Non-sequitors, tangents, Jimmy Fallon, and deep play

I guess it’s becoming a habit: me writing post-call. Just finished number six out of seven calls this month. More and more hallucinogenic each time.

Here is a complete list of all the things I ate while on call: 6am yogurt with peanut butter en route (lucky breakfast). 9am (EnDLeSS ROUNdsssss are killlaaaah!) a single pack of graham crackers with single-serving peanut butter. 11:45am: free resident lunch. it’s either boneless, surprisingly tender chicken (kosher) or pork (verboten). I don’t ask too many questions. 3:15pm: a single packet of saltines and a nonfat milk (aka: restraint!). 5:00pm: sushi. 9pmish: peanut butter cracker four-pack (transitioning to the hard stuff). 11:15pm: a 100calorie packet of goldfish crackers and a single serving vanilla ice cream from the not-so-secret cardiac post-op recovery freezer (culinary highlight). 3:55am: The last serving of french fries from the cafeteria grill station 5 minutes before closing. Cold. Four packets of ketchup. 6:55am: Cheese eggs, a biscuit, hot tea (thanks, A!). 7:15AM: A slice of chocolate cake (Thanks again, A!). EnDDDLessss Rououounddsss, round t-t-t-t-t-wo. Too focused on avoiding failure to eat. 11:30AM: Second slice of chocolate cake (Thanks thrice and finally, A!) Made it downstairs in time to partake of free lunch number 2 of the endless day but my heart’s just not in it. Free food can’t keep this engine running anymore.

I am seeing the light at the end of the tunnel and it’s all blue skies and palm trees and Audrey Hepburn or is it Lucille Ball? It’s me on my staycation in 6 days from now. One call, two day shifts and one overnight moonlighting shift from now I’ll have 13.5 days off in a row.  Last time I had a vacation, I went to the dentist, organized my mail, did dishes and POOF! it was over. I am determined to make this one count.

*          *          *          *          *

Had a nice conversation with one of the NPs last night about the anxieties of leaving your child with a babysitter in the evenings. And mothers and mothers in law. And being a mother. If I’m honest with myself it was one of the most friend-like interactions I’ve had in a while. The sharing of oneself with someone else. Ye olde “Oh, me too!” and “I know, I feel the same way.” Both parenting and residency are so isolating. Sometimes I talk to myself silently in the bathroom mirror while I’m brushing my teeth in the dark before dawn. I say things like “What did you dream about?” and “Hmmmm, interesting.” I look at my reflection and try to read the passage of time on my face and body. This weekend my best friend in all the world called while I was asleep during E’s nap and I was so happy to hear her voice, like diving into a cool pool of water which used to be my favorite sensation before sleep became my favorite sensation. Just as I had finished the “what’s going on with me” part of the conversation and my friend started to talk about what’s going with her, E woke up and started crying out for Mommy. My heart sped up because I was excited to see her after her two hour nap (parenthood is such a miracle of self-sustaining energy, like the eight crazy nights of Hannukah oil for the rest of your life) but it was friendus interruptus yet again. I put my friend on speaker phone and E said a few words. I have to hope that the people who love me are ok with this form of conversation. Maybe I’ll call my friend back later instead of sleeping after I write this instead of sleeping.

Just to be clear a lot of laughing and camaraderie goes on in hospital work rooms. The days of the month are long and every combination of people each month develops its own culture, it’s own jokes that no one else can understand, it’s own rhythms of dividing and conquering the work at hand. As a result there are a cadre of people that I care a lot for, my co-residents, my interns, my fellows, NPs and nurses and pharmacists: we’ve shared some things. And yet, it’s a different kind of friendship. What shape would it take outside the hospital? Sometimes joking around in the work room I imagine a dinner party with whomever is doing a spot-on interpretation of the uptight mean consult attending. How would it go, me and them and my partner and whoever is their partner? Contextual collision! Whenever I get the chance to spend time with folks outside of work it’s awesome and bittersweet because I know what has to be important right now and that’s my time with little E. It’s like that line from Moonstruck when Olympia Dukakis is walking home with her impromptu dinner partner and he asks her to invite him in and she says “I can’t invite you in because I’m married and I know who I am.” It’s the strange emotion of confidence mixed with nostalgia mixed with sadness mixed with pride. I can’t go out for happy hour because I’m a mama and I know who I am. All of which is to say to my co-residents: You guys are awesome and I wish we had more time to get to know each other.

*          *          *          *          *

OK, this might seem like a non-sequitor but when I’m post-call I squander at least an hour when I should be sleeping getting caught in the internet’s stickiest spider webs. It’s a huffingtonpost-buzzfeed-top-10-lists-how-to-keep-your-romance-alive-celebrity-childhood-photos psychosis. When it’s 12:09 I say I’ll do it until 12:15pm but then it’s 12:17 so I keep going until 12:20 and so on. Today I stumbled upon a you tube video of Billy Joel singing “In the jungle” with Jimmy Fallon:

 

Which led to a video of Jimmy Fallon singing with the Roots and Miley Cyrus:

 

Which led to a video of Jimmy Fallon in a lip-syncing contest:

 

Which led to a video of Jimmy Fallon singing with someone named Robin Thicke and once again the Roots, which was my favorite:

You may or may not believe me when I tell you that I am so far removed from popular culture that prior to this internet tangent I had only a vague sense of who Jimmy Fallon and Miley Cyrus were and no idea who Robin Thicke is. Ditto Stephen Merchant. Had to google them all. But what I liked about these videos were that the people involved seemed to be having some fun doing a thing that they are good at. I have always been taken by watching performers inhabit the moment, inhabit themselves, take risks and share their talents. It’s sexy and brave and energizing and inspiring. I know all of these things are staged and half the people are probably unbearable prima donnas, but they look like they’re having a good time together and it’s fun to watch. There’s the concept of deep play coined by Diane Ackerman, the state of ecstatic flow and sensory immersion associated with intense play at every age — whether its music, sports, theater, sex, hiking, rowing, writing, painting or just tumbling with your two year old on the couch. Watching these videos I suddenly remembered the feeling of deep play.

There’s a poem I love by Yehuda Amichai called “Forgetting someome:”

Forgetting someone is like
forgetting to turn off the light in the back yard
so it stays lit all the next day.

But then it’s the light
that makes you remember.

That’s how is was in that moment with deep play: I remembered it thus realized I had forgotten it thus remembered it. And I missed it.  A lot.

