc! I really don’t want to get into an ambulance, I am going to have a hell of a time finding anyone to give me a ride back here from the city if I have to go, so I would much rather stay here.”

Things are going well. I feel good. We are respecting a patient’s desires, stretching our staff a little, and, I think, staying within safe practice.

Seems like a win all around.

And It Doesn’t Go To Shit

The most shocking thing is, the world didn’t come crashing down. Harold did well in the hospital. We corrected his INR easily, his hemoglobin stabilized, and he discharged with plans for an endoscopy two days after discharge.

He had his endoscopy as planned, it went well. An nonbleeding AVM was located in his colon as the likely source of bleeding. I saw Harold in follow up a week or so later to discuss his blood thinner.

“Doc, I don’t think I want to go back on the blood thinner, this is the second bleed I have had in the last few years. I don’t want to take it anymore.

I reviewed the higher risk of stroke with his atrial fibrillation if he did stop it. He was comfortable with those risks. In the end, I thought it was reasonable given that we knew he still had that AVM in there, waiting to bleed again. We restarted his high dose aspirin and agreed on another follow up in a few months.

I stood up to leave the room, had my hand on the door. And Harold opened his mouth.

“Hey, Doc.”

My heart sank, most doctors know that what whenever a patient starts talking right as you are about to leave the room, it is rarely a good thing, and usually a whole new can of worms that you weren’t planning on addressing.

“Thanks for everything.”

I smiled, not visible under my mask. “It was my pleasure, I am just happy everything worked out alright.” And, I meant it. I closed the door and walked back to my office, triumphant.

It was on of the best clinical experiences I had had in a long time. I left town that evening and drove home for the weekend.

I felt damn good.

Next Week

The next week, I drive into town and walk into clinic. My MA greets me.

“Hey Doc, Harold died over the weekend, car accident in the next town over.”

“Well, shit.”

I just stand there for a while, accepting my own smallness in this world, just letting steeping myself in it. I did not look for any lessons, purpose, or meaning, just let myself be in a complicated moment.

And there I was, with a patient waiting.

Image: Robert Scott Lauder 1803-1869 – Christ Teacheth Humility -_National Galleries of Scotland


I am terrible at finding mentors. I accept this as it is primarily my failing. I am silently critical and judgmental of anyone I audition for the part. Not too intensely, but enough to tarnish the sheen which drew me to them in the first place.

I expect too much from a mentor. A mentor must have figured out all of life before I am willing to sit at his or her feet and await the flow of wisdom. I have never had harsh break ups with possible mentors, I simply never pursue the relationship past a certain point.

This is not to say I do not learn things from people. I study and examine decisions and approaches individuals have to life and career and pick and choose lessons from them all. I will learn anything from anyone who has something to offer

Yet, I can never quite slide into the role of mentee. I cannot quite let myself be vulnerable enough to to commit. That more complete learning relationship continues to elude me.

Invariably, I find something disappointing in any possible mentor. They may be highly successful in their field, but I always seem to find some flaw in their history or personality which leads me to slowly extricate myself from any burgeoning mentor-mentee relationship.

The reasons are numerous:

They have sacrificed more time with family than I am willing to.

Medicine fills them up enough, they don’t seem to have any other intellectual interests.

They aren’t philosophical or thoughtful enough.

They aren’t skeptical enough, too sincere and believing.

Despite all their success, they seem unfulfilled, not satisfied, sometimes even unhappy.

They are boring or uninteresting

There are many more.

Why Am I so Harsh?

Why do I do this? I don’t necessarily find myself yearning for a mentor, but I certainly think it would have been beneficial for me to find one at some point along the way. Yet, I cannot say I have ever had a long term and truly fulfilling mentor/mentee relationship.

I have come to an annoyingly Freudian conclusion: the mentor-mentee relationship is too close to a paternal relationship for me to ever be comfortable with it.

Unlike many young men with complicated paternal relationship, love and affection were never the issue.

My father is simply bad at functioning in the world on society’s terms. He has never been able to play the game. I have learned more about how to function in this world from his mistakes than I ever could from his example.

He struggles with his mental health and in typical boomer male fashion, avoided addressing it at all costs for most of my life. While loving, I also remember him being angry, impatient, and emotionally unreliable.

Additionally, I have inherited a certain amount of his difficulty with playing by the rules. Not the written rules, or the ethical rules, but the unwritten cultural rules which only exists to enforce group mediocrity.

And, I have found, it is the breaking of these rules which engender the harshest backlash because they are irrational, so the response to their transgression can only be similarly irrational.

Unfortunately, in practice, medicine is a life that punishes those who break from orthodoxy more fiercely than most.

I have come to terms with these things about my own father, but I cannot help but feel they are the root me being unable to be comfortable with a mentor. No mentor will ever be complete enough, reliable enough, wise enough for me to let my guard down.

I will always find some failing – moral, intellectual, spiritual, ethical which will sow doubt, and my walls will go up. Sadly, it has led to a rather lonely professional existence.

Mentors from the Page

As a poor substitute, I find myself turning to authors as mentors in situ. I can go to the arts and literature, the great stories to try and glean wisdom to apply. Occasionally, the inspirations have been specific to medicine, but more often they are general.

They are usually men, not surprisingly. Usually already dead, their story having reached its terminal moment, I can safely know the whole arc, analyze their decisions, inspect their psyches as best I can from the page.

They are Hemingways (who has been mentioned on this blog frequently), Edward Abbeys, Steinbecks, Anthony Bourdains. Their unconventional lives are a common thread. As noted above, I am drawn to the unconventional, unorthodox – not in my personal life, but in my intellectual life.

