Sanitized Human Experience in a Reality Challenged Culture

 

My column in today’s Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2017/01/27/commentary-hollywood-sanitizing-human-experience-reality-challenged-culture/97136066/

I love a good action movie. I tend to prefer the Marvel franchise over DC. I think Superman is too perfect and Batman just too moody. I mean, which rich guy would you rather party with? Bruce Wayne or Tony Stark? Exactly.
But I have always been amazed at the amount of destruction wrought by my beloved X-men and Avengers when battling monsters, aliens, gods and other ne’er do wells. Buildings and freeways and bridges destroyed, untold cars exploding, earthquakes and giant holes in the ground. It’s apocalyptic! In fact, if that were really happening, the toll of human dead would be staggering. Tony Stark could probably make a fortune selling coffins, and ER docs like me would be overwhelmed.
Movies like that are obviously meant to be outlandish; and to take your hard-earned vacation money. But I fear that television and movies sanitize too much of our bitter human experience, making misery somehow palatable.
Take regular action films for instance. Whatever the underlying story, it seems that gun-fights are everywhere! Bullets fly in all directions. Then, at the end of it all, bystanders aren’t injured. Nobody lies moaning or screaming for help. We don’t see the pools of blood spreading across the ground, the skin becoming more clammy, more pale as police call for an ambulance, as the paramedics or surgeons try frantically to stop the flow. We don’t see, or hear, the family member of the dead when they’re told what happened. I’ve done that a bunch and it’s something you never, ever forget. Scenes like that don’t make for fun entertainment.
In our movies nobody sees survivors, good and bad, condemned to paralysis, or with colostomies or amputations from those exciting gun-fights. What about characters punched and kicked to a pulp, their faces bloodied until they can’t breathe? They get chronic headaches, brain damage, vision problems, inability to chew or smell. I have seen them die too.
But we’re oblivious to more than real violence. When we watch trials and cheer for justice, when we want this or that person to go to prison for their crime, we sometimes forget that the imprisoned don’t see their families much, and their families miss them for years, or for life. And let’s not forget that prison, real prison, is a place where violence, rape and drug addiction are far too common.
I hate it when someone says, ‘guess he’ll get it good in prison; I hope he enjoys his cell-mate,’ or some other bit of cruelty. It’s never OK to wish for someone to be raped, male or female. Ever. Although prison has a necessary role, maybe we need to revisit the boundary between punishment and torture. We should want better for even the worst; especially if we call ourselves Christian.
There are others disconnects, of course. When characters in movies have multiple sexual partners, it looks like nothing but fun to modern, sexually liberated viewers. But we seldom see the misery of loneliness that comes from all of those connections, made and broken. Films and television do a poor job of showing us the pain and terror of HIV or hepatitis, the anxiety of unplanned pregnancy and the reality of abortion. They fail to reveal the suffering brought by cervical cancer associated with HPV. The don’t show the tears shed over infertility caused by chlamydia or gonorrhea infections; the danger to newborns caused by herpes. It’s also hard to fathom the fact that many who work in pornography are miserable in heart, mind and body, and some around the world are compelled to do it against their will, working as sex slaves.
On screen, getting drunk is just what you do. We have all laughed at intoxicated characters, for as long as actors have played them. But we seldom consider the mortality and disability from car crashes. We rarely think about the way men and women die from head injuries or asphyxiation due to alcohol or drug abuse. We don’t get to witness the abuse and neglect of children, the cruelty to spouses, the lost hope, lost productivity and broken families from both.
We have to remember that what we see in movies and television is seldom the whole story. Sometimes, the truth is better. And sometimes, unfortunately, the reality is a lot worse, and far darker than the screenwriter, producer or director can ever, or would ever, convey to our entertainment soaked, reality challenged culture.

Once Upon a Time in Medicine

Gather round kids! Let Grandpa Doctor Leap tell you a few things about the old days of doctoring in the emergency room…

Back in the good old days, medicine was what we liked to call ‘fun.’  Not because it was fun to see people get sick or hurt or die, but because we were supposed to do our best and people didn’t wring their hands all the time about rules and lawyers.  Sometimes, old Grandpa Leap and his friends felt like cowboys, trying new things in the ER whether we had done them before or not.  Yessiree, it was a time.  We didn’t live by a long list of letters and rules; we knew what was important. And we were trusted to use our time well, without being tracked like Caribou through electronic badges.  Those were the salad days…

When I was a young pup of a doctor, we took notes with pen and paper and wrote orders on the same. It wasn’t perfect, and it wasn’t always fast. But it didn’t enslave us to the clip-board.  We didn’t log-into the clip-board or spend twenty minutes trying to figure out how to write discharge instructions and a prescription. We basically learned in grade-school.  EMR has brought great things in information capture and storage, but it isn’t the same, or necessarily as safe, as the way humans conveyed information for hundreds, nay thousands of years.