Also, I have to admit that I have a sudden crush on Jimmy Fallon for the past hour or so. He can really wear a tie. And I’ve always been a sucker for falsetto. I’m so tired right now that I can’t feel my feet. I didn’t get to lie down at all last night. I haven’t slept in 33.5 hours and I had to use my fingers to calculate that just now.

I’m trying to figure out how much of my upcoming staycation to protect from the tentacles of work. There’s a research project I’m woefully behind on. There are several project in my residency program that I want to get cracking on. There is oil to be changed and the house to get cleaned. But maybe I need to just clear my schedule for some Jimmy-Fallon-with-the-preschool-toys-music-making-time. For some adventuring, or as much adventuring as can be accomplished between daycare drop-off and pick-up, or the kind of adventuring that only a curious toddler can make possible. Maybe it’s playtime. Is that even allowed? But why should only beautiful people and rich people and people without student loans get to play? Don’t we all deserve to play?

Meanwhile it’s 2:47pm and I have 45 minutes to sleep before going to pick up my little joy machine. It’s going to be sweet, all of it. Playtime.

What’s your magic number?

Here a funny thing that happens when your child turns two. You are supposed to have another child. Like, right away. Suddenly all anyone wants to talk to you about is when you will be having another child. Not if. When. Your lack of a second child is almost a source of anxiety for people, like a dissonant chord that has been allowed to linger without resolution.

For example, a few weeks ago I was in my hunkered down work mode (aka lightening fast typing fingers, wry jokes, case management to-do lists) when one of the house physicians on my current service came to sign me out (cue chorus of divine angels). Let me preface this by saying that I had only known this person for maybe three or four days at this point. And by the way she is very lovely and I don’t mean to single her out here because what follows is a conversation that has played itself out in one form or another with everyone from total strangers to my closest friends. So anyway, a few minutes into sign-out I mentioned my daughter off hand and she asked, “Oh how old is your child?” and I said “She’s two” and she said “Oh, when are you going to have another child?” and I said “Oh, we’ve been thinking a lot about it and we are pretty happy as a three-person family” (note here how suddenly intimate the conversation has become, because any honest answer about procreative plans is not really small talk anymore). At this point she looked a bit shocked and dismayed, “Oh, but your daughter is going to be so lonely!” to which I just said again, rather more weakly, “Oh, we are pretty happy” and she gave me another look akin to the look you might give a woman leaning over to give her toddler a big sip of her Manhattan. A look that says: “Your parental judgment is seriously impaired.”

I have this kind of conversation at least once a week these days, with grocery store cashiers, neighbors, fellow parents at daycare.  Some people react as my colleague did, invoking my parental duty to provide E with a sibling. People have even used the word “abuse” in reference to only childhood which I guess makes me the potential abuser? Which is a disturbing thing to imply over a pile of avocados at the Trader Joe’s. Other people smile and say “Oh just you wait. You’ll want another one.” Which always makes me think of that old ad for potato chips: “Betcha can’t eat just one!” As if you might pad downstairs to satisfy a midnight salty-food craving and end up + 1. Some people talk about how two kids isn’t twice as hard as one kid, it’s only 1.5 times as hard, as if I’m not having another child because I’m afraid of hard work, to which I want to say a) my child is a pure delight to me so why wouldn’t I want to multiply that by two? and also b) I just worked for 30 hours in a row. Again! What absolutely no one has said when they find out I am planning on stopping at one is: “Awesome!” or “Cool!” or even “Tell me more about that.”

The fact is that I always planned on having two children. I have vivid memories of lying in bed as a five or six year old imagining the one boy and one girl child I would one day have. When we settled on E’s name towards the end of my pregnancy, I made a secret list of sibling names for boys and girls. Even during E’s first year I saved every piece of clothing for the second child. But now that E is two and more verbal every day and she can both ask and answer the question “What are you thinking about?” I’m just so excited to keep moving forward with her. I don’t want to start all over again. I want to travel with E and take her to concerts and gardens and plays and support her in every curiosity. I want her life to be full of every vividness that money and time and energy can provide. I don’t want to divide up those resources, even though I know it’s possible to do so well.

At the same time, I am beginning to realize that I need to be able to write in order to live well inside my own life, which for me means blocks of quiet daylight hours and also some time for reading and maybe even an occasional week far away from the quotidian in a new environment by myself. Which has to be on top of full time work if we are to eat and be clothed and pay off our student loans, the mortgages we have taken out on ourselves. All of which is also true for my partner. Right now, the financials kind of work out, the logistics kind of work out, and we are all of us kind of getting the things we need (except sleep and retirement savings but that’s for a later time, right?) I don’t want to tempt the gods by saying it out loud, but there’s enough joy in our household to balance out the stress, even during residency. While one of us does the dishes, the other of us has a dance party or does alphabet puzzles in the living room with E. Then we switch and one of us does bathtime while the other catches up on work email. Adding another person to the  mix seems like asking too much of ourseves and the universe. Then there’s the matter of my destroyed post-pregnancy sacroilliac joint and the pain of every step for the last two years and the possibility of that getting even worse….. It just gives a person pause.

I am sad for E that she might not have the potentially good experiene of having a sibling but I think it is important to acknowledge that when it comes to that experience there are no guarantees. I know people with siblings for whom their sibling relationship is one of the core narrratives of their lives and people who haven’t spoken to their siblings in twenty years. I know people who have great relationships with their siblings, neutral relationships with their siblings, and some sad examples of horribly acrimonious and damaging sibling relationships. People often invoke the importance of siblings in the care of elderly parents and yet I know many people with siblings who have still shouldered the lion’s share of the care of their aging parents, whether due to geography, preference, or family politics. Having a sibling is no guarantee of fellowship in life’s struggles and the absence of a sibling does not preclude experiences of intense mutual commitment and support with spouses, friends, and other relatives.

But I didn’t set out here to defend my decision (that is not even really a final decision yet. Check back in five years for the final child tally!). What I wanted to convey is that we should not need to defend the choices we make about how our families are structured.

When I heard on NPR that someone had written a book on being and having an only child, I literally pulled my car over to the side of the road to look it up. I didn’t realize until that moment how isolated I felt. Even with all the diapproving looks and talk of lifelong loneliness, I don’t think I had ever fully identified the stigma associated with having an only child. The book is called “One and Only: Why Having an Only Child, and Being One, Is Better Than You Think” by Lauren Sandler and it seeks to present both a scientific argument and series of personal anecdotes that argue for the benefits of being and having an only child. While I was grateful for the author’s meticulous and thought-provoking research and her articulations of some of the joys of parenting an only child (like the smallest things: being able to call your child your favorite smoos in the whole wide world), I found myself thinking: why do we have to prove that having an only child is better or even as good as having more than one child? Do we need society’s permission NOT to grow another human being in our uteri? Which, of course, is an old can of worms…..

