Gratitude

St. Francis of Assisi knew gratitude was good for us long before this month's Harvard Mental Health Letter added its two cents, but isn't that the way it usually goes? Evidence follows intuition. Well, according to my friends at Harvard, gratitude helps make us resilient. In fact, it's one of many things that have that effect. For instance, working at something you love rather than working less, having a sense of life purpose, giving for no other reason than because you can, forming and maintaining meaningful relationships, and possessing the confidence to steer your own course, also render a person more resilient in the face of whatever life throws at us along the way.

Resilience doesn't mean resistant, it means durable. Resistance can carry the connotation of immunity to injury. Resilience and durability are fluid concepts that describe those who endure what Hamlet called, "the slings and arrows of outrageous fortune," and come through scathed and scarred, perhaps, but not embittered. Resistant, to me, is a wall; resilient is a membrane, tough and tender, alive, open to experience.

Thinking about gratitude and the resilience it engenders, on this Thanksgiving eve, I'm grateful for a young woman who became the first live human in whose body I've inserted a scalpel to make an incision. She was unconscious at the time, "thanks" to the wonders of anesthesia, but I was sufficiently aware for both of us and so grateful for the privilege she'd granted, I was close to tears when the final sutures were in place. It felt as though I was incising something from my own life (a topic for another post) as much as something from hers.

I feel grateful for my entering medical school class, a group of people, all of them younger than me by months to years, in whose company and because of whose support, I've somehow managed to come this far. They play hard, work harder, each having sojourned in at least one of Dante's Twelve Circles of Hell, and survived with hope and heart intact. It's a privilege to be numbered among them.

I'm grateful for the snow that began falling overnight, the plow that woke me at 4.06 AM and the hunger that followed in its wake, dragging me from the warmth of bed to face the chill of my upstairs room. I'm glad I raked the leaves crowding close to the kitchen door and straying carelessly onto the driveway last night, so that shoveling snow this morning was easier. It was dark in central Maine, dark and cold, and the drive to my hospital slickly hazardous. I'm grateful my CRV takes little note of the weather, embracing ice and snow as a challenge, instead of a threat.

I'm even grateful for the fuse that blew in the kitchen this morning. Power outages in the forecast, I made coffee last night and put it in the fridge -- cold coffee being better than none. Warming it in the microwave was too much too early, it seems, so I had to take flashlight in hand and brave the depths of the cellar I've considered the ghastly realm of goblins, spooks, and creatures unspeakable. It was nothing of the sort, but gazing into the black basement of our creakily ancient temporary housing, my imagination ran rampant. Yoo hoo, Stephen King, are you down there?

Some things only a fool or a madman would be grateful for, but it's the trivial we most often overlook. Those insignificant moments of inconvenience over a blown fuse teach us how to draw upon gratitude when we need it the most. Those moments that remind us that faith, hope, and love can be found anytime, anywhere, and not merely the one day of the year we remember to give thanks. Whoever said, it's the little things that count, wasn't kidding.

Happy Thanksgiving!


(Creative Commons image of St. Francis of Assisi via Wikipedia)

Paying Your Dues or to Paraphrase Charlie Brown...

"Doesn't anyone know what surgery is all about?"

I've been wrestling with this question for the past four weeks and it hasn't been an easy match. I thought I had it pinned a couple of times and then it squirmed out from under me. Think about those occasions when you've watched Olympic wrestling and you'll get an idea what I mean. Both shoulders have to touch the floor at the same time for a winner to be called and close isn't close enough.

For my friends who are surgeons-in-residency or our preceptors, the answer is probably straightforward, surgery is about cutting. Suggesting there is a deeper philosophical significance for what they do is likely to trigger a smile, a good natured nudge in the ribs, and, "There Beggar goes again." Sorry, guys (a non-gender specific term for me, inclusive of gals, guys, and a dog or two thrown in for good measure). I can't help it. Finding meaning is what I do.

That said, I'm really not referring to surgery as such, but to basic surgical training, i.e. third-year surgical rotations. The former is way out of my league, but regarding the latter, to borrow from Country singer/songwriter Garth Brooks, I'll "choose to chance the rapids and dare to dance the tide." But as anyone knows who's rafted the Colorado or any other big river, you've got to have a guide who knows the water, and on this chilly November morning, it's my father's turn to take the tiller.

What does a saddlemaker have to do with surgery? Aside from the fact that he was well-acquainted with sharp knives and slicing through flesh? He knew what it was like to be an apprentice. You see, at the end of World War II, when he was discharged from the Army, the way someone pursued a career in saddle making was by apprenticing themselves to masters of the art. These were men, predominantly, who began honing their craft well before my father was born. They started out precisely as he was expected to, by sweeping the shop floor, watching and listening, doing a lot of what we call in medicine, "scut work," and waiting his turn.

It was frustrating, he told me years later, because he wanted to learn and surely, that was best done by doing. Being told he wasn't ready to "do," that he'd be told when he was, tried every ounce of patience he could muster. Slowly, over time, he was allowed to take carving tools and scrap leather home to practice and eventually, one thing led to another. It was very much like a third-year surgical rotation, I've decided.