Back then, kids, the hospital was a family!  Oh yes, and we took care of one another. A nurse would come to a doctor and say, ‘I fell down the other day and my ankle is killing me! Can you check it out?’  And the doctor would call the X-ray tech, and an X-ray would get done and reviewed and the doctor might put a splint on it or something, and no money changed hands.

In those days, a doctor would say to the nurse, ‘I feel terrible, I think I have a stomach bug!’  And she’d say, ‘let me get you something for that,’ and she’d go to a drawer and pull out some medicine (it wasn’t under lock and key) and say ‘why don’t you go lie down?  The patients can take a break for a few minutes.’ And she’d cover you for 30 minutes until you felt better.

We physicians?  There was a great thing called ‘professional courtesy,’ whereby we helped one another out, often for free. Nowadays, of course, everybody would get fired for that sort of thing because the people who run the show didn’t make any money on the transaction.  And when you have a lot of presidents, vice-presidents, chief this and chief thats, it gets expensive!

When medicine was fun, a nurse would go ahead and numb that wound for you at night, policy or not; and put in an order while you were busy without saying, ‘I can’t do anything until you say it’s OK or I’ll lose my license.  Do you mind if I give some Tylenol and put on an ACE?  Can you put the order in first?  And go ahead and order an IV so I won’t be accused of practicing medicine?’ Yep, we were a team.

There was a time, children, when doctors knew their patients and didn’t need $10,000 in lab work to admit them.  ‘Oh, he has chest pain all the time and he’s had a full work-up.  Send him home and I’ll see him tomorrow,’ they might say.  And it was glorious to know that.  Or I might ask, ‘hey friend, I’m really overwhelmed, can you just come and see this guy and take care of him?  He has to be admitted!’  And because they thought medicine was fun too, they came and did it.

In those sweet days of clear air and high hopes, you could look up your own labs on the computer and not be fired for violating your own privacy.  (Yes, it can happen.) You could talk to the ER doc across town about that patient seeking drugs and they would say, ‘yep, he’s here all the time.  I wouldn’t give him anything,’ and it wasn’t a HIPAA violation; it was good sense.

Once upon a time we laughed, and we worked hard. Back then, we put up holiday decorations and they weren’t considered fire hazards.  We kept food and drink at our desks and nobody said it was somehow a violation of some ridiculous joint commission rule.  Because it was often too busy to get a break, we sustained ourselves at the place we worked with snacks and endless caffeine, heedless of the apparent danger that diseases might contaminate our food; we had already been breathing diseases all day long, and wearing them on our clothes.  Thus, well fed and profoundly immune, we pressed on.

In those golden days of medicine, sick people got admitted whether or not they met particular ‘criteria,’ because we had the feeling there was something wrong.  We believed one another.  Treatment decisions didn’t trump our gut instincts.  And ‘social admissions’ were not that unusual. The 95-year-old lady who fell but didn’t have a broken bone and didn’t have family and was hurting too much to go home?  We all knew we had to keep here for a day or two and it was just the lay of the land.

I remember the time when we could see a patient in the ER and, because my partners and I were owners of our group, we could discount their bill, in part or entirely.  We would fill out a little orange slip and write the amount of the discount.  Then, of course, the insurers insisted on the same discount.  And then nobody got a discount because the hospital was in charge and everyone got a huge bill, without consideration of their situation.  The situation we knew, since we lived in their town.

Back when, drug reps left a magical thing called ‘samples.’  Do you remember them, young Jedi?  Maybe not.  Young doctors have been taught that drug companies, drug reps and all the rest are Satan’s minions, and any association with them should be cause for excommunication from the company of good doctors.  But when we had samples, poor people could get free antibiotics, or antihypertensives, or all kinds of things, to get them through in the short run.  And we got nice lunches now and then, too, and could flirt with the nice reps!  Until academia decided that it was fatal to our decision-making to take a sandwich or a pen.  Of course, big corporations and big government agencies can still do this sort of thing with political donations to representatives. But rules are for little people.

When the world was young, there was the drunk tank.  And although mistakes were made, nobody pretended that the 19-year-old who chose a) go to the ER over b) go to jail, really needed to be treated.  We understood the disruptive nature of dangerous intoxicated people. Now we have to scale their pain and pretend to take them seriously as they pretend to listen to our admonitions.  They are, after all, customers.  Right?

These days, we are perhaps more divided than ever.  Sure, back in Grandpa Doctor Leap’s time, we were divided by specialty and by practice location; a bit.  But now there’s a line between inpatient doctors and outpatient doctors, between academics and those who work in the community, between women and men, minorities and majorities (?), urban and rural, foreign and native-born and every other demographic.  As in politics, these divisions hurt medicine and make us into so many tiny tribes at work against one another.