A few nights ago E was sitting on C’s lap and watching Schoolhouse Rock. I was sitting on the bed folding laundry when the following clip came on:

My eyes actually filled with tears. “It’s our song!” I kept saying to my two loves. Which is funny because it’s all about a man and a woman having a baby and that’s not our story at all. But it captures something that is special about our family. It takes all three of us to hold the table up! It feels good to say what I’m about to say: I am so proud of my family.

Three is not everyone’s magic number. Some people are happiest in a family of one. Some parents are raising various numbers of children alone or with people who don’t live with them. Some people can’t imagine being happy unless their family is big enough to fill the pew at church (shout out to my friend KP whose family I very much admire and enjoy following through the years on facebook!). Two adults and two kids is working for a lot of folks. Unto each and every one of these: a blessing!

I guess what I’m saying is: Next time you are tempted to ask someone if or when they are planning on having another kid (or when they are planning on marrying their boyfriend or whether they are dating someone, for that matter), maybe instead ask them: What’s your magic number? Or better yet, what’s awesome about your kid or kids or spouse or life? Have you read any amazing books lately? What is the thing you are most looking forward to today? Can you imagine the conversations we could be having with one another?

What’s your magic number?

On call

I am post-call, so this post will be post-call, angular, unedited or strangely so. Like the jokes you make post-call, this post may be just a little too sloppy, a little too specific, a little too true.

The worst part of call is the anticipation of call. The night before, everything feels extreme and over-precious. I have to read just one more book to E because I won’t see her again for almost FORTY-EIGHT WHOLE HOURS. I stroke her hair. I snuggle her little body close. “I have to remember her smell,” I think to myself, as if I am being deported to interstellar space on a mission of national importance with no return ticket. Later, instead of sleeping, which is the only rational way to prepare, I decide to stay up with C watching a movie, because I deserve it in advance. Or I waste a precious hour of sleep reading about the 27 most important things your grandparents would want you to know on buzzfeed. On some level, it feels like if I don’t go to sleep, call won’t come.

The vibrations of my phone alarm signal the worst hour of the whole enterprise. I lie in bed and worry. What if E doesn’t wake up from her sleep? What if the brief migraines I have been having turn out to be a massive AVM and I bleed into it and die before I see C and E again? I’m too tired to do it. I just can’t do it, I think to myself. I just can’t do it again. I don’t have it in me. I wish for death. Not really. But sort of. Or maybe just a permanent disability. Then I get up and stumble through the dark like a blind person getting ready as my most loved ones sigh and shift in their sleep. I only own five pairs of scrubs and have spent more than 5000 hours in them since medical school. In my scrubs I am neither fat nor thin, short nor tall, beautiful nor ugly, girl nor boy. I am just a person who is capable of continuing to function no matter what. The drive to work in the shuttered, sleeping world is ethereal. On the radio, BBC world is telling me about Italian tire factories or sex workers in Malaysia and I am balancing my open container of yogurt between my thighs and trying to avoid black ice. I pray to nobody and everybody: Please don’t let me make a mistake and hurt someone.

Here’s what I love about my job: The faces of children, marked by whatever emotion they are inhabiting in the moment. I love the moment when, despite the chronic exhaustion, despite the parent’s fear and frustration, despite the child’s innate distrust of strangers, you make a connection. You make them laugh, or you acknowledge their fear, and something in the room shifts. You answer a scary question and it is less scary. The kid who is initially clawing at their mother and crying ends up holding the stethoscope against their own chest and they look up at you with curiosity as you hear the familiar acoustics of a beating heart.

Once I step into the workroom to get signout on my patients, the worst part of call — the resistance to call — is over. Now the only way through is through. My co-resident confided to me that he writes the hours 1 – 30 out on a piece of paper and X’s off each hour as it passes. The inevitability of time’s motion will carry you through. As I assemble the little idiosyncratic bundle of checklists and signouts that will be my point of orientation for the next 30 hours, I feel like I imagine any athlete might before the jump, before the climb, before the big game. I’ve done this before, I remember. I can do it again.

What is a more effective method of teaching and learning: Meticulous apprenticeship or trial by fire? Nurses at the hospital where I work are oriented for weeks, even months, to a particular floor before they are allowed to work independently. They work alongside an experienced nurse, first watching them, then being observed and critiqued by them. They are taught exactly what to do. As a resident I switch to a new floor every month — which usually means a new organ system or set of diseases — and am lucky if someone tells me where the staff fridge is. Maybe there is a handout or binder with information on the most common order sets for that floor or the phone numbers of the case manager and social worker. But as far as decision-making goes, it’s luck and guts and humility and intuition and misses and near misses. There are always people you can reach out to for advice, but you have to know what you don’t know.

Yesterday I arrived on the Cardiology floor for the first time ever at 6am and twelve hours later I was the one fielding all the floor calls from nurses who in some cases have been taking care of cardiac patients for 10-15 years. “Can we give the anti-rejection meds for this heart transplant patient late? They’re down at radiology.” Um, sure? Or no? “Is 2000mg of magnesium too much for a patient with heart failure?” (Me making a thinking sound as I madly look up magnesium dosing in the hospital formulary.) “Baby P with the BT shunt looks a little blue and his sats are down. Can you come take a look?” You better fucking believe I’ll come take a look. I will be running there. All I know about BT shunts is what was in the handout I was given just this morning: “BT shunts carry 15% mortality. They can clot off anytime. If anyone is concerned about a patient with a BT shunt, assess them right away.” The last resident on this rotation told me that he was paged about a BT shunt patient who was vomiting and before he could slip on his shoes the child went into bradycardic arrest. As I am staring down at the patient’s tiny blue hands, I am grateful for each of the thousands of hours I have spent assessing patients and watching other people assess patients. At least I know where to begin. Mental status, perfusion, vitals, physical exam. All the hard-won habits.

When I am called to a bedside to assess a sick child, I try to assemble as many other people around me as possible — the parents, the nurse, a respiratory therapist.  Anyone with eyes and, preferably, more experience than me. I listen, I try to make a good decision, I elicit feedback on my decisions. As more time passes and I get a little better at this job, I am more confident about what I know and more confident in admitting what I don’t know and asking for help. During a 30 hour call, one thought dominates: What could I be missing?

