kayaking

I grew up kayaking on tranquil lakes and rivers but developed a taste for brutal oceanic waters when I lived in Washington.  It was a thrill to paddle furiously trying to conquer waves that tossed you like leaves in a tornado. I loved the push, dizzy unpredictability of which direction you'll be facing next and the necessary hyper-awareness of the balance of your boat. One tiny off-center moment could result in a dunking. 

Yesterday's excursion through a marshy nature preserve was a relaxing reminiscence of early kayak days. There was no danger, no choppy ship canals or 6ft waves to navigate, just glass-like water, the sound of the breeze skipping like a stone & the occasional call of a morning dove.  The thrills were subtle: spotting a great blue heron, seeing the sky reflect perfectly in the water.

Homestretch/Green Mile

I've had a busy week.

I've reorganized my closets. Twice.  And replaced the inner tube on my bike's front wheel and bought a new saddlebag basket and new reflectors. It's been a few years since I've biked regularly in the city and I can barely wait to get back in the habit.  I love love love not having to find, or pay for, parking!

I killed one of my herbs, the lavender. I don't know what happened. It had good drainage and I watered daily. I think the heat conquered. I fear that this is an ominous sign of the coming year. I'll report back next June on the number of plants that survive MS1.

I  had my respirator fitting and TB screen. Why do hospitals not trust other hospitals' ppd results? Tuesday marked the 4th time in the last 7 months that I was poked (once for the yearly at work and twice before volunteering at a hospice). But BCMS required that I have one done by them too. Argh. Of course, it was negative. Again.

The obligatory pre-first day pimple woke up on my chin this morning. Yay.

I've been trying, the last few weeks, to adjust to waking up earlier. With over a decade of working second/third shift, my body understands that anything earlier than 9:00 is obnoxious. But, this morning I woke up before my alarm at 6:45! I'm thinking optimistically that it's the retraining of my circadian rhythm and not stress, despite the pimple. And the nightmare.

Ask any professional restaurant server (the career that paid for all my adult life) and they'll tell you all about the typical server nightmares: the section or table that swells with new people every time you go back, the unreasonable boss, the evil chef etc.

Years ago, when I started working for a truly nasty boss, my server nightmares stopped. I suppose with actually living the nightmare, My superego had to deal with coping with the stress thus leaving nothing for my subconscious.

On rare occasions, the night before terminally extubating my mother or, as the case may be, the nights before medical school, the server nightmare manifests.  Last night, I was back working for the nightmare boss.  I guess that shows how stressed I am. MCAT pshaw, moving cross-country pshaw, tackling two full time jobs simultaneously hah!  The day before school being on par with deciding to let my mother die?!! 

I know that the next few years are going to bring incredible stresses.  I'll be really lucky if my nightmares continue to be about waiting tables and not about things that could happen in the hospital. I can deal with the angry diner who didn't get her Coke refill.

Today, I do laundry, clean, and pay all the bills for the coming months.

Oh. I received a call from my service provider. The other phone I pay for has shown a spike in activity; would I like to add texting to the plan? Apparently, my grandmother has discovered a great new way to communicate to her friends and family. She's sent out 637 texts this month alone.

It makes sense for a woman who is very hard of hearing- there are fewer misunderstandings. I laughed despite the added cost. My almost 90yo Gram is so tech savvy. She has more facebook friends than I do!

Tomorrow, I go grocery shopping- with my new bike basket! and hit the zoo. I wanted to do something fun and relaxing the day before D-day.

One Week.

The moment came today. I was walking to the market, a truck drove by and cast a cloud of dust and grime into my face. I coughed and pulled out a cloth to wipe my glasses. Then it happened. My perspective shifted. Medical school ceased being a vague, holy-cow-not-really-happening-to-me, intangible ambition and suddenly became real.

The financial aid is in my bank account. Orientation comes next week and I pick up my books tomorrow. Tuesday is the ppd screen and respirator fitting.

I am so completely terrified.

I walked past the market, continuing on aimlessly. Thinking. I ended up in a little rundown park by the river in an iffy neighborhood and sat, staring at the garbage bobbing in the murky water.

Am I making the right choice?

I remember telling the doctor-uncle of an old flame that I was thinking about becoming a doctor. I was 21 at the time, fresh out of working in the national parks and hadn't even started college. I had no idea then how challenging just getting accepted would be. He wasn't encouraging, a sentiment echoed by the soon-to-be ex.  Life became dramatic and I left that dream on a musty closet shelf of an old apartment.

The years passed and I continued to ramble aimlessly across the country.  I found myself 26, living in Seattle with lots of disposable income. What to do? What to do? Hey! I'll take a couple of community college classes!

And so it began. That first day, my chemistry professor told us that half the class would drop before the term's over. Humph. I'd show him. And I did. I ended up with the highest grade in the class and friends with a premed aspirant. She reminded me of the idea I had had once and, soon, I found myself on the road to medicine.