Deep down, I have always been a puzzle piece which doesn’t quite fit. Always a little uncomfortable in any given role or position. Always pushing moving, pushing, straining.

I may not have been well suited to a career in medicine because of this tendency. I am not saying poorly suited to being a doctor, but poorly suited to a medical career. All my sages tend to be tortured, horribly flawed, often kind of miserable shits, with some hole that can’t be filled. And, disproportionately men who have killed themselves.

Even in my imaginary world of mentors from the page, I seem to be able to learn only from their mistakes, from their character flaws, their weakness. Maybe this is because great art is inherently emotive, not intellectual. And only those who wrestle with great emotions can make art which makes you feel something meaningful.

Let me tell you something. Happiness is bullshit. It’s the great myth of the late 20th century. You think Picasso was happy? You think Hemingway was? Hendrix? They were miserable shits. No art worth a damn was ever created out of happiness. I can tell you that. Ambition, narcissism, sex, rage. Those are the engines that drive every great artist, every great man. A hole that can’t be filled. That’s why we’re all such miserable assholes.

Ed Harris, as Ben in Kodachrome (2017)

I have learned much from some of these names. Their grand pursuits, their art, all seemed to stem from a deep unhappiness. And so I increasingly shy away from the addictive pursuit of art, accomplishment, money, career. They all seem to lead to a generally miserable life, punctuated by acclaim and accomplishment – but certainly not happiness.

Is it all a sham as Ed Harris’ character says? Is happiness a myth of the late 20th century which has visited upon us the curses of consumerism, the opiate epidemic, multiple other converging mental health crises?

Are greatness and happiness antithetical? Is is impossible to have a family, to be generally content with life, and work in the pursuit of something larger and more meaningful than oneself?

Who knows? I guess all I can do is keep reading, because I am pretty sure I am never going to let anyone show me the way.

Featured Painting: Alcibiades being taught by Socrates, François-André Vincent, 1776. Musee Fabre.

America’s COVID Response is Old News

Our current media environment is simply overwhelming. Talking heads dissect and opinionate on every minute occurrence and off-handed comment ad nauseam. Enough true news simply does not exist to support the advertising driven media ecosystem which now saddles us.

The pandemic has only made this worse.

I suppose whenever you live within an environment or industry, it is always rather amusing when the news and social media discover what has been known for years within your circles. This is how I feel about much of the news surrounding the boots on the ground handling of the pandemic.

None of this is New

“America’s health care system is neither healthy, caring, nor a system.”

-Walter Cronkite

Hospitals overwork nurses, doctors, EMTs, clinical staff everywhere leading burn out and unsafe conditions? Who knew? COVID just shines a light.

Hospitals have making money hand over fist on procedures which, when postponed have apparently had little effect on the over health of the population(which begs the question of why we are doing them in the first place), This has destroyed hospital hospitals bottom lines. COVID shines a light.

America incentivizes hospitals not to care for the sick and ill, but to provide procedures aimed at making the lives of people with good insurance more comfortable. Is it so shocking this has led to hospital systems prioritizing such care over general health? COVID shines a light.

Health systems were caught flat footed protecting front line workers because prioritizing staff safety didn’t generate RVUs and billable procedures? COVID shines a light.

Health inequalities are rampant and appalling – both at point of care but as part of the baseline health of large portions of the population? People of color are suffering more disability and dying at higher rates than the general population? COVID shines a light.

The American Healthcare System Prioritizes Private Wealth over Public Health

Walter Cronkite knew what the problem was decades ago, and we haven’t done a damn thing to fundamentally alter the situation. COVID isn’t anything new, it is just happening all at once when we are all paying attention.

We do not have a meaningful public health system. We have a private disease treatment facilities. Our healthcare system works great for young, healthy, and wealthy individuals. Guess what? They rarely need healthcare.

Why can’t we effectively respond to a widespread, nationwide public health crisis? Because we do not have a comprehensive, nationwide public health infrastructure.

As long as we treat health as an individual problem, we will be unable to respond to any true public health problem.

Just Look at our track record:

Obesity Epidemic – only getting worse

Opiate Epidemic – people dying by the thousands

COVID 19 – check the counters on your favorite news platform.

Well…you get the idea.

Hospitals are not substitutes for Public Health Infrastructure

Hospitals treat individuals, they do not coordinate responses to widespread public health disasters, even if those disasters produce individual illness.

Yet, we keep trying to force a square peg through a round whole. We call it population health now, as if it is somehow different from public health. Hospitals and clinics will always fail to address these problems because they are the wrong tool for the job.

Healthcare services determine only about 20% of a person’s health status. That means, 80% of the outcome of any individual’s health is already decided when they show up at the hospital.

We need to actually protect the public’s health

It is unfair to our fellow citizens (particularly to the poor, people of color, and the mentally ill) to expect doctors and nurses to make up for a lifetime of abuse and neglect society has visited upon many people in our society.

Yes, bias (based on race, class, disability, mental illness, etc) in the provision of healthcare negatively affects the health of many people. However, it is time that society accepts responsibility for our fellow citizens and recognizes the patterns of our lives drive our health far more than anything that happens within the doors of a hospital.

My work reminds me of this reality daily. I have the power to do many things, yet more often than not, I am effectively powerless in the shadow of a life lived without access to healthy food, a good education, a safe environment, the list goes on.

Poor people will always have poorer health outcomes than rich people, because resources matter. Yet, we as a country can and should do better. And we need to stop looking at the end of the pipe for solutions.

The disaster COVID is wreaking on the health of Americans is no surprise, if you were paying attention.