For me, all calls contain the following elements:

1) The click: Sometimes only once, sometimes more than once, you make a decision, you have a good conversation with a family, you get in the groove with a nurse, you help a patient get better and you think: I nailed that one. Maybe I am, in fact, learning something. This moment is usually followed by:

2) The total fail: No matter how many times you make your list and check it twice, you will inevitably miss something — you didn’t look in the ears?! you didn’t order a lipase?! or bigger, scarier things like forgetting to get antibiotics approved. Often this mistake will become the disproportionate focus of the team on rounds. I have learned to embrace the total fail. It’s like the imperfection in the Persian rug through which God is allowed to enter. I am imperfect!, I want to shout into the whirring fluorescent hospital lights, I am broken and divine! (Actually, I obsess endlessly over these mistakes whether small or large and have great difficulty forgiving myself.)

Corollaries to the click and the total fail are:

3) The tiny point of light: The attending turns to you and asks a question like, “What was the last bicarb on the previous admission?” And from somewhere in the recesses of your exhausted, addled, overstuffed mind, the right answer pops out: 16! The human brain is a miraculous thing. Everyone seems impressed even though they are all also using the electronic medical record via which this piece of information is readily available. There there’s:

4) The endless sea of ridiculously specific questions you don’t know the answer to: “What dose of metoprolol was this patient on in 2012?” “Was the pancreatic duct visualized on the CT scan three years ago?” “Do you know if this patient has ever seen a dermatologist?” Um, no idea, don’t know, and no. This was my sixth admission last night and I’m not a soothsayer.

And no call would be complete without:

5) An assortment of bizarre physical sensations: A hand momentarily goes numb. I am awoken from the abyss of sleep by my pager and I jerk out of bed, convinced that I am lying in a pool of water. I catch a glimpse of one of my own hairs out of the corner of my eye and am momentarily convinced that there is a squirrel running up the wall. The exhausted human mind is a den of snakes. And:

6) An interpersonal glitch: On every call someone will do something so strangely anti-social, so rude, or so galling that you have to sit back and marvel. It might be a nurse, a fellow resident, and attending, a patient or a patient’s parent, or (most likely) a subspecialist consultant whom you are forced to call overnight. The other night I had to call the dermatologist on call (key words being “on call”) and he said, “Um, I’m trying to sleep.” Ha! Sorry, buddy, we’re all here in the hospital trying to take care of sick people! Everyone who is working overnight is at least a little tried and stressed out. It’s a cauldron of bad behavior. Then again, people are also the kindest to each other during these moments. It can go one of two ways. When you encounter people who are kind to you in spite of an annoying request you are forced to make of them, you remember that forever. Similarly, when someone lets slip a racist comment or yells at you over the phone, you remember that forever too. The stress of call has a searing effect on memory (though not the kind of memory that helps you memorize the nuances of pathophysiology).

Call time is a vortex. Admitting a patient at 2am, you have to keep asking them, “Do you mean yesterday, like the yesterday that just happened or the yesterday before yesterday?” The cafeteria closes at 7:30pm and you can almost never make it there even if you start trying to get there at 4:30. You can complete a five page note in ten minutes and then it can take you 45 minutes to figure out what the right home dose of a seizure medication is. One minute it’s 5pm, then next its 2am and you still haven’t finished your admission notes from the daytime. I am getting off the elevator on my way out of work and a woman gets on the elevator with two pieces of pizza and a Diet Coke. “Ew,” I think to myself, “who eats sausage pizza for breakfast?” Then I remember that it is actually noon. Since I started work, that woman had gotten up, eaten breakfast, come to work, eaten lunch, worked some more, went home, ate dinner, slept all night, gotten up, eaten breakfast, come to work, worked all morning, and gotten her lunch. No matter how you cut it, it’s just crazy. As the hospital doors slide open, my eyes sting with the light and the cold and the wind.

The end of call should be the best part, but for me the best part is when the first of my colleagues arrives for signout in the morning. A blessing on the head of each of my co-residents who, moored to their own undulating schedule of exhaustion and relief, has rescued me from the solitary crucible of call. It’s so nice to be able to run a decision by someone, to laugh about that crazy thing that mom said, to hand a patient back to the clinician who knows them best, hopefully none the worse for their time in your care. It is a tradition that the on call person brings the post-call person breakfast and no eggs are ever sweeter than those eggs. The only thing worse than call would be having to take it all alone.

And then it all begins again. Driving home, I have to put the car in park at each stop light because I am nodding off. My body feels too light and too heavy at the same time. This afternoon, I will sleep without any awareness of time and space, then the ecstatic reunion. “Mommy!!!” E will shout and then run in the opposite direction because that’s her way of saying hello. There will be cuddling. There will be cookies. I will not demand anything of myself nor will I make healthy food choices. I will rest because I will be capable of almost nothing else. The post-call flop-out doesn’t cancel out the exhaustion and stress but it does help.

One thing I have learned from residency is that it is hard to kill a human. The patients I am taking care of these days have one, two, even more holes and misdirected parts in their hearts. They undergo surgery after surgery, unattaching and reattaching their vessels too many times, and yet still, the blood finds its path through the madmade maze. Life is amazingly committed to its own continuation. The same, I think, can be said of people’s souls. People are remarkably resilient! They find a way, in spite of everything, to survive.

Evidence of things not seen

For my co-residents and for little O

I am on retreat with my residency class. We are in an otherwise empty hotel on the Jersey Shore whose just-an-average-hotel-ness is intensified by the lonely quiet of the off season. I can imagine the bustle of summer filling up the space — trails of sand from little feet tracked in from the beach, brightly colored umbrellas stacked up on the deck, all the various sounds that people can make from within hotel rooms — but in the emptiness of winter the rooms seem tired. Why are hotels decorated in brown and beige? Are there people who are offended by color? Or is it just to mask wear and dust and dirt? Is the bored eye less likely to see?