For my part, I spend a great deal of time watching and keeping my hands to myself. Students have two primary tasks in a rotation like this. The first is learning how to refrain from contaminating yourself or anything and anyone else in the operating room, no small feat in itself. One false move and you've touched something you shouldn't or bumped into someone you wish you hadn't. Mikhail Baryshnikov would cringe at the choreography.

The second task is harder, perhaps hardest of all. It entails practicing knot tying and suturing at home, standing next to the surgeon for what feels like forever, waiting to be invited to participate at the most rudimentary of levels, i.e. holding a retractor, snipping sutures, or if you're lucky, stapling an incision closed. If you're really lucky, like I was the other day, you get to guide a laproscopic camera, which has been inserted through a plastic tube called a trochanter, into a patient's abdomen, while your preceptor removes an inflamed gall bladder. It felt like I was moving up in the world.

Seriously, you want very badly, as a student, to do something that matters. It's one of the primary reasons we attend medical school in the first place. In a specialty like surgery, however, and truthfully, in all medical specialties, we have to learn the value of humility. We're students, after all, and the only proficiency we possess at this point in our education is that of memorizing large quantities of material, a skill which, our preceptors inform us, has limited applicability in the world of real medicine. It's all about learning how to wait your turn and appreciate every opportunity to do more.

Horace Mann wrote, "More will sometimes be demanded of you than is reasonable. Bear it meekly, and exhaust your time and strength in performing your duties, rather than vindicating your rights." Eventually, your time will come and those who've witnessed your commitment and devotion, will remember you as one who worked your heart out and didn't complain. As my father would say, it's called paying your dues.

(Creative Commons image of Charlie Brown shopping for a Christmas tree by KIT via Flickr; The River lyrics copyright by Garth Brooks)

I Heard Sleigh Bells

She must have been about four, old enough to go shopping with mommy but still too young to make the entire trip without being carried to the car afterward. She was holding her mother's hand, waiting, as was I, for the Portland Williams-Sonoma to open. 

If the holidays are magical -- and for me they definitely are -- Williams-Sonoma has a corner on the market. From peppermint hot chocolate to china to cookie and pie cutters (my target purchase this time) -- I wonder sometimes if they don't have a direct line to the North Pole. I realize Thanksgiving is a couple of weeks off, and you're right, it really is too early to be writing about Christmas. I mean, Madison Avenue is bad enough. Turn on the tube two days before Halloween and from the ads, it appears Thanksgiving is nothing more than a minor bump on the road to December 25. But what was about to happen in front of Williams-Sonoma would be enough to make even the most jaded forget about the date and simply be glad the Holidays are here at last. 

I was standing with my back to a long hallway leading to the mall offices, preoccupied by my sweet, diminutive fellow watcher and waiter and her fascination with the window dressings. A toy train bearing the name, The Polar Express, rolled round a track decorated with artificial pine bows, green ribbons on red packages, and a tiny town replete with a snow-capped mountain. She couldn't steal her eyes from it and neither could her mother -- there they were, two little girls, hand in hand, riding The Polar Express. 

Suddenly, I heard a loud, "Ho! Ho! Ho! M-e-r-r-y Christmas!" and quickly turned to see Santa Claus step from the hallway into the mall. Oh yes, you bet I smiled and waved, I never miss a chance. He smiled and waved back, then greeted other shoppers who stopped at the sound of his voice to wave. Then, I heard something else, a rapidly indrawn four-year old breath that made me look down. With eyes like saucers, she whispered in awe, "S-a-n-t-a." At first, I wasn't sure how it would all unfold -- did he notice her? Of course, he did, he's Santa, he knows when we are sleeping, he knows when we're awake -- not a child on the planet goes unnoticed by him and that includes this one. 

His two female elvish helpers continued on to his "workshop," unware he'd halted in front of Williams-Sonoma and knelt down on one knee. He reached a mitted hand to his face, thoughtfully stroking a beard I'm absolutely certain had to be real, and softly said, "Merry Christmas, Jennie." She looked up at her mother, whose face was a study in amazement, then broke free and ran into his arms. I didn't hear what was spoken, that's between she and Santa, and maybe nothing was. Maybe her actions said everything. I know they spoke clearly enough that when he released her and tenderly touched her hair, rising to his feet he looked at me with eyes moist with tears. Yes, Virginia, Santa has a heart, you can be sure of it. 

Something told me only a fool would let this moment pass, so I followed after him and laid my hand on his shoulder. "I'm sorry to intrude, but..." He interrupted me and said, "You want to know how I knew her name. Well, Beggar -- yes, I know yours, too -- after a few hundred years at this, you start to develop a pretty good memory. Merry Christmas." Then he smiled once more and winked. As he walked away, I could have sworn I heard sleigh bells.. (Creative Commons image by dkjd via Flickr)

Things Dads Do

For a long instant, it felt like Thanksgiving this morning, stepping into a warm living room from the chilly garage where I keep my ready access firewood. With four inches -- nearer six or eight if it was powder -- of firmly