A system is designed to get the outcome it gets. We have designed our system to produce these unequal, inconsistent, and often deadly results.

The outcomes the pandemic has brought to light have been happening every day, in every corner of this country, for decades.

The light was apparently just not bright enough.

Our Sacred Grief

With nonessential procedures and medical visits postponed, an eery quiet has descended on hospitals on the High Plains. The surge is not yet here, and the curve, thankfully, appears to be flattening.

It is, however, the quiet of an undisturbed bowstring. Taut and tense under pressure, yet ready to snap. Most of us have tried to lose our anxiety in work, yet work provides little respite from the anxieties of this moment.

I am awash in time aplenty to catastrophize and perseverate on my anxiety regarding our current pandemic. I am thankful not to be sick. I am thankful not to be doing battlefield triage on people’s grandmother and grandfathers.

Yet, the time means I am awash in stories of others’ grief. Of people losing children, parents, spouses, siblings. All tragic, some seemingly more so than others.

The stories of young parents and children lost strike me the hardest, of course. The distance all too small between them and I. There but for the grace of God.

I Know This Valley

While my own grief is not in the front of my mind anymore, I know it is not gone. It sits on a shelf in my soul, perfectly undegraded.

Occasionally, I pick it up in my mind, dust it off, and the pain of it comes rushing back. I reminder of love as well as pain. As I read stories of other’s grief and know of how much more grief is yet to come. I feel their pain reflected off my own preserved grief.

Even moreso, I feel the pain of their loneliness. I think of the thousands of people who, panicked and in fear, kissed their love ones good-bye in the ambulance or at the ER door. They watched gloved and masked helping hands carry them away, desperate to see them discharged safely from the hospital in few days.

Yet, too many will never hold them again, never see them again other than through a camera lens in an App. They will grieve at a distance, knowing that somewhere, their loved one’s bodies have been hermetically sealed and placed in refrigerated trucks, waiting to be taken somewhere else.

I know the pain of holding my daughter and watching her take her last breaths. Yet, no matter how painful that was, it was better than not holding her, not carrying her around the house she didn’t get to grow up in.

I am reminded of stories of how grief changes when the world is turned upside down. During WWI, Russian villagers would have a funeral for any young man called up to the front from their village before they even left.

As a teenager, this story simply seemed really sad and evidence of how likely death was in the Great War. Now, I also see it as an attempt to maintain something human in the midst of inhumanity.

Better to grieve together and be wrong than to never get closure.

I can only imaging the anguish of not being able to grieve next to all who also loved your beloved. So, this disease steals not only lives, but the opportunity to grieve together, to say good-bye in an embrace.

Why Do We Grieve?

When I was struggling with my grief, I did what I always do when I don’t feel prepared. I read about it. I am an intellectualizer to the core.

I read multiple books and grief and grieving. A question I had never asked myself, but which exists in the literature is a simple one:

Why Do Humans Grieve?

Grief extracts such an intense cost, personally and communally. Some literally die from it. What could be the evolutionary basis of such a thing?

I found a few posited answers to this question, none with good evidence. One was that grief shows the community or future mates the intensity of the bonds you form.

This didn’t really hold much water for me.

The one which resonated with me was that grief serves to bind a couple, family, or community closer together. Not only in sorrow, but in love for the who or what is lost. It is a sacred function of grief. When we grieve well, we grow richer in love for everything.

When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that which has been your delight

-Khalil Gibran

What strikes me is how, on a physical level, COVID will deny many of us the opportunity to participate this sacred aspect of grief. I literally cry thinking about it.

Yet, the lack of that connection in the moment also amplifies a need for community, for humanity on a much larger scale. A time will come when contagion no longer separates us from each other. We will hold hands and embrace again.

We must remember to take that opportunity and hold it with the weight and reverence it will have earned. All of the death and loss will give us a gift. A gift of communion in pain with more people than we have ever met. Our local, national, and international loss has the power to bind us together in sorrow and love, if we let it.

Every one of us will be touched by this event. We must not slide into comparison and recriminations as a people, but join together in a collective wail of wild grief and love for what we have lost, but also with whom we are will be so blessed to remain.

Grief is pain, yet it is also a gift, because it can only come from love. I hope we do not waste the gift this plague will bring us.

Photo: Grief, by Oskar Zwintscher, 1898.  Work created before 1925 and public domain in the U.S.

Beware, Narcissus!

By now we have all seen the images. Carousers on beaches, partiers in bars, etc. The exuberance and perceived invincibility of youth which the government and media boosted with poor messaging. Modern incarnations of narcissus, so in love with their own beauty and youth they can see no other truths.

Sure, on a population scale, statistics are near destiny. However, on an individual scale, statistics are a poor substitute for adequate personal protective equipment.

Trust me, I know something about being the 1 in thousands. So does my wife and our first daughter. We were young, healthy, with access to good medical care. Statistically, we were destined for a healthy and uneventful pregnancy and healthy child.

Here is the thing about statistics, someone is that 1 in 100, 1 in 1,000, 1 in 10,000. And all the statistics in the world will not stop you from being that one.

At 3 weeks old we had to sit and hold our baby while she took her first and last breaths without a machine to breath for her. Statistics didn’t help me sleep. Statistics didn’t comfort my wife. Statistics didn’t soak up our tears in the middle of night.

Some of us young, otherwise healthy people will die from this. And the more people who get sick at once, the more of us and others will die.

The other side of those statistics is this: we all know 100 people, including people who are compromised or elderly. At the rate we are going, we will ALL know multiple people who will die from this virus. It will touch us all, one way or another.