And finally, before Grandpa has to take his evening rest, he remembers when hospitals valued groups of doctors; especially those who had been in the same community, and same hospital, for decades.  They were invested in the community and trusted by their patients and were valuable.  Now?  A better bid on a contract and any doctor is as good as any other. Make more money for the hospital?  In you go and out goes the ‘old guys,’ who were committed to their jobs for ages.

Of course, little children, everything changes.  And often for the good. We’re more careful about mistakes, and we don’t kick people to the curb who can’t pay. We don’t broadcast their information on the Internet carelessly.  We have good tools to help us make good decisions. But progress isn’t all positive.  And I just wanted to leave a little record for you of how it was, and how it could be again if we could pull together and push back against stupid rules and small-minded people.

Now, Grandpa will go to bed.  And if you other oldies out there have some thoughts on this, please send them my way!  I’d love to hear what you think we’ve lost as the times have changed in medicine.

Love,

Grandpa Doctor Leap

 

 

Halfway Betwixt Worlds

Alfred is 95 years old, and sits quietly in his wheelchair, rocking back and forth.  His strength is gone, and his veins and tendons bulge through fair, translucent skin, stretched over muscles of long lost size and use.  His greatest foe is gravity, which holds his lithe, bird-like form in the chair enough to cause sores on his hips, but only barely.  It looks as if he might float away.

He remembers little, but smiles often.  And his simple joys are coffee and sweets, pecan pie, banana pudding, chocolate cake  These things, these beautiful, delicious gifts anchor pull him into in reality, and out of the reverie which possesses him for hours at a time as he stares out the window at passing seasons, and passing lives on the highway.

He is not bitter.  Sometimes he sings, and sometimes he laughs.  And she knows the name of his roommate, Jake, but forgets it weekly.  He kisses the hand of his nurse, Kendra, who loves him like a grandfather and sometimes reads the Bible to him, drawing from the well-worn and underlined pages in his copy, which his children brought years ago.  When the verses are read, he closes his bright, tired, grey eyes and leans back in repose, ready for the journey.  But he cannot recall a word that was said; there is no need, for the are well carved into the stone walls of his mind, whether he remembers or not.

Alfred dwells, it seems, betwixt worlds.  His muscles and bones, his frayed and frazzled nerves and short-circuited brain, his assorted plumbing and weary organs all remain in part, but not in youthful whole.  His thoughts so scattered, his memories like abstract art, known only to the painter.

Perhaps, Alfred has already begun the journey.  Maybe across the bar, there is a house where he lies asleep; or the beginnings of him, what will be fully Alfred.  His memories are traveling there like files being stored.  His wisdom and laughter, his busy hands, by which he farmed and worked, making and fixing, fathering and providing, and with which he cared for his dear Ruby before she went ahead.  All of these pieces surely precede him and are being assembled by God’s angels, guided by the King Himself.  Like bits of a great temple crossing the sea to be reassembled; but even better and more solid than before.

A shape is there, a form, a place prepared for him.  All that is strong and good and well is becoming more and more real as he, every day, becomes less and less real in his room, in his chair, in his world where he sweetly greets the strangers that are his own children and grandchildren, and hugs them and kisses them with tears he could not explain, his love deeper than breath even if he does not understand it.

Do not fear for Alfred.  He is, slowly and patiently, becoming more and more than we can possibly believe.  He only appears to be less.  He is, unseen by any of us, transforming before our eyes.

One day, Alfred will depart.  He will leave the broken, failing bits of form behind, an empty shell on a beach, a shed snake-skin, old antlers.  One day Alfred, finally and fully himself, will draw a deep, first, precious breath from air in a place he prayed to go, and open his new eyes on landscapes and visions and joys he could never in his best imagination hope to have.  He will touch his own arms, firm and strong, and new blood flow through vessels that will never narrow.  He will stand and be amazed. He will hear waves crash, or wind in trees, and the music of being truly alive at last.

And if all goes as he dreams (and it is likely his dreams are now visions), he will see God first, and his Ruby second and all the others who make the same trip and longed to see him again.  And then all the journey and trouble, all the wait for finality, all the pain and loss will not only make sense, but be irrelevant to his new, redeemed, perfect life.

Forever.

 

 

My column in the Winter 2017 Gray Matters, Newsletter of the Osher Lifelong Learning Institute at Furman University.

 

THE NEWSLETTER OF THE OSHER LIFELONG LEARNING INSTITUTE @ FURMAN

http://www.furman.edu/sites/OLLI/member-resources/Documents/GMJan2017-PDF_reduced.pdf

PAIN MANAGEMENT AND THE TIE TO ADDICTION – PART 2

Sometimes medicine offers us wonderful, almost unimaginable gifts. Heart attacks that were devastating, life-altering events a few short decades ago are now treated with an expediency and skill that our grandparents couldn’t imagine. A couple days pass, and the victim is home with stents in occluded arteries and directions to modify activity and diet. Pneumonia, once the ‘old person’s
friend’ (so called because it took the aged to eternity), is far less terrifying, thanks to both antibiotics and the pneumonia vaccine.