There are few opportunities in my life to sleep in but today I could have slept until 8:30am, which as all parents of toddlers can attest, is the new noon. I went to bed early last night, in fact, because I wanted to experience the sensation of restedness this morning, the feeling of waking up out of readiness instead of necessity. But because the universe has both good wisdom and a good sense of humor, my eyes opened at 5:45am — the very time that my alarm will ring tomorrow morning — and I couldn’t go back to sleep. At first I was filled with a familiar sense of cynical irritation, the “why me” and “well isn’t that always the way” that residency has brought to my life despite the comforts and advantages that I enjoy. But then I thought to myself, how often do I get a chance to walk on the beach as the sun rises? According to weather.com the sun would be rising at 7:01AM. I put on several layers and slipped out of my shared room, through the muzak in the lobby, and out towards the ocean.

There was no one else in sight. I walked toward the ribbon of pink spreading up from the horizon. The hard, frozen sand up near the beach grasses gave way to the satisfying sink of each step into the wet shore. Several gulls circled and dipped. I looked for shells to bring home to E — not too small, not too sharp — and came across some of the odd hints that the ocean delivers up to us about itself. Cracked orange crab shells and dismembered legs half buried in the sand. Plant fronds of various colors and textures and widths. A foot-long brown spear that widened up to what looked like the end of a bone with some white and yellow flesh still attached — tooth? spine? tail? Breaking the smooth contour of the shoreline, a sudden small pile of sea sponge. I walked for an unknown distance. The sky became lighter and lighter beneath and around the layers of cloud. I wondered to myself when the sun would rise and what would mark the sun’s rising. I looked at my watch and it was 7:13, already past the appointed time. The part of my legs between the top of my boots and the bottom of my coat began to tingle and sting with cold and I turned to walk back to the hotel as the daylight continued to bleed into being around the edges of the sky.

*         *          *          *          *

How should I say this? I am worried about the state of health care. I am worried about the state of my own heart. I am worried about the way doctors are trained. I am worried about the way health is defined. I have been in and around hospitals for almost a decade at this point and I feel like I know less and less about how to help people achieve well-being. I feel like I’m getting better and better at keeping people alive and less and less good at helping them live well. I am maybe a little depressed or to use the somewhat more socially acceptable term, burned out.

I went into medicine with a desire to be with people in life’s most terrifying and difficult and potentially ecstatic moments. I wanted to understand the body, to understand more about life and illness and death. It’s a cliche but a deeply felt one: I wanted to be of service. I also wanted financial stability and the ability to provide for my children. I wanted a job that would be meaningful even on the worst days. But mainly I wanted to form deeply satisfying therapeutic relationships — it’s what I wrote my residency application essay about and it is still what I aspire to accomplish, somehow.

Now, almost ten years later, I spend more than 90% of my day in front of a computer. Sometimes the computer is actually physically located in between me and my patients and I have to crane my neck around its unsleeping eye to see them. I type through the majority of my clinical encounters. During a typical day on the wards, I see my patients for — at most — 5-10 minutes per day each. My day is filled with entering and reentering orders on the computer, writing endless admission notes and progress notes which recapitulate information that is already recorded elsewhere in the medical record, waiting on hold to talk to primary care doctors’ answering services, calling pharmacies and insurance companies for prior authorization, calling subspecialists to address each of the body’s organ systems, and coordinating the complex behemoth of a large tertiary care center to get tests and studies done for my patients. I work up to 28 (actually more like 30 but shhhh don’t tell) hours in a row every fourth night which wouldn’t bother me except that of those hours I spend at most 2-3 in total with patients. Patients turn over so quickly in the hospital that I might be responsible for the care of over 100 patients during a given week. During clinic hours I am perpetually beset with anxiety at how far behind I am, unable to get through a well child visit meaningfully in the 20 minute time frame allotted for this purpose and because of the fragmentary nature of residency scheduling, I often do not see these patients again. I want to form relationships with my patients, but at times it feels like talking to patients just takes time away from the tasks that need to be done for them. It’s crazy, but it’s true.

Some of these issues are unique to residency, which is time-limited (though formative), but surveys of post-residency physicians suggest that as a group, we are in trouble. In a much quoted and discussed survey of 24,000 physicians by Medscape in 2013, only 54% reported that they would choose medicine if they had it to do over again. Fourty-nine percent of physicians surveyed reported at least one symptom of burnout and 40% reported that they were burned out.

On the receiving end of medical care both as a patient and as a loved one advocating for sick family members, I know what it’s like to receive care from a system of overwhelmed and/or burned out providers. Test results are not communicated. Small details are missed. You wait 7 hours to speak with the doctor, then that person does not know some of the basic details of your case. The care you receive addresses a symptom or a part of the problem, but rarely the whole problem, and rarer still, you as a whole person. I fear being that kind of provider yet I have been that kind of provider despite my fervent desire to avoid it. There are just too many patients, too many data points, too many notes to read and write. There is so little time for relationships to form. There is no magic there.

Doctors are a hard group to sympathize with. Once we finish training (it’s long, but let’s face it, life is longer) most of us land in the top 10% if not the top 5% or 1%. Training is hard and the hours are long but we choose this life with full knowledge (as much as you can have full knowledge) of what we are getting into. We hold a lot of societal and political power and on an individual level,  in hundreds of thousands of exam rooms across the world, we have the power to examine, to question, to diagnose, to prescribe, to get it right and heal or get it wrong and harm. But if we as a society want to get the kind of health care that not only cures but heals, we are going to have to look at how doctors feel, how they are trained, how their work-life is organized, what we ask of them, and how we support them in their work.

*          *          *          *          *

If you work around sick children long enough, there will be a death that crushes you, that doesn’t let go, that you can’t let go of. Little O came into my care last month and a few hours later passed away under the most difficult of circumstances. Oddly enough, I don’t remember her name — perhaps because the intensity of our efforts to keep her alive and the adrenaline coursing through my body erased it from my data banks, perhaps because I have been afraid to reopen her chart. I think of her as little O, the little O of her mouth, the round moon of her little face which I saw for weeks every time I closed my eyes. If I will it, I can hear her mother’s screams in my mind’s ear as vivid as the sounds of my household humming around me as I write: “No es justo! No es justo!”

I want to make contact with her family, to tell them that I feel for them, that I think of her, that even though our lives touched for only a few short hours, I feel the weight of their loss. I have never done such a thing before and I’m not sure if it is even appropriate. Who should I ask? Do I need to get permission from my program director? Do I need to run it by risk management? In the end, the question comes down to one of the nature of my relationship to that baby and her family. Was there one? And if so, what was it? I have been training for many years but have received no apprenticeship in this most important aspect of my profession.