As someone who knows about grief, do what you can to limit how many people you will have grieve over the next year. You may not be able to spend time with the people you love in their last hours because of restrictive hospital quarantines.

Someone you know, and in all likelihood, someone you love, will die alone in a hospital bed in the next year.

Why do anything which means this will happen more than has to?

Because it is inconvenient? Because it will cost money? Because it is boring? Because it isn’t necessary?

Because I don’t want to sacrifice for something which may not directly benefit me?

The Individual will No Longer Be King

We are at a deflection point in our nation’s soul. For the last 60 years, the role of the individual has increased in our nation’s psyche. Society and the good of all have occupied a smaller and smaller place in our national priorities.

This must change. This will change. The only way for as many people as possible to emerge from this alive is for all of humanity, but in our case, Americans, to remember we are part of something greater than ourselves.

Our petty desires and whims pale in contrast the great struggle humanity is embarking on. This is terrifying, but also an opportunity. Our dependence on one another, the bonds which keep families and communities functioning will grow clearer than they have been in a long time.

We are part of a whole. A mass of humanity, connected now more than ever. We must find where those connections can be nurtured, strengthened, and where each of our own gifts will contribute most.

Specifically, this is a calling to my generation, often known as Millennials to stand up and make our contribution. We must show up, we must act. This is the beginning of a great test as a nation and a generation. It has been decades since humanity has been called to such an epic task.

For some of us, it will be 3D printing of needed parts, sewing of masks, running to the front lines in hospitals, caring for elderly or high risk neighbors, getting groceries.

For others, this will simply be staying home. We will contribute to breaking the chain of infection.

We must not underestimate the courage of staying of home.

The act of staying home is no simple feat. Staying home makes real the fear of the threat we face. It would be much easier to pretend no threat exists, because no fear could torture us.

By staying home we sacrifice the sweet delusion of the absence of fear. It is worthy sacrifice, as we cannot be courageous until we have first felt fear.

Courage is resistance of fear, mastery of fear – not absence of fear.

-Mark Twain

So, I call on all of us to act courageously, to allow ourselves to feel afraid. We can only begin to know the depths of our collective courage once we have touched that fear collectively.

We cannot continue to hide our fear behind paper tiger statistics. We will not have truly entered the fray until we have allowed ourselves to feel at risk. We must show up and give of ourselves.

This means giving not what one wishes to give, but what others need. We must give what is so desperately needed, not something easily dispensed.

History has given us a moment to rise to the occasion. It is terrifying. Yet, it is an opportunity for us all to be our best.

Beware Narcissus, my fellow Millennials, live your best life, feel afraid, act courageously, stay home.

Image: Narcissus, by Michaelangelo Da Caravaggio, circa 1597 – 1599. Galleria Nazionale d’Arte Antica.

The Tide Went Way Out

When a disaster comes to the High Plains, the sky holds the warning. It has always been this way. The sky dominates the land on the plains. Of course it where the warning first appears.

When wildfire rushes across the plains smoke clouding the sky announces its imminent arrival. When the “black blizzards” rolled across the plains in the Dust Bowl their towering clouds of dust blocked out the sun on the horizon. The sky lets you know ahead of time.

Except this time it doesn’t. The sky is serene and blue as far as the eye can see.

The pace in clinic and the Emergency Department is slow. I have only been on staff here for about a month, but I know this is slow even for here. Physicals have been cancelled, colonoscopies postponed, the usual minor urgent care visit in the ED have effectively ceased.

I think of stories from the islands of the Pacific during Tsunamis. First, the tide goes way out suddenly, then the wave builds in the distance and it just keeps coming. As I stand on the edge of town, looking West at the setting sun, I feel like I am watching the tide rapidly recede.

I have spent the last 48 hours running around the hospital checking for what supplies we have, asking pharmacy techs to order more vecuronium (on backorder), steroids, duo-nebs, and morphine, oh God, please make sure we have enough morphine. I verbally underline the need to stay stocked with morphine to the pharmacy tech.

I repeat Dr. Edward Trudeau’s mantra in my mind, “To cure sometimes, to relieve often, to comfort always.” In a preparation meeting, I remind my colleagues Rural America looks demographically a lot like Italy. Mostly older, and in our case, very chronically ill.

We unfortunately have even fewer doctors and hospital beds per capita than Italy. This will swamp us, I emphasize to my colleagues. And our typically release valve, “transfer to higher level of care,” is going to stop working pretty soon, because it will hit transfer centers before it hits us.

I am preparing to practice mass casualty, battlefield medicine. I fully anticipate we will run out of IV fluid, IV tubing, etc at some point. I insisted we order 3% saline so we can mix it with D5 or Sterile water to make more normal saline than we otherwise would be able to order.

I made our pharmacy tech other oral rehydration solutions, feeding bags, and NG tubes. Once we realize we are getting low on IV supplies, hydration will have to be done orally, with NG tubes if necessary for the weakest.

Just like everyone else, we have started rationing PPE. Hopefully the supply lines catch up by the time it really reaches us. We will probably have a 1-2 week lag compared to urban centers.

When I get home, I completely strip, all my clothes go into the wash – on sanitize. I shower more thoroughly than I ever have. Only then do I get to kiss and hold my wife and daughter.

Like everyone else is saying, please stay home for us and our families.

20% percent of Italian healthcare workers have contracted the virus, when one out of every five healthcare workers is out and cannot work, more people than need to will die.

This is what I dread is coming….I hope I am wrong….but I don’t think so.

The Wave is Building

We all take comfort in our founding myths and narratives. The physical and social isolation of the High Plains from the coasts and cities allows people to act as though the problems of those places exist in another world. This time has been no different. People have reacted slowly and still aren’t sure whether or not to take it seriously.