However, some of the things we do give benefits that are less clear. Although it could be an entire column in itself, the ‘stroke center’ movement, with the promise of miracles from ‘clot-busting drugs’, is a thing full of as many questions as answers. And what about depression and anti-depressants? When I looked up the side-effect profile of an anti-depressant a friend was taking, I was reminded that all of them have the potential side effect of increasing suicidal behavior.

But what about pain management? Thanks to improved understanding of the physiology of pain, the persistence of medical providers, and the investment and research of pharmaceutical companies, we have a wide array of pharmaceuticals available for the treatment of pain. Some are over-the-counter, like acetaminophen and ibuprofen. And others, those we refer to as narcotics or opioids (because in previous times they were derived from opium), are useful, potent, and (as is increasingly evident) fraught with danger unless used very cautiously.

Of course, for a very long time, physicians were taught to be judicious in prescribing narcotics. Our venerable teachers warned young doctors in training to be frightened of the side effects. We were especially aware of the very immediate danger that patients would stop breathing and die due to excess sedation. We were also aware that over time, patients on narcotics might develop problems with addiction.

About 20 to 25 years ago, that whole paradigm shifted and physicians were suddenly accused of callous disregard of suffering for prescribing too few narcotics. I remember this because I was in my emergency medicine residency at that time. We were constantly reminded to give more narcotics and be sensitive to pain. We were taught to use the ‘pain scale,’ in which a patient-reported score of zero meant no pain and a score of ten meant ‘the worst pain of your life.’ Never mind that it was entirely subjective and that there was no objective standard, no ‘painometer’ against which to measure it. We were instructed to see pain as the ‘fifth vital sign’ after blood pressure, pulse, respiratory rate and temperature. Of concern to many, these initiatives coincided with the development and aggressive marketing of ever more powerful, addictive medications like Oxycontin tablets and Fentanyl patches and lozenges.

Patient satisfaction surveys included the question ‘was your pain adequately treated?’ Physicians were castigated when those satisfaction survey scores fell. Physicians were instructed, by non-clinician

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administrators, to give more pain medication to make patients more satisfied. (A satisfied customer/ patient is one that may come back!) Physicians who resisted, in the name of science or safety, were too often met with threats of reduced income or job loss if patient satisfaction scores fell. In some instances, physicians were (and still are) reported to state medical boards for alleged inadequate treatment of pain.

I sincerely believe that most of those encouraging us to write more narcotics prescriptions did so out of genuine concern and compassion. People are in pain, so why not treat the pain? In medicine, where science meets suffering humanity, it’s so easy for us to say, ‘Well, it just makes sense, doesn’t it?’ We assume that our compassion will be supported by our science. It happens with infections; sure it’s probably a head cold, but what’s the harm in an antibiotic to keep the patient happy? The child bumped her head pretty hard, so what’s the problem with a CT scan, even though she looks good? The parents are customers, after all, and want a scan!

With tragic consequences, our compassion sometimes causes harm as the Law of Unintended Consequences rears its ugly head. For instance, those antibiotics for colds? They can cause dangerous allergic reactions and life-changing intestinal infections requiring hospitalization or surgery, and resulting in death. Those CT scans everyone wants? Physicians are trying to reduce the number of scans, as many of us are concerned that they may induce malignant tumors later. And those pain medications? The evidence looks pretty damning.

Addiction to prescription narcotics is growing at a terrifying rate in the U.S. Likewise, death rates from narcotic overdoses have soared. The U.S. has seen 165,000 deaths from opioid overdose between 1999 and 2014. http://www.cdc.gov/drugoverdose/data/overdose.html. In fact, opioid-related deaths have now surpassed deaths from firearms in the United States. http://www.cbsnews.com/news/drug- overdose-deaths-heroin-opioid-prescription-painkillers-more-than-guns/ Admittedly, some of those deaths are not due to prescription opioids but rather to injected heroin. However, many heroin addicts began their addiction issues when taking legitimately prescribed pain medication.

Sadly, seniors are not immune. Physicians don’t want to see seniors suffer, so they often give narcotics even for pain that in decades past would not have been treated with those drugs. We give them for back pain, headache, arthritis, or other less serious conditions. And we use them extensively in treatment of chronic, intractable pain. In fact, in 2015, one-third of Medicare recipients received a prescription for an opioid analgesic; some 40 million prescriptions. https://www.statnews.com/ 2016/06/22/many-opioid-prescriptions-seniors/

Furthermore, seniors not only develop addiction, not only die from accidental overdoses, their narcotic analgesics have a host of side-effects, including (but not limited to) the following: excessive sleep, impaired thinking, increased pain sensitivity, nausea, constipation, and cardiac arrhythmia. In addition, opioid drugs contribute to weakness and loss of balance and thus to falls, resulting in head and spine injury, various fractures, and other trauma. Their already impaired reflexes are dampened by their medication so that for those who still drive, it becomes an even more dangerous activity than before.