It quickly became apparent how competitive the premed curriculum and the med school application process were.  My ambitions were not very well received on the family front and my college mentor adamantly wanted me to go into a graduate chemistry program rather than medicine. Having striations of a strong Irish-Scot stubbornness, my "I'll show them" attitude came on gusting. Somehow, the determination to succeed, to beat the challenge by getting an acceptance got tangled up with my purer reasons for wanting medicine. Those reasons I had had before I knew that the challenge, the doubt, existed.

Today, in my terror, I tried to unwind them. Am I starting this insane, exigent path for the right reasons? Now, having shewed them, is this what I really want?

Or is my fear that I'm not good enough, that I won't, can't succeed, murking up the waters, like the garbage floating in front of me, causing me to question my own motivation?

I don't know. 

I'm reading my journal from work, remembering my favorite patients and how the medicine and the dynamics of medical care intrigued me. It's helping a little.

School needs to start. I'm hoping that once I'm on the rat wheel, I won't have time for these self-defeating doubts. Oh, I hope.

New Year's Resolution.

It was a rough end of the year for me. I try hard not to resent the families abandon their older relatives at the emergency department... "Grandma (who is 96 and unable to walk without assistance) attacked us"... My own family, parents, grandparents, siblings has decreased to two (my brother and grandmother) over the last few years. I don't know if I'll ever share the joy of the winter seasons again like I did in years before. I hate that people can just throw the gift of family away.

My heart breaks when the holiday passes and the poor 'social admissions' wonder what they did, cry for their families or stare blankly at the wall. The families rarely seemed to visit.

I did have a lovely time reflecting on the year to come though. I'm hopeful that it will be a monumental series of experiences.

I don't normally make resolutions but I'm determined to squeeze out every bit of adventure, enjoyment, stimulation and happiness that I can. I have a tendency to be complacent; spending my time reading in my apartment and being alone. The last few years of my life have revolved around taking care of my mother, my grandmother, my brother's family and work. I hadn't made any plans because other things were more important. I fell into a deep gloomy rut.

I want to get up and go every morning, make plans and rediscover an anticipation of life that I've somehow lost. I won't wait anymore for things to just happen; I will do.

I've got months of time off saved up and I'm going to use every drop before I leave my job.

That's my New Year's Resolution.

Cheers all.

Tripping Down the Stairs of Higher Education

I have heard that the college experience transcends generations, that Powerpoint is the main difference between a Harvard freshman class in 1900 and a Harvard class today. My parents and I bonded over similar experiences. As a non-traditional (read: older) student though, I have always been acutely aware that in many ways my academic experience has been profoundly different than even that of those my own age.

Students now deal with the enormous lectures halls and the reviled clicker questions. The body of knowledge to learn and the competition for top grades seem to grow exponentially before our eyes.

Each generation, each class, seems to develop radical ideas that change the world and the way we learn. When our parents had few resources outside their professors and material libraries, we have virtual access to libraries and scholars across the world as well as instant access through sites like Pubmed and Biomed Central (among countless others) to cutting edge research. We can clarify any confusion we may have about lecture material from almost infinite sources during the lecture. There is a beauty in the changes that America has witnessed in higher education. It is incredibly exciting to be right there and witness new developments unfold.

For example, Einstein fundamentally changed the world of physics for future students like Richard Feynman who, in turn, amended it for the new generations. Lisa Randall is continuing this evolution for current and future scholars. The biochemistry that I learned last year is radically different that that I would have learned had I studied it with my high school classmates. When they were studying advanced biochemistry lab techniques, the human genome had not been completely mapped. Certain technologies, like gene sequencing, that were cost-prohibitive to even postgraduate research centers then are now common in undergraduate laboratories. I was able to witness the development of new approaches like the development and use of homing endonucleases to cut HIV DNA that already been inserted into the host chromosome. But despite seemingly vast differences, the feel of college is the same.

Students are taught in essentially the same manner. Though we see a growing trend of non-traditional early learning philosophies (e.g. Montessori), at the collegiate level, the lecture method grips the undergraduate world just as we see in favorite stories like Tom Brown’s Schooldays or Tales of St. Austin’s. We suffer the same 500 seat lecture halls that our parents did as freshman, and at the graduate level, the fierce defense of one’s dissertation to a critical examining panel echoes softly in the memories of Cambridge’s fierce Wrangler mathematical examinations. Both parents and children relate to and laugh at the antics of Rodney Dangerfield in Back to School.