I have been trying to create a sense of urgency without panic. A narrow balance beam to walk. I don’t know if I am succeeding.

I can feel the shocks of the formative earthquake rippling through my body, even if the wave is still not visible. It is corporeal. The wave is building, rising. I survey the horizon, there is no high ground. No where to run to. We are it out here.

The state has already told us not to expect extra equipment any time soon. The strategic stockpile is already spoken for.

Already, we are accepting low acuity patient’s from the nearest large urban hospitals in an attempt to free up bed space for them. Our normal Critical Access bed cap of 25 has been lifted to 35 beds.

The wave is building.

We really normally only function with 5 acute inpatient beds which normally hold the lowest acuity patients who would ever be in the hospital. We have one ventilator, and it is transfer vent. No bipaps, our nursing home is physically attached to our hospital – a disaster in the waiting.

We won’t be keeping anyone alive on ventilators out here. To try and do so would utilize valuable resources in the hands of physicians and staff who are not well suited to maximize that person’s survival.

The role I anticipate we will play is three-fold. Surge capacity for low acuity cases who simply need oxygen, hydration, and nursing care. We will likely provide convalescent care for people who are weakened after serious illness and sent out here to take the load off of urban referral centers. And, finally, hospice and palliative care.

We will comfort the dying. Comfort always. At some point this will be the greatest gift we can offer.

Death will Walk with Us

In a moment between meetings, I sit dumbfounded in my chair in front my computer. The photo is an Italian military convoy hauling trucks full of bodies out of Bergamo. This is different.

The wave is building.

As a physician, we have all interacted with death before. This will be different. Italy is showing us this now. I learn the next day, we don’t even have a funeral home in town. Our options are 20 miles in either directions.

I ask our emergency preparedness director what the plan for moving bodies out of the hospital is. She tells me the mass casualty plan includes a plan for bodies to stored in the community center until refrigerated trucks or another location can be identified.

Well, that’s at least something, I think and take walk to the edge of town to watch the sun go down.

It seems fitting that the edge of town is also the edge of the cemetery. I estimate the space left in the cemetery, probably insufficient. I guess it doesn’t matter much anyway. People’s bodies who die in a pandemic are supposed to be cremated anyway.

This is rural medicine in the age of the pandemic. A family medicine doctor is running around helping to creatively order supplies for the entire hospital. I am urging administration to build a list of somewhat medically trained people in the community to use as an auxiliary nursing force.

Trying to think of anything and everything we can do to keep people out of the hospital – I plead with our leadership to start building a framework of phone trees and community health volunteers to check on the vulnerable and elderly.

We need to compile and update a list of recovered people in the community, because in 1 month, they will be like gold.

I worry about where the dead will go.

This is our life now and for the foreseeable future. Acceptance will be key to maximizing survival, not only of individuals, but of communities and our way of life. We must not stick our heads in the sand.

Comfort always.

Photo: The Great Wave Off Kanagawa, c. 1829-1833. in Metropolitan Museum of Art by Katsushika Hokusai.

The report of my death was an exaggeration

The report of my death was an exaggeration.

-Mark Twain

Yep, not dead. Not even internet-dead. Although, since I don’t have an Instagram account, I think I may have never been internet alive – technically.

I am still practicing medicine roaming the High Plains. I just stopped writing. Not even on purpose, at least if I had done that I could say I had made a decision. One day, I didn’t post anything, then another, then another, then suddenly it had been weeks.

Writing is hard, doing it consistently is even more difficult. More specifically to my situation, things have just been better. So, I have less to process and complain about on the blog. Or, I should say, my life has been better.

Having a kid who can breath on her own has turned out to be pretty awesome. It also means I am busier than I was and something has to take a bit of back seat, e.g. the blog. Moreover, we have decided to buy a house, so I had been working more to save up for a down payment.

I still kind of feel like buying a house is a big scam, but, I would really like to plant some fruit trees and grow more of my own food – much easier when you own a piece of land.

It also seems to make more sense when you have a small child. Having a kid doesn’t mean you need to buy a residence, but somehow it makes doing so seem a little more logical.

The Bitterness Subsides

On the other hand, medicine is a still an FOS crazy train barreling towards a bridge the Wile E Coyote of corporate healthcare waiting to blow up.

I am just more ambivalent about it all.

At one point, I felt a burden to make healthcare in America better. It drove me crazy to think how terrible it all was. How the incentives were all misaligned. The way we harmed people through overtesting, overtreatment, and overprescribing on a daily basis appalled me.

All the while treatments which could actually make a different in people’s live are not available to huge numbers of people because of our terrible health insurance nightmare.

Yet, anyone can score some oxy or sildenafil without much finagling at all, legally. And usually get some or all of it paid for.

I have come to accept my smallness in this shitstorm. I have also come to accept the sad fact that a lot of people would rather have the shitty system we have than risk a different system or especially risk changing their own lives to improve their own health – physical and mental.

Occasionally, I do something noble and decent as a physician. Usually, I am just moving people’s problems around and giving them pills to treat the physical symptoms of a broken, lonely, and self-destructive society.

We seem to prefer it that way. Better the suffering you know….

Settling Down, Kind of

So, with my life outside of medicine improving, and my expectations from medicine having decreased significantly, I have decided to settle down – kind of. As I said above, we are buying a house. I will continue to travel for work, but mostly to the same location.

I have signed a contract to work as a staff physicain with one Critical Access Hospital 80% of the time. I have worked with them off and on for the last year. It is a low volume place with a good set of local staff. It has very few resources, but a rather pleasant patient population.