So many hundreds of children pass through my life and I through theirs and we are like ghosts to each other. There are so many layers between me and my patients, layers of bureaucracy, legality, scheduling, vulnerability and power traded back and forth in a complicated dance. Was this always so? Sometimes I fantasize about becoming a small-town doctor, about being part of the community I serve, of knowing my patients and allowing them to know me.

I will likely never send a card or see little O’s family again, but this is what I would want to tell them: I will hold your daughter in my heart forever.

*          *          *           *          *

Meanwhile, back at retreat, I am surrounded by the loveliest people. My co-residents are intelligent, accomplished, funny, and kind. To a person they are motivated by the desire to be of service. They are scientists and humanitarians who hold as sacred the trust placed in them by children and their families. They are also spouses and parents and children and friends who struggle to balance the commitments they have made in so many domains in their lives. I feel lucky to know them and I think children are lucky to have them as their doctors.

What I wish for them and for myself as doctors, what I wish for myself as a patient, for my patients, and for my loved ones who are someone else’s patients, is a system that allows us to be healers, that helps us to heal. I want a system that allows me to express my compassion, that gives me the space and time to care for people in a meaningful way. Unrealistic? Selfish? Possible? I plan to find out.

beachmorning

What I learned about parenting from the Man with the Yellow Hat

I haven’t posted in so long, it’s hard to know where to start. There is lots to say on such topcis as the New Year, death, illness, stress management (, the failure of), the Total Money Makeover, residency (which currently has the upper hand in the battle for my soul — think Sauron before Isildur cuts off the one ring). But I’m going to start with the smaller quotidian battles of toddlerhood that have been playing themselves out on our stage of late.

E has been into Curious George recently. There is lots to talk about with Curious George (e.g. colonialism, class issues in Manhattan, why everyone from crane operators to hot-air balloonists seem unphased by interacting with a talking monkey) but what has been striking me most is the way The Man with the Yellow Hat’s parents George, the ultimate toddler. The typical episode of Curious George begins with George causing a minor calamity, like covering the entire apartment with wet toilet paper, burying The Man with the Yellow Hat’s important papers in twenty-seven different holes in the ground, or inviting a family of doves to reside in the bathroom. The Man with the Yellow Hat’s response is unformily thus: A brief expression of displeasure (“George! My new bedspread!”) followed by an attempt to see things from George’s point of view (“You were just trying to figure out how toilets work.”) followed by a turn toward the practical (“We’ll just have to go to the hardware store and find a new handle for the refrigerator.”). Never once does The Man with the Yellow Hat yell, put George in time out, or refer to himself in the third person (“The Man with the Yellow Hat is very disappointed in you, George!” Um, no.). The Man with the Yellow Hat seems to understand that a) George has good intentions, and b) he is a monkey and there are limits to his capacity for understanding.

Now there are some important differences between The Man with the Yellow Hat’s situation and that of the average parent of a toddler: George is not expected to progress in his judgment or life skills whereas a child will eventually have to be left alone in the room with a stove, drive a car, and remember their social security number. George’s escapades also seem never to result in injury whereas real life is not so kind. Finally, The Man with the Yellow Hat has no apparent job and yet has an unidentified soure of endless cash and thus is able to seamlessly absorb even the most property-damaging and time-consuming calamity. Still, as the parent of a delightfully curious and sensation-seeking toddler, I find myself at those critical moments of toddler parenting asking myself: WWTMWTYHD?

I love E beyond the beyond and this phase of emerging language and the ability to describe her thoughts and desires is full of magic. At the same time, it can be — how should I put this? — challenging. Putting on a sweatshirt can take 45 minutes. Bedtime can take much, much longer. There are days when I feel my interactions with her largely involve saying “no,” speaking her name in an exasperated tone (awful), coming up with feasible yet appealing (?) rewards and consequences (“if you put on your diaper, we can go downstairs and [pause for dramatic effect] MAKE OATMEAL!”), and showering her with praise for things that don’t matter like lying down long enough for me to put her pants on. Is there not a better way?

Here are some things that I have learned from the Man with the Yellow Hat:

1) Tell me when you are ready. Despite the fact that George’s speech is entirely unintelligible, The Man with the Yellow Hat almost always prefaces an activity or decision by asking George’s opinion or asking if he is ready to go. He doesn’t just take George’s hand and lead him out of the house. When there is a task to be done, instead of trying to wrestle E into doing it when she has no interest or negative interest, I ask her to tell me when she is ready and then pretend to busy myself with something else. At which point, she will busy herself with something else and then 10-30 seconds later inform me that she is ready. This works about 25% of the time and is only useful when there is no looming time limit.

2) Abandon all hope of things remaining clean and tidy. It is clear from The Man with the Yellow Hat’s repeated decision to leave George unsupervised at home that he does not mind cleaning up messes. I am not so evolved. It is hard for me to watch E use the questionable dish sponge to “wash” the dried banana off her shirt or drink milk from her cup by carrying it in a spoon across the kitchen and sipping what remains of it while facing the backdoor. Every cell in my body wants to say “no” and redirect her. But really, who cares? The clothes she starts the day in stay on unless they smell or are so wet as to put her at risk for hypothermia on the way to school. Everything else is just part of toddler life and I don’t waste my conflict chips on them. Or rather, I try not to.

3) You break, you buy. Or rather, you break, you help with the cleanup. When George breaks the museum’s most precious dinosaur display, he has to work with the museum director to glue it back together. Similarly, if E throws rice all over the floor such that archeologists centuries from now will still find its marks under what is left of my cabinets, she has to help clean it up. This teaches natural consequences and also occupies her so that she doesn’t have a chance to create another disaster while I’m cleaning up the first disaster. This works about 10% of the time but when it works, it just feels so good.

4) When you mean no, just say no. As a Generation X/Yer, I find the ethics of parental authority challenging. But does the Man with the Yellow Hat worry about scarring George by exercising his authority and setting boundaries? He does not appear to. This may be due to his troubling sense of colonialist mastery over George, but I’m gonna to see the glass as half full and assume that he is just comfortable asserting himself in situations when his judgment is more developed than George’s. Instead of cajoling and bargaining and negotiating with E, when I mean no, I just say no in a firm and case-closed kind of way. I’ve been getting better at this and it actually seems to lessen the toddler madness. Well, about 50% of the time. On a good day.