No one is immune from this devastating epidemic, not rich nor poor, not young nor old. The medical profession, the mental health community, law-enforcement, social services, churches, families, and friends all have to come together and find ways to roll back the rising tide of death and addiction, which came as an unforeseen outcome of attempting to ease suffering with compassion and science.

This problem will be highlighted this spring at an OLLI bonus event, March 31, 2017: Seniors and Opioids: Unexpected Origins of a Greenville Epidemic. I will be speaking in conjunction with James Campell of the Phoenix Center addiction and rehabilitation facility. We really hope you join us to learn more about this pressing public health crisis.

New Year’s Eve With My Best Friend

This is my column in today’s Greenville News.  Official link not up yet at the News website, but I’ll post it when I can.

IMG_3368

 

I remember being an adolescent, ringing in the New Year with my family. My mother a nurse, and my father a pastor, we just weren’t big ‘party people.’ Their mantra (which is now mine) was ‘nothing good happens after midnight!’ (I have plenty of anecdotal doctor stories to back up that assertion, by the way.)
We’d shoot some illegal fireworks off, or fire a gun from the back porch at midnight, and we’d eat some shrimp as the ball dropped in far-off, sparkling, exciting NYC. Then mom and dad usually fell asleep early and I wished for something to do. They were busy folks, and reasonably tired, so New Year’s Eve wasn’t much different from any other night. My wife’s childhood memories were similar, as her parents worked hard and rested when they could. Furthermore, those were the ‘dark ages’ when the Internet wasn’t part of life, and communications to the rest of the kid world were restricted to the house phone and the postal service. (Can you imagine?)
So it was no surprise that Jan and I celebrated a remarkable event on December 31st. For the first time in 22 years, we spent New Year’s Eve together… with nobody else. No kids, no relatives, no friends. Zero.
We aren’t opposed to enjoying the holiday, mind you. Over the years of our dating and marriage we’ve had lots of wonderful New Year’s Eve celebrations, from small affairs with friends to dress-up evenings in crowded restaurants.
We’ve had many parties at our house on the hill, with plenty of food and fireworks, bonfires and chaos. We’ve had church youth group events where dozens of young people played capture the flag in the freezing cold, the night illuminated only by flashlights, after which shivering teens (and leaders) warmed themselves by the fire and passed out on the floor from fatigue.
Most years the attendees were simply bunches of our kids’ friends and our own, along with as many family as possible, whom we promised that the fun and laughter would outweigh the danger of stray bottle rockets, brush fires or jackets set on fire by sparklers.
But this year, all of our ‘children’ from ages 15 through 22 (not so much children now), had things to do, people to see and places to go. Based on our own experience as young people, we could hardly blame them. And rather than try to make them feel guilty, rather than be stuck on some dead-end, potentially toxic nostalgia, we said ‘be careful and have fun! Keep us posted where you are and what you’re doing!’
I had worked all day in the ER and arrived home, where Jan had a yummy meal waiting. I took dinner to our room where we settled in for a very, very uneventful evening. Good Clemson parents, we periodically paid attention to the score of the Clemson-OSU game. Good former homeschool parents and life-long nerds, we watched Tolkien’s Return of the King on TV. We weren’t cold, nobody around us was intoxicated, we didn’t have to drive anywhere and the wait for food was non-existent.
I seem to recall learning that Clemson had won, and the dark forces were pouring out of the gates of Mordor, right as I said, ‘I love you baby! Happy New Year!’ At that point the dark forces of fatigue enveloped me and I was out around 11:30. Jan, with more fortitude than I, stayed awake until after midnight.
Emotions are funny things. And we humans can keep lots of competing emotions in constant tension together. That night, even as we missed our children and thought back on all the beautiful, laughter-filled evenings of the past, we were buoyed up by the deep, underlying love and friendship that we have had since our first date almost 33 years ago. We rang out the old, and rang in the new together, with joy and contentment.
Parents everywhere should try to remember that as wonderful as our kids are, and as delightful it is to spent time with them and others, our marriages are the deep, holy bond that will remain, and see us to the end. We know there will be parties again. But party or not, the best New Year’s Eve, the best day, the best night, the best life, is the one we spend together.
How do the vows go? In sickness and in health, for richer for poorer, at parties or at home with only you? I do. Always.