We will not, however, be moving to this town. Once bitten, twice shy. We may end up splitting time for a while. We may even move there eventually if it all works out. I’ll spend 2 nights a week there and give it a shot.

You might ask, why travel out to the middle of nowhere when there are plenty of good suburban urgent care or PCP jobs available closer to home?

I will make more in this new gig that I would in the City practicing 5 days a week as a PCP. I will even possibly be able to access some loan repayment. And the volumes I’ll see would be laughably small in a City. I’ll get to see patient’s in the ED, Hospital, clinic and NH. So, other than delivering babies, will be able to keep my skills up for the most part.

Chief Complaint – R foot swollen, hurts.

But mostly, it is because of stories like this:

I was working at this location a few months back and this older man comes in to see me in clinic.

Chief Complaint – R foot swollen, hurts.

Walking in the room, I see my MA has exposed his right foot to the knee. It is swollen, red. It looks painful. The remains of a homemade bandage lie on the floor next to the foot covered in dried blood and pus.

So, Mr Banks, what happened here?

I cut the bottom of my foot on the screen door three days ago. The day or so has been swelling, getting red. Hurts like a sonofabitch now.

I bet, let me take a look.

I bend over and look at the bottom of his foot. There is a 4 inch gash at the base of his right small toe down to the tendon. Shockingly, his toe’s movement and function is fine. Red, swollen, cellulitic skin surrounds the wound and streaks up his leg. A golden crusty discharge of a staph infection frames the image.

I lean back and sit down. Well, Mr Banks, it is definitely infected. Unfortunately, even it weren’t infected it has been too long to close it with sutures, so we’ll have to let heal on its own. Given the how bad of an infection it is, I think we should have you in the hospital for a day or two on IV antibiotics…

Hold it, he interrupts. I am not going into the damn hospital. I’ll take some antibiotics, but I am not gonna be in the hospital.

I startle a bit. My normal experience is people trying to convince me they are sicker than they are and need more pills, treatments, nights in the hospital than I think will do them any good. I pause and look him in the eyes. Well, I say, let me think about we can do.

After a bit of creative restructuring, I pitch him this plan.

If you’re willing to come to the hospital twice a day for a couple of days for wound care and IV antibiotics as an outpatient we might be able to work something out.

I am not crazy doc, I’ll do what I need, I just don’t want to be in the hospital.

Ok. We’ll check a CBC and CRP daily and a Vanco level every 2 days, make sure the infection is improving, and then transition him to oral antibiotics.

I can handle that, doc.

I write the outpatient orders for the hospital nursing staff and set him up for clinic visits for the next two days. These will physically take place in the hospital outpatient ward, but will be billed as clinic visits.

In 30 minutes, I have set up an outpatient hospitalization for this man. Medicare has saved a huge amount of money. I will see no benefit. No financial incentive exists for this kind of care.

I was meeting the patient in the middle and get him the care he needed.

I know of no other setting where a clinic doc could arrange this kind of creative care without a huge outlay of time and energy.

This poor doctor would still probably fail in the end. Angry patients would then punish her for being late. She would sacrifice time at home with her family to more charting. Yet, it was possible for me to do this fairly quickly at a Critical Access Hospital.

Sure, it was a little more work, but not an absurd amount. Honestly, it was less work than a hospital H and P and medication reconciliation plus a discharge summary at the end.

This is why rural medicine pulls me back in. There is still a place for creativity and bending the possible on the High Plains. I am not sure for how much longer, the corporations are at the gates.

But, very little money grows in the Big Empty, so they may just stay at the gates for a while longer.

Photo Credit: Mark Twain, by AF Bradley, New York, 1907.

Special Shout out to Dr. Mo, his recent post lit the fire under my rump to write another post.

Mental Healthcare, Still Excising the Stone of Madness?

My phone rings.  I stop walking.  The sudden change in velocity causes the gravel under my feet to let out a slow grinding noise.

I often walk the gravel roads on the edge of town when things are slow, even at night.  Maybe especially at night.  Getting away from the few lights allows the full grandeur of the night sky of envelop me.

It is an expanse I rarely get to appreciate in the city where the smog and light pollution only let a few key stars shine through.

Of course, I am always within 20 minutes of the ED, but at my walking speed, that could be over a mile away.  I answer the phone.


“Hey Doc, the police are bringing in a guy who has been acting strange and his mother called a safety check on him. So, they are bringing him in for evaluation.”

“I’ll be there shortly.”  I turn and head back to the hospital at a slightly faster pace than before.

The Rural Mental Health Crisis Team

I walk through the doors into the ED.  The standard mental health crisis is now assembled: Two small town police officers, an ED nurse, and myself.  God help this poor soul, because we probably won’t.  At least, not in any way which changes the trajectory of his illness.

“Hi,” Char, my nurse cohort for tonight begins. “So, this is Tim, his mom called the cops because he has been acting strange the last few days.  He is talking all the time, wouldn’t let his mom into his room in the house.  He has had a lot of problems with meth, so, y’know…”

I acknowledge Char’s statement, but also mentally try to put it on a back shelf.

One of the double edged swords of small town doctoring is everyone knowing everyone.  On the one hand, it is quite a bit easier to get a detailed and relevant social history on people.  On the other, people often have their story made up in their mind about who a person is and what is going on.

Could Tim be on meth? Sure.  Does the fact that he’s done meth before mean he is one meth now?  Not necessarily.  I have developed a technique of trying to mentally disprove the suggested theory while also proceeding as if it an equally likely possibility.  It seems to help me find balance in diagnosis.