5) When you are with the monkey, be with the monkey. The Man with the Yellow Hat sometimes leaves the house to do things (what we never know) but when he’s with George, he and George are engaged in the same activity, whether it’s going to the hardware store or staring at birds or exploring the chicken coop. You never see The Man with the Yellow Hat trying to answer email or polish the family silver while George is jumping up and down in the background. I find the most personally frustrating times to be the times when I am trying to accomplish something that has nothing to do with E while she is trying to engage my attention in whatever she would prefer to be doing. This is sometimes inevitable (aka: everyday at dinner time) but I am trying to be a better planner so that I have enough time to myself (thank the lord for babysitters and grandparents and the fact that children sleep more than adults do) and can be more present when I am spending time with E. Also, like the Man with the Yellow Hat, I involve her in whatever I am doing, from cooking to shopping to folding laundry. This makes us all happier.

Then there is the little piece of advice I kinda wish I could give to the Man with the Yellow Hat: You are expecting too much of your monkey! The Man with the Yellow Hat leaves George unsupervised all the time despite repeated evidence that he cannot be trusted to avoid disaster. Seems like George needs a babysitter! The (often unattainable) key to toddler parenting is to figure out what where your toddler is developmentally and then set your expectations accordingly. It doesn’t make sense to leave a toddler in a room with a small pile of swept up dust while you go to find the dustpan and expect them not to touch the tantalizing pile of dust (um, just a hypothetical example from, oh, yesterday). The exasperation I felt upon my return was 0% E’s fault and 100% the fault of my own faulty expectations. The great thing about a toddler is that, instead of putting the swept up schmutz in her mouth, E tried to make a dustpan out of a sheet of paper and sweep it up herself. What would the Man with the Yellow Hat say? “Good job, George!” And that’s what I said.

The bird of death, the bird of love

When I went to see B for the last time, his parents were in the hospital bed with him, his mother beside him, his father squeezed crossways at the foot of the bed. They were all barefoot and his father had one hand on his wife’s foot and the other on B’s foot and I could see how similar they were, these two sets of feet. Genetics alone do not a parent make but there is something about the uncanny likeness of parent and child that always catches in my throat. I felt tentative, worried about interrupting this intimacy, but his father waved me in, smiling. I had just finished my first call as a supervising resident on another floor and I was exhausted, pungent (can other people smell the post-call smell?), still roiling from the overwhelming responsibility that had abruptly been mine overnight. I was wearing one of C’s sweatshirts, several sizes too big, and an old maternity shirt, the middle deflated around my no-longer-pregnant belly, for luck. “Your first day as a senior resident and that’s what you wore?” B’s father quipped. I had to laugh. He had taken an unusual interest in me and his other providers and the workings of the hospital and as a result I had shared more than usual with him about myself and the challenges of residency.

It was to be the day of B’s death, the day his parents had decided to withdraw the care that was keeping his lungs expanding and his heart beating but doing nothing to reverse the irreversible damage to his brain. It is a cruel and unwarranted term — “withdrawal of care” — and it’s more politically correct cousin “withdrawal of support” is not much better. A better term might be “the hardest thing you’ve ever done or will ever do in your life” or “the ultimate act of putting your child’s needs before your own” or at least “releasing your child from the pain of futile interventions.” I was expecting the mood in the room to be very dark but B’s parents’ tears were intermixed with funny memories of their son, pride in B and in the family they had built together, and so much tenderness.  We took turns playing a little word game that B had liked to play. We talked about the course of his ICU stay, the milestones of hope and despair, the various providers they had interacted with along the way. We talked about their children, about my child, about parenthood. I could tell from our conversation that we might not agree if the topic shifted to politics (when they asked about my husband, instinct told me to go along with it instead of doing the whole “actually I have a wife” thing), but they were the kind of parents I aspire to be — thoughtful, generous, loving, engaged. As we talked, I held B’s hand. It was the first time I had touched him without a clinical purpose.

There is an inherent asymmetry to the relationship of doctor and patient. I touch my patient’s bodies along their entire length, examining their cavities and contours. I witness their tears, their anger, their caresses, ask them questions about their families, their diet and personal habits, their sexuality, whereas they neither touch nor see nor know almost anything about me. There is also an uncomfortable power dynamic related to knowledge, whereby I often understand the context and trajectory of their illness better than or before they do.  Try as I might to communicate the facts and my impressions, there is often an unbridgeable gap that is the product of the sheer complexity of the medical situation or the emotional context which causes patients and parents to receive information in a particular way. There is a certain trading back and forth of significance and anonymity. Sometimes I walk into the room of a patient I care deeply about, about whom I have spent a lot of time thinking and talking with other doctors, and it is clear to me that they have no idea who the hell I am (“I’ll have to call you back,” they say into their phone. “The nurse is here.” Proving that gender is still complicated here in 2013.)  I am one of the dozens of faces that are passing through their lives at a stressful time. On the flip side, sometimes I am stopped in the elevator or the hospital lobby by a parent who tells me I took care of their child on so-and-so floor and I am disturbed to realize that I have no memory of them. They are one of the dozens of patients that have passed through my life at a stressful time.

Then there is the awkward question of love, which I feel toward my patients but which cannot be spoken. I wanted to tell B’s parents how much I admired the strength of their love and care for each other in a time when guilt and blame could just as easily rule the day. I wanted to tell them how deeply I mourn for their son and for them. Holding B’s hand I wanted to whisper, “Go in peace, beautiful boy.” But instead I just said, “I have been thinking of you all” and hoped that they would somehow understand that I was feeling for them and with them, beyond the blood pressures and infusion rates and MRI findings.

The moment came when it no longer made sense for me to linger. I said goodbye and then we talked a little more and then I said goodbye again. I was halfway out the door when B’s dad called back to me “Be the best parent you can be.” I turned to him and nodded and awkwardly put my hands over my heart. There was nothing more to say.

I once heard a Zen saying: Live as if death is a bird always on your shoulder. No one likes to talk about death and certainly not the death of a child, but I think it’s bound up with love, especially parental love, in ways that people don’t acknowledge. The passionate, euphoric, desperate love of a parent for a child contains within it the terrible awareness of how much might be lost. If I were to face that loss, I would want to be able to say to myself, to my partner, to my child: I loved with my entire self, as well as I could.

B passed away a few hours later as peacefully as possible. I will probably never see his parents again but I think of them almost every day as I kiss E’s neck  and tumble with her on the bed and listen to her breathing from the door at night and try like hell to do a good job at being her parent. On one shoulder the bird of death, on the other the bird of love.