The Christmas Gift we All Desire

My Christmas column from Christmas Day, 2016

Merry Belated Christmas!

http://www.greenvilleonline.com/story/opinion/contributors/2016/12/25/commentary-christmas-gift-we-all-desire/95788966/

The Christmas Gift We All Desire
It’s here at last! What seemed to take forever for children arrives and passes like a shooting star for adults. But joy of joys, it’s Christmas morning! And a special morning since it’s Sunday. Families who attend worship services will, based on personal experience with small children, be up at zero dark thirty, as kids rush to the presents and the chaos begins.
Photos will be staged. (My parents made us stay in the hallway while they prepared the camera…Jan and I have since done the same, forcing children to stay on the stairs while we took our time tormenting them, they like horses headed to the barn for oats.) Families will have systems, as gifts are handed out in a manner devised to avoid wholesale riots.
Food will be prepared; in our home Christmas breakfast is bacon and cinnamon rolls. Cats will be watched carefully to avoid the climbing, and tipping, of trees. Mostly they will busy themselves with wrapping paper,licking and pretending not to be as excited as the kids. The dogs (at least our dogs) will look in through the glass of the door in puzzlement, and wait for partially eaten anything (and any chance at cat food).
Gifts will be opened, as parents and partners hope that they have given joy to those they love with this gift or that. There will be joy and squeals, hugs and kisses. Hours will be spent enjoying new items or searching through wrapping paper for batteries or lost instructions.
Those off to church will have to pry the kids away from their recently obtained treasures, or take some along. Older children will wear new clothes. Parents will fall asleep in chairs, as they were up until the wee hours wrapping, assembling items or simply enjoying the sweet wonder, the special silence of Christmas Eve. That stillness, in a dark house with tree lights, is every drop as precious as the big day itself. Personally I find a much greater connection to the whole nativity story on Christmas Eve, as if I were watching the tale unfold in a starlit lens to antiquity.
And yet. There are those families where the above is as fantastical as Santa and his reindeer. For some, for those in poverty, those with family members separated by prison sentences, those whose homes are the slave-quarters for addiction, Christmas will not look this way. Nor for those with loved ones far away in school, in work, in war. For many the separation from loved ones is the great gulf of death, and even sweet memories are painful reminders of what is no more. Still others find the day hard because of recent illness, injury, surgery, diagnosis of cancer. Our family walked through some of that too. However beautiful the wrapping paper and lights, however delightful the gifts, a pall hangs in the air and the thoughts turn to what was, or what might be, ‘if only.’
But that is, ultimately, the purpose of this day. It is not, it turns out, a day especially made for the joy of the now, nor for pets to get new sweaters, or adolescents to stock up on electronics. The joys and wonders of Christmas, from Santa to gifts, from feasts to surprise visits, are magnificent side-effects of the joy and purpose of the day. The day we remember the one born to set all things right.
The passage that I have come to most associate with Christmas (having lived life a bit) is not found in the Gospel accounts of Jesus’ nativity. It is found, oddly enough, at the end of the Bible, in Revelations, chapter 21. Dear old St. John reports:
‘And I heard a loud voice from the throne saying, “Behold, the dwelling place of God is with man, and He will live with them. They will be His people, and God Himself will be with them as their God. He will wipe away every tear from their eyes, and there will be no more death, or mourning or crying or pain, for the former things have passed away.” And the One seated on the throne said, “Behold, I make all things new.”’
That’s Jesus telling us that one day, things will be more grand than we can ever imagine; even better than our best dream of Christmas. He will meet our deepest needs and desires and banish suffering. Forever.
Now that’s a Christmas gift I can’t wait to open. Merry Christmas!

The Questions we Cannot Answer

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My column in the December issue of Emergency Medicine News.  Merry Christmas to all and to all a good shift!

http://journals.lww.com/em-news/Fulltext/2016/12000/Life_in_Emergistan__The_Questions_We_Can_t_Answer.13.aspx

I remember the early trials of thrombolytics; not for stroke but for MI. During my residency we were still comparing tPA with Streptokinase. It was pretty incredible stuff. Now we’ve moved beyond that positively ‘medieval’ method of treating heart attacks and have advanced to incredible interventions in coronary and cerebrovascular disease. Furthermore, we are able to rescue more and more people from the brink of death with advanced medications and with techniques, like ECMO, that our medical forebears couldn’t even imagine. These days, people can say things like: ‘I had severe sepsis last year, but I recovered,’ or ‘A few years ago I nearly died of Stage 4 cancer, but here I am!’ Fifty years ago, twenty years ago, their families would have told their stories with sadness.