If You Get Hurt on this Rotation, You Fail.

We did our emergency psych rotation in medical school in the ED of the county hospital, a level 4 trauma center in the middle of downtown.  It was the quintessential urban ED.  On orientation day, safety was the first and last thing addressed.

The attending psychiatrist, a tall, thin man who projected both bookishness and a tempered, pulled bowstring kind of hardness, listed some maxims:

  1. Do your first cursory exam from the door
  2. Never let a patient get between you and the door
  3. Try to project calmness
  4. If you feel unsafe, leave

He finished his talk with this warning: “If you get injured on this rotation, you will fail this rotation.”

Honestly, this was the scariest threat he could have made to a room full of medical students.

Whenever I find myself back in this situation, I stop at the door and do my initial exam.  I look Tim over.  He sitting in the bed, his hands flailing over his head in somewhat rhythmic circles.  If he’d had glow sticks, he would have fit right in at a rave.

“Tim, what’s going on?”

“Just keeping everything together.” He spat out in between his rave routine.

“Are you feeling okay?”

“Oh yeah, I feel great. I just got to keep everything moving.”

“Have you been doing any drugs?”


“Do you know where you are?”

“Yes, the hospital.”

“Do you think anyone is out to get you?  Do feel in danger?”

“No, but people have been watching me, talking about me.”



I review the chart.  His heart rate is quite elevated and his blood pressure his very high.  It could be meth, but he also seems to have some paranoia and something else going on.

Of course, true psychosis and meth intoxication are not mutually exclusive diagnoses.

“Give him 4mg of lorazepam IM, if he calms down, start an IV and give him and a liter of normal saline, he’s probably dehydrated and we’ll need some urine.”

Collateral History

I leave and call his mother.  She tells me he smokes marijuana still (of course, I think to myself, marijuana is just a vitamin these days). But, she continues, he hasn’t been acting like he used to when he was on meth.  He has been saying that he has been talking to his deceased father and repeatedly saying everything would be okay because they would be seeing him soon.  He has not been sleeping, eating, or drinking she goes on.

She runs through a disconnected description of the past few days.  She is clearly very shaken.

I return to the ED about a half hour after Char gave Tim his sedative.  He is out cold.  Rousable enough to avoid intubation, but way more sedate than someone psychotic on methamphetamine would be after that much lorazepam.  His vital signs have normalized.

His story is starting to sound more and more like true psychosis, possibly a manic episode.

“Okay, Char, I don’t think this is meth, we should get mental health here.”

“They won’t come til we have a U Tox which shows no meth.”

“Of course, well let’s get that urine then.”

We Count the Hours…..

What is understood between us is how long this is going to take.  The closest emergent mental health evaluator is 90 minutes away.  So, even if we immediately had a magical urine sample at that very moment, we would be 2 hours from someone actually evaluating him (which has to happen before we even discuss placement).

2 hours later, we finally have a urine sample.  We call the mental health evaluator.  She agrees to come.  I go out for another walk.

After Julie, the mental health person has evaluated him, we talk.

“He is psychotic and needs placement?  Right?”  I prod her.

“Oh yeah.  He definitely needs placement.  I have already placed him on a mental health hold. I am going to go start making calls looking for placement.”

“I love you already, Julie.”  She smiles back.

This is music to my ears.  I hate placing people on holds.  It is a huge legal move to restrict their rights and comes with a lot of paperwork.  I love it when someone else does it.  And placing them on a hold pales in comparison to the work of finding a mental health facility to take him, which she is already starting.

Seriously, I love Julie right now.

I stand up and turn to Katie, the nurse who has replaced Char.  This has already gone on so long shift change has already come and went for the nurses.  I am here for 48 hours, so no such luck for me.

“Call me when you have paperwork for me to sign, I am going to go to sleep.  He can have more ativan if he gets agitated again, I wrote for it already.”  I think about ordering him an antipsychotic, but since he is compliant enough on the ativan, I would rather the psychiatrist get to see him in his full psychotic glory rather than already partially treated.

I trudge off to the sleep room.

A New Day Dawns

I wake up to the phone ringing again.

“Hello,” my voice comes out a froggy moan.

“Hey Doc.”  It is Char again, shift change has already happened again.  He has now been here for 18 hours. “Need you to come out and sign Tim’s transfer paperwork, we have placement and transport is on their way.”

“Okay, I’ll be right there.”

I scribble the legal necessities on the paper work and finish my half typed note from the night before.  Honestly, I am pretty pleased at how relatively seamless this was.  It took a long time.  I feel like it went well.

Cynicism Creeps Back In

However, my cheerfulness quickly fades as I am honest with myself about the situation.  Sure, we did what we were “supposed” to do.  Theoretically, the ramshackle network of mental health on the High Plains worked.

If I am honest with myself, all it succeeded at was passing the buck.

I know from experience how this will play out in the end.  He’ll get stabilized on medications in an inpatient setting, then he will be sent back to the High Plains to the care of his elderly mother, where the closest psychiatrist is 2 hours away.  Even then, the psychiatrist is only available 2 days a week.

No one will have the power or will to make sure he stays on his medications.  One day, he’ll stop them, because self-medicating with marijuana feels better than antipsychotics, and eventually the cycle will repeat.

Who knows if he or anyone else will get hurt next time.

Dividing the Care of the Person

This is how we make ourselves feel better so our souls don’t rip in half.  We break down the tasks involved in caring for human beings into such small parts so we can all feel like we’ve “done a good job,”  All the while, for the person, nothing really changes.

This is our “system” of mental health in this country.  A revolving door of failure.