The students themselves are essentially the same. Roger Ashcam who wrote The Schoolmaster, a treatise on proper teaching in the 1560s, claimed “Some wits, moderate enough by nature, be many times marred by overmuch study and the use of some sciences, namely, Music, Arithmetic, and Geometry. These sciences, as they sharpen men’s wits overmuch, so they change men’s manners oversore… Mark all mathematical heads, which be only and wholly bent to those sciences, how solitary they be themselves, how unfit to live with others…” We can assume had he known the future evolution of chemistry & physics, he would have also securely included their scholars. We can all see this truth today. Everyone, regardless of her age, can remember growing up with a Milhouse, Urkel or Screech.

We see in the structures of universities, their classic Georgian or Gothic architecture, a lingering look to the past. The traditions of Greek Life, though on the wane, still exist. Students are still proud of being a multi-generational legacy. Memories of college shared between generations are that of a place out of time: days that start late and nights that never end.

The substance of academia is in constant transformation but the experience of being there is fundamentally the same. Though some of those newly found ideas shake the foundations of our world, our experiences, those joys found in intellectual awakening and the contribution of ideas to the great body of knowledge, may be shared trans-generationally.

As Ronald J. Daniels told the most recent freshman class of John Hopkins University “So although universities are in one sense symbols of permanence, they are – owing to their devotion to ideas -- paradoxically incredible engines of change. They change science and art, history and philosophy – even our understanding of what it means to be human – by the ideas they generate.”

Why am I waxing poetic over the college experience? Having dined at the smorgasbord of learning delights, having been able to choose to study something in depth under the guidance of great scholars, I have recognized how important it was in the development, the maturation of my character. The pleasure I feel when I can go to an art museum with an (somewhat) educated eye or read something, understand and appreciate some of its underlying social, economic historical forces is indescribable. But it is more than that. I was a full-fledged adult with strong opinions and curiosity before I pursued my college education. Post-college, I can look back and recognize that my full-fledged status did not mean fully formed. I know that my thinking and opinion formation now is deeper and more critical than before and I hope (and expect) that as I continue on in my education, that I will grow keener and more thoughtful.

On a greater scale, education is the driving strength of the development of our culture and nation. We would not be able to compete in the global market without the innovation an educated population develops. Those symbols of permanence and engines of change are undeniably some of the greatest sources of the innovation required to keep our country one of the most enlightened and innovative nations in the world.

I know that certain medias’ portray ‘the educated elite’ as unnecessary and even threatening to ‘normal people’; I see the fundamentalists try to disparage and discredit scientists in their attempt to sell creationism over evolution and I always laughed at the silliness. I mean, all of the comforts in our life, the luxuries (food, clean water, electricity, medicine etc) that allow us to focus on things other than physical survival, are due to the innovations by the very people that are being discredited.

But there are increasing unhappy trends in our status as the innovative and educated nation that make it more difficult to laugh off silliness. For the first time, we are looking into a future whose children will be less educated than their parents. They'll be less educated in a world of growing education opportunities. As a population, we need more, not less, education to compete on the global stage. We need more education to evolve as a society. Last year, the United States fell to an international rank of eighteenth in secondary education. That is almost as low as an developed nation can fall. We seem to be losing our drive to become the strongest or we're using a warped meter stick to measure our progress. Whatever the cause of this educational downturn, I’m just saying that I probably won’t be dismissing any silly attitudes anymore.

*The statistics I cited are from the Organisation for Economic Co-operation and Development.

Panegyric

The weather this weekend has been misty and gray. The trees quiver with the weight of the moisture on their leaves. With every gust of wind, the dew patters to the ground to echo the footsteps of my ghosts as they run through the woods.

One year ago yesterday, I decided to change my mother's care to palliative. It was the day before her 55th birthday. After some contemplation, I had decided not to wait until after her birthday to sign the paperwork. Though it had felt like I was giving up just when I should have been celebrating her life, I had finally recognized that she had given up long before and I just wanted her pain to ease. I didn't want her to have to struggle through her birthday.

Over the last year, that decision, all the decisions over the course of her care haunt me. I question if I should have waited, if I should have made the decision weeks earlier. I wonder if my self-interrogation stems from the melancholy that I feel right now, struggling with the convergence of her birthday, her death, my birthday (the 20th) and the anniversary of her funeral. I probably won't ever know if I made the right choice for her and that abrades me. I hope that as time passes, the erosion resembles less the calving of glaciers, monstrous pieces felled in a swoop, and more the gentle tumbling of sea stones.

Last night, a husband, surrounded by his family, decided to transfer his wife to hospice. The time spent in her room with her family was like a crampon squeezing my heart but they seemed desperate to have someone they trusted, who had cared for their wife, there to reassure them of their decision. I stayed because her daughter wouldn't let go of my hand and I couldn't bring myself to extract it.

The staff lounge was awash with comments like "it's about time" and judgments about the family's decision, a typical occurrence during these transitions. I completed her paperwork and then took a 5 minute bathroom break to rinse my grief from my eyes.