What we do is amazing. The science behind our saves, coupled with our training and passion, make medicine all but miraculous. I am proud of what I know, proud of what I do. I am so impressed with my colleagues. And I am often awestruck by the scientists and engineers, without whom we would be apes poking bodies with sticks (good-looking apes in scrubs, mind you).
If we could, at the end of our lives, look back at the gifts we gave to the sick and injured, we would see that they far outweigh our errors and mistakes, our losses and failures. And yet, for all our modern innovations, we have limits. We can ask and answer a constellation of questions, and we can fix untold numbers of problems. But there are questions that defy us, and problems that leave us shaking our heads.
In spite of our pride in science, and our common dismissal of all that is ‘unscientific,’ suffering remains, and we can’t answer why. Who knows this better than those of us who have dedicated ourselves to emergency care?
For all of our miraculous saves, men and women, boys and girls, still suffer horrible injuries and have cardiac arrests, fatal pulmonary emboli. They still die at the scene of car crashes. They still develop mental illness and kill themselves. Addiction still separates families and leaves parents weeping for children, lost from life or lost in the jungle of drugs and desperate lives.
Despite the extension of life we offer so many, even the healthiest men and women will, at some point, leave one another and pass away from this life. And, knowing this fact does nothing to ease the pain of the loss. The most ancient husband or wife still shudders and weeps with the loss of a spouse the way a newlywed would; perhaps more bitterly, knowing love more deeply at 85 than ever they did at 25. And yet, for all our scientific wonders, we can’t say what lies beyond this life.
What I’m saying is that for all our medical wonders, there are just questions we can’t answer, and things we can’t fix. And it is likely that our science, however wondrous, never will have that capacity.
We know it. It’s why we cry after failed resuscitations, and why we call our children when they travel, frantic to know they have arrived. It’s why every EMS tone terrifies the parents of teens and every scan of a loved one is terrifying to those of us in medicine. We can’t control the troubles of this life nearly as much as we think.
Mankind has always known this. Ancient physicians, as limited as they were, did their best and wanted more. They saw the dangers of this life, and their own incapacity, with what was likely more immediacy than we. And sick, injured humans have always known the fear of loss, the questions of suffering, the pain of death.
Into this ‘vail of tears’ we proceed every shift. This is why I often tell young physicians that they should read and understand more than medicine. I favor religious faith, natural to mankind as it is. But if they decline religion, they must have a philosophy. Or they should read great novels, stories, poetry; or reach into the depth of music for some kind of solace in this mess of the unknown.
But let me say this, now that December is here: Christmas comes to offer hope to the hopeless and answers to the hardest of questions. There are those of us who believe its message with all our broken hearts. But even those who find it a charming myth can surely see beauty in the story of God (however you perceive God to be) become man. God suffering with men and women and rescuing them. God come to give a hope of forever to humans trapped in mortality. This is especially poignant to those whose lives have been a succession of one devastating loss after another. It is comfort beyond medicine for them to believe in a God, come to forgive their wandering ways, answering them in the midst of their cutting, suicidal, self medicating cries for rescue. No pill is as good as God come to make every loss whole, and heal every pain in eternity. No resuscitation comparable to God come to die and defeat death.
The pain of this life is enormous. We try so hard, but we can do only so much. The manger in Bethlehem is, if nothing else, a beautiful story to remind us that just maybe, there is healing for the wounds that lie beyond our science. Perhaps the very dream that there is meaning, that there is hope, is a suggestion that there is more there, more here, than meets the eye.
And maybe, the manger is even more than a distant dream, more than a quaint bedtime story, glowing as it does in the chaotic night of human suffering that darkens our ER’s and trauma centers.
Merry Christmas!

The King is Here. Merry Christmas!

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http://www.greenvilleonline.com/story/opinion/contributors/2016/12/11/commentary-king-here/95198746/