Sadly, I shouldn’t even complain.  I was thrilled to find out such services even existed. In large parts of rural America, the same patient would have been placed in the local jail.  In many towns, the jail is the only secure location in town for these people until placement can be found.  At least Tim avoided that fate.

I played my part in this farce brilliantly.  We efficiently and effectively “placed” Tim.  Who could find fault with my actions?

Of course, it is not my fault we have such a failure of a mental health system and my participation does not mean I own all of its sins.   Nonetheless, it is just one more of the millions of tiny cuts physicians endure to our souls while working in our healthcare system.

The history of mental healthcare is filled with terrible and inhumane practices. Will we look back on today the same way?  We might not be lobotomizing people anymore or cutting into their heads looking for the “stone of madness,”  but we should not delude ourselves.

Repeatedly sending ill people into a world their brains cannot process to self-medicate with drugs and endure repetitive trauma through physical and sexual abuse at the hands of each other is not a more humane choice.

At least the old quacks cutting the stone were actually trying to cure something.

Featured Image: Cutting the Stone, Hieronymus Bosch, 1494 or later.

What is Adulthood?

The tumultuous diversity of America is great gift.  Our dynamism as a country surely depends on the constant exposure to new ideas and ways of thinking.  On the other hand, it comes at a cost, too.  Community cohesion seems to be the cost we are paying for this wonderful engine of our country.

One of the binding forces of community is ritual.  Traditional cultures have rituals for all major life events.  These rituals bind us to one another and help us feel rooted in our people and place in the world.  One such ritual I often feel is missing in our culture is that of passage of into adulthood.

I think many of us reach adulthood at different times in our lives.  Clearly 12 years old is no longer the time for recognizing our transition into adulthood.  Yet, I think clarity would be helpful.  Those of us in Medicine often seem to have a prolonged entrance into adulthood due to the many years of schooling and training.

When did I become an adult?  At 18?  When I graduated college, or medical school, or residency?  Maybe, for us Millennials, the transition to adulthood happens when you have to start paying off your student loans?  I had a long slide into adulthood, slowly gaining more and more responsibility.

A little ritual to mark a moment might have provided some clarity.

Is responsibility what marks our transition to adulthood?  I am not so sure.  I always had a fairly large amount of responsibility, often more than my peers.  Yet, it did not make me feel more “adult.”

Growing up, adults are the ones who have the answers.  They teach us the rules of life.  They provide structure and certainty to young, expanding minds.  I know more thing than I ever have, but often feel like I have fewer and fewer answers to the questions which matter.

I still don’t really feel like an “adult.” I certainly don’t feel like I can offer anyone else any certainty.

Feeling Old

Yet, I do know what it means to feel old now.  Unlike adulthood, I learned what feeling old feels like within a matter of 2 months.  After the first, burning, searing weeks of grief gave way to a smoldering, tired blanket of grief.  Our first daughter dying made me feel old.  All of the sudden, I was world-weary and inexplicably brain-and-soul-tired.

It seemed as though the world had gone gray, and taken me with it.  Everything took more energy than it had before.  Then, the hospital-pharmaceutical complex came and demanded I keep performing my RVU tricks.  Any hope I had had of finding some comfort and solace in work and my supposedly noble profession was dashed.

I have hurt more deeply than I knew possible.  Yet, life keeps going.  Now, I visit my grief at times.  Sure, sometimes I feel guilty I can not feel it for a few days to even a week at a time.  Sometimes, when I feel guilty about having joy and pleasure in life again, I got back to the day we had to say good bye.  I remember holding her as she stopped breathing.  Soon, I am softly crying, and I know I haven’t stopped feeling her loss.

The grief of losing my daughter was by far more painful of the two wounds I sustained at that time.   No one should have to lose a child, but people do.  Sadly, it is more common than many realize.  A path exists, there are books, and people want to be supportive (even if they are often bad at it).   Maybe because of this, I have found the process of coping with her loss and healing from it to be simpler, if not easier, than coping with my disillusionment with Medicine.

You Can’t Turn Back The Clock

The repeated grief of coming face to face with my disillusionment with a calling I had had actually grown to believe in seems to be never ending.   The Hospital-Pharmaceutical Complex seems to take joy in reminding me of its callousness and love of profiteering.  It never fails to slip comfortably under the already low bar where my expectations are.

While I have come more to terms with the reality of modern doctoring, it still makes me sad.  Sure, sometimes I am angry, too.  But really, it is mostly sadness.  I don’t have the energy to be angry at a giant faceless industry.  That sadness seem to be the well which feeds my feeling of elderliness.

Before, I felt like I was participating the arena of Medicine.  I was an eager young pupil, ready for action. Now, I view the going-ons of all the little hospitals as an old man on a bench dispassionately watches a cat stalk a squirrel in a park.  It is a drama, but a small and distant one, separate from the man’s life.

Sure, it will be sad for the squirrel, but the world is simply this way.

Welcome to Adulthood

Maybe, I wonder, this is what adulthood is.  It is not rituals, nor accomplishments, nor financial responsibilities.  It is the world teaching you it is not a place of endless possibilities, at least no longer for you.  Is adulthood the place and time where we realize life can be just as cruel as it is wonderful?

Do we become adults when we transition from an excitement about how the world could be to a acceptance of how it is?  No longer the young revolutionaries, we become harnessed bureaucrats and accept our fate?

Maybe then, I was lucky to make it to 32 before I became an adult.  I had a long and wonderful childhood, full of joy and discovery.

On my better days, I hope to return there.

Maybe that hope means my transition to adulthood isn’t so foregone, after all…