Post-call post

I am post call. I worked thirty hours in a row with 20 minutes of “sleep” (aka answering pages while lying down). I am in the pediatric intensive care unit these days and the number of pieces of data to interpret, management decisions, pages to answer, and things to worry about are all a hundred-fold moreso than anything I have ever experienced. Is there a word for feeling simulateously more energized, more exhausted, more competent, and more incompetent than ever before? And sadder. I fantasize all day and all night of escape, yet when we finish rounding in the morning and I am relieved for the day (relieved!), I find I cannot leave. I walk around to the rooms of the children who were sickest overnight and listen to their lungs again, exchange a few words with their parents, make sure their nurses don’t need any orders to be put in. I have carried these children with me for thirty hours — or have they been carrying me? I have worried over them literally breath to breath to breath, watching the loops of their inhalations and exhalations on the ventilator for clues on how to help them. It feels wrong to leave. I can slip out of the PICU and re-enter the unbroken world but they cannot.

The hours after I return home have a strange emotional architecture. Everything is superlative: If I eat a cheese sandwich it is the BEST cheese sandwich I have ever eaten. Then I take the BEST shower I have ever taken. My bed has NEVER felt so good. My house and my loved ones radiate an aura of perfection. Could the light coming in through the kitchen window be more golden? Then suddenly my stomach clenches with the memory of a mistake I made or that I think I might have made on one of the patients from overnight. I want to turn on my laptop and log on to the electronic medical record and check but I don’t because that would mean crossing a certain line in the sand that I cannot cross if I want to recover enough to go back to work tomorrow. “The patients are fine,” I say to myself, half believing it. I take a nap for a couple of hours then E comes home and shrieks with delight as she climbs into bed with me. I am filled with an almost painful degree of adoration for her every feature and action. I can’t stop touching her cheeks, her elbows, her cute chunky thighs. She points to a picture of a cup on the back of the New Yorker and says “cup” and I am convinced that she is the SMARTEST toddler that has ever drawn breath. It’s 4pm and I should be taking her out to the park or reading her a book but my body feels like the nerves are no longer connected to the muscles. I can’t. We turn on a movie and she watches it while I close my eyes. She is incredibly wiggly and I find myself wishing she would just be still for a few minutes. A voice inside my head whispers “You are a terrible mother.” I know I am not a terrible mother, I know it to my core, but every time I am post-call, my exhausted head fills with this same toxic thought. “You are a terrible mother.” I have been apart from her for too long, I think. I feel like crying but don’t. I am so fucking tired.

In summary: Euphoria –> anxiety. Euphoria –> guilt. Exhaustion. Et cetera.  Do other people experience this?

C makes my post-call afternoons and evenings feel celebratory. She says, “I am going to make you a special dinner” and even if she makes the same tacos she might make on a different night, I feel like they are directed towards me especially, patching the holes with love. I am acutely aware from moment to moment of how lucky I am.

On this particular day, C puts on music during dinner, Bach’s Piano Concerto in G Minor (the second movement of this performance by Glenn Gould is crushingly beautiful). The familiar first chords hit me as if from the distant past, as if delivered via gramaphone from some deep phylogenetic place.  I can feel each harmonic shift and small arrival in the music zinging down my spine, up through my neck. I am vibrating. E, perceptive of her parents as all children are, grabs my hand and C’s hand and starts pumping our hands up and down with the beat. I remember myself suddenly, the person who is capable of wonder and pleasure in beauty and intimacy and gentleness.  It’s like the poem by Yehuda Amichai: “Forgetting someone is like / forgetting to turn off the light in the backyard / so it stays lit all the next day. / But then it’s the light / that makes you remember.”

How long has it been since I was myself, I wonder. Hours? Days? Months? Minutes? I’m too tired to remember. At work, I walk fast and feel resentful when people start taking too long to do something. By necessity I am always doing more than one thing at once and a part of my brain has taken on the role of air traffic control, evaluating the tasks that need to be done and figuring out ways to get them done more efficiently. I page a consult while calling back a nurse who has just paged me, calculating that I will be done with the current conversation before the consultant calls me back. I send a document to the printer and stop by a patient’s bedside to give a parent an update on my way to the printer. Sometimes things are so busy that I don’t get to see all the patients I am taking care of overnight and they remain just headers on sections of my to-do list.

Smith

[ ] Call social work

[ ] Check urine output

[ ] AM labs

At the same time, there are hot spots of tragedy and horror that I have to suppress in order to function. A toddler who fell into his family’s pool while his father ran in to answer the phone and is now neurologically devastated. A baby who was shaken and is now neurologically devastated. Otherwise healthy children who have been maimed or paralyzed in accidents. Babies with cancer. And at each bedside, a parent whose desperation and fear is barely contained.  I want to throw my stupid to-do list away and hug them. I want to wail and keen and pull all the tubes and lines out of their tortured bodies and give them some peace. What I certainly do not want to do is lift the dressings and view the wounds, literally or figuratively. But I must and so I do. I calmly check my to-do list boxes and manage the smallest of details. I know cognitively that this is in their best interest, that what I am doing is helping them. But sometimes it doesn’t feel that way.

Now, at the dinner table with the people I love most in the world and vibrating to the music I love most in the world, I find myself crying. “They are suffering so much,” is all I can say. They are suffering so much. I am both contributing to and palliating their suffering and I have to live with that. It feels good to feel something.

E looks concerned so I wipe away my tears and we get on with having a marvelous evening together. We have a dance party. We tumble on the couch. We read books in bed. We take a bath together. Gratitude. Joy. Endless gratitude and joy. I try not to think about whether or not there are any potentially cancerous cells lurking somewhere in her bone marrow. I mostly succeed. Later C and I eat ice cream sundaes (see above re: C’s ability to make the ordinary seem celebratory) and then turn on a movie. I am asleep before the opening credits end.

It was a good day (that was also two days). Maybe there are some people for whom the hard stuff and the amazing stuff can be separated out, but for me they always bleed together, each arising as a result of the other.  I dream of a life that is easier, less complicated, containing fewer contradictions, less work, and less ache, but not really. What I really dream of when I sleep is my daughter, running down the sidewalk beside my partner, kneeling in the grass, picking up a perfectly round stone and looking up at me with amazement. I dream of the ceaseless oscillations of heart beats on monitors, lab values that I have to understand, the bodies of my patients, swollen and wounded. All of these things are bound together by love, by the best that I have to offer the world. This is the life I have chosen and perhaps even the life I have been chosen for, depending on what you believe.  I am grateful for it.