Whenever I see the opening scene of Lion King, when Simba is presented to all the animals of the plains, I get emotional. Not because his character is a cute, sneezy fuzzball, but because of the reaction of all of the other beasts. As the music rises to climax, and Rafiki the wise mandrill presents the future king to his subjects, the animals do something that seems decidedly ‘non-Disney.’ Certainly it doesn’t appear ‘modern.’ All of the animals on the ground, looking up at the cub, begin to growl, roar, trumpet, jump, shriek, stomp the ground and, in the end, bow down silently in honor of the newborn king of the beasts. It gives me chills every single time. The kingdom is giving honor to the king.
I get the same feeling when I read about Aragorn in Tolkien’s Return of the King. He is the suffering servant, the mysterious wanderer of many names who travels the wilderness for years, growing stronger and wiser, protecting the innocent. He ultimately confronts evil and tyranny on fields of battle before he is crowned. No longer Aragorn, he is King Elessar, the latest in an ancient, nearly lost line of nobility, returned to rightful rule at last. It is an image of joy and hope, as the King ascends the throne and all’s well with the world; or at least Middle Earth. I want Elessar to be my king too.
Just as I always loved tales of Arthur, who may or may not have existed as we have been told, I enjoy stories of the not-at-all mythical Alfred, the only king of England ever to be called ‘The Great.’ He unified smaller kingdoms into one, promoted Christianity, order, justice and education. This despite many troubles, including invading armies and a chronic intestinal illness that left him wracked with pain.
There’s just something about kingship. I know, this is America and we don’t have kings. (Well, not exactly.) But deep in my heart, I want a king. I want a good king, a just king, a holy king. I want a king I can kneel before, serve, live for and if necessary, die for with joy in my heart.
This isn’t about misplaced patriotism, or some rejection of democracy. Monarchs are perilous things. But the king I want deserves to be king. Not only is it his birthright, he has earned the crown through fire and battle. He knows his people and has gained his kingship by love and sacrifice. The king IS the country. He loves the people and wants only the best for them. The king I long for, ache for, not only lives for the country but would die for it and his subjects.
Which brings us, round about, to Christmas. Hidden beneath the camouflage of fat Santas, elves, sentimentality and commerce, Christmas is the Christian celebration of the coming of the King. Not held high, but born low. Sought by poor shepherds and wise men, also searching for a king. Feared by another king, Herod the Great. Condemned by Pilate (not quite a king but close). Born among the people he lived a most ‘unkingly’ life on earth, living his few years as a common man, who was nevertheless most uncommon. He worked, healed, taught and rebuked the great. He told his followers that he came to serve not be served. That was the model for his reign. He announced his Kingdom with a thundering whisper, like no king mankind had seen.
The prophets knew this: ‘…of the increase of His government there will be no end…’ The apostles did too: ‘Then, opening their treasures they offered him gifts, gold, frankincense and myrrh.’ The carol writers understood it. ‘Come adore on bended knee, Christ the Lord the newborn King.’ That word, lord. We use it so flippantly as just another church code-word. But the lord is the one to whom we owe devotion, the one with authority. Our ancestors in less democratic times understood. ‘Thank you Lord. Help me Lord. Have mercy on me Lord. Send me Lord.’
Christianity is far more breathtaking than its detractors, or even many adherents, realize. For it celebrates the coming of the King and his Kingdom. Same king, past, present and future. The King that puts all other kings, counsels, parliaments, presidents and ministers to shame and flight. And gives the word King it’s proper meaning for all time.
If that’s not a reason for a celebration, nothing ever was.

Malpractice Isn’t a Sin

Dear physicians, PAs, NPs, nurses, medics, assorted therapists, techs and all the rest:

The great thing about our work is that we intervene and help people in their difficult, dire situations.  We ease pain, we save lives. Our work is full of meaning and joy.  However, we sometimes make mistakes.  But remember, in the course of a career you’ll do far more good than any harm you may have caused.

I know this issue lingers in many hearts.  I know it because it lies in mine.  And I’ve seen it in other lives.  I said this once to a group of young residents and one young woman burst into tears. I never knew the whole story, but I imagine there was some burden of pain she was carrying for an error she had made.

But just in case you too have lingering anxiety or guilt about some error you made in patient care, I feel it necessary to say this: neither honest errors nor even malpractice are sins.  They are mistakes, born of confusing situations, fatigue, inadequate experience or knowledge, overwhelming situations, the complexity of disease and the human body, social situations, systems problems, general chaos.  Born of your own humanity and frailty.  Your ‘shocking’ inability to be perfect at all times, and in all situations.  They do not make you evil, bad, stupid or even unqualified.  (PS If you’re not actually a physician but pretending to be one, you’re actually unqualified so stop it.)

As a Christian physician I have contemplated this over and over and have come to the conclusion that God knows my inadequacies and loves, and accepts me, regardless.  He has forgiven my sins.  I embrace that reality every day.  He forgives my pride, anger, sloth, greed, lust, all of them.  But he doesn’t have to forgive my honest errors.  Because they are not sins. Go back and read that again.  Your honest errors are not sins.

Mind you, all of the brokenness of this world is, in my theology, the result of ‘Sin’ with a capital S.  (Not in the sense of minute, exacting moral rules, but in the sense of the cosmic separation of the creation from the Creator.)

So, my mistakes, my failures are born of Sin, but are not ‘sins.’  If my mistakes, if the harm I may cause, come from rage, vindictiveness, cruelty, gross negligence, murder, drunkenness or other impairment on the job, then they could reasonably be due to ‘sin.’  But even so, those sins can be forgiven, and washed away with confession and true repentance.  (Not platitudes or superficial admissions of guilt, mind you, but genuine heart felt ‘metanoia,’ the Greek for repentance, which means ‘to change direction, or change one’s mind.’)

If you are not a believer, join us!  But if you aren’t interested, I love you too and want you to move forward, not burdened by unnecessary guilt.  If you are a believer, and a practitioner, remember that Jesus (The Great Physician) set the bar pretty high and doesn’t expect your perfection, only your honest, loving best.

Mistakes, even mistakes that rise to malpractice, are not sins.  But even if they rise to sin for reasons listed above, they are no worse than any other.  Which means Jesus atoned for them as well.

Move forward in joy.  You were forgiven before you even started worrying about it.

Now go see a patient. The waiting room is full of people who need you!

Merry Christmas!

Edwin