My sadness for her family and their coming sorrow, my sadness for the other six patients that I've transferred to hospice, particularly those who had no loving family to take on the burden of loss, and my memories of my beautiful vibrant charismatic mother sit like lead in my chest.

It's ironic that those who are most vocally critical of the choices that families make are those who have had the least experience dealing with any major decision, loss or grief and the least experience with the patient and her medical history. There were nurses who had never worked with the patient, never read her chart, never met her or her family who felt comfortable deriding the family and what they perceived as an unnecessary delay of the inevitable.

With a few questions carefully chosen to prick holes in their balloons of certainty, I made my point that this was a complex situation that could not be boiled down to an imprecise diagnosis and that making these types of decisions isn't easy or simple for clinicians who've been in the field for decades, let alone the families who are newcomers.

I started this post intending it to be a panegyric for my mother and the incredible staff at the Kindred LTACH in Wilkes-Barre, PA. Throughout the last months of her life, they nurtured the joy that she felt being around people- not an easy thing to do working in a hospital. Despite their many responsibilities and her inability to respond, they took time to visit with her and amuse her. They also supported me completely as I tried to navigate the bayou of treatment options. When my mom reached her limits and began to withdraw, I requested and they unhesitatingly joined me, her physicians and an ethical committee to discuss withdrawing treatment.

I am grateful that they demonstrated the power of empathy in softening the uncertainty and distress a family feels in these circumstances. Though, as an aide, I have no medical authority to ease the doubt and fear someone has in making a decision, I can follow the example set by the folks at Kindred. I hope that I made the family's trauma easier last night. I hope that I will always remember as vividly as I do now what it felt like grieving, frightened, unsure and dependent on the guidance and understanding of doctors and nurses.

Choices

Finishing my stint on third shift this morning, I stepped into the clear cool air and watched the beautiful blushing sunrise. It was a serene moment after a long night and a tense early morning.

One of our patients had left AMA just after morning labs. Last week, high on cocaine, Russell** started a bar fight and injured his shoulder. Dr. Joe told him that the surgery would be delayed for several days to allow his body to metabolize the cocaine. Russ was not happy to be stuck in the hospital for a week and recompensed by abusing the nursing staff: dumping his urinal over his sheets and the floor, barking at us when we walked by and spitting at anyone who came into the room.

We, of course, avoided him as much as possible. Well, Dr. Joe neglected to mention to Russ that he would have to have another drug screen before the surgery. Apparently his visiting friends had decided to bring him more drugs instead of flowers. When the lab tech went in to draw his blood, he went a little nutso, pulled out his IV and, blood dripping down his elbow, stormed out of the room toward the nurses' station screaming about bovine stool and ordering us to procreate with ourselves. Thinking he was going to attack us, we called a security code.

After the grey coats wrestled him back to his room, Dr. Joe came up and told him that the surgery was, yet again, delayed. Russ decided that he didn't want the surgery and demanded to be allowed to leave. Dr. Joe, quite angry and quite willing, retrieved the AMA paperwork and Russ left.

I stopped by the grocery store for cat food on my way home. I settled in the express line as a heavyset young woman unloaded her cart of items with the corresponding WIC vouchers on the counter. I had the rest of the day off and so buried my natural impatience with a magazine.

I soon found myself eavesdropping on the transaction ahead of me. The woman, refusing to pay the 58c difference for a bunch of grapes, told the cashier to take some grapes out of the bunch. I watched as the scan was voided, grapes removed, rescanned, voided, grapes removed, rescanned, voided, grapes removed, rescanned, voided and then grapes added one by one until the weight matched the amount allowed by the WIC voucher. *sigh*.. "day off.. day off.. day off.. breathe.."

The cheese came next without issue. The juice wasn't juice but punch and not allowed under the rules of the program. Argument. Huffing. Return with Lemonade. Argument. Huffing. Apple Juice.

Finally, the cashier began scanning the non WIC items: HungryMan dinners, bagels, jars of baby food and beer. Total $21.53. Oh, only have $18.37.. Big eyes look at the cashier then move to me. I bury my face in the magazine. Hummm... Ok, take the baby food off.

I drove home judging her. I drank my black coffee and judged her. I thought about the choices that she could have made but didn't. I began to reflect on the decisions that I have made that could be better and I felt guilty. I could have had something other than that blueberry muffin this morning. I could have had tea instead of wine last weekend. I make awful decisions all the time: too much cheese, not enough greens, not enough water, reading trashy novels instead of literature, watching True Blood. I have a degree in chemistry and a passion for studying nutrition. I still make crappy lifestyle choices. I think most people do.

Lady, you're doing alright. Keep going to your classes at WIC and keep fighting for every grape. Please just don't do it in the express line. And don't date anyone with a gimpy shoulder; he's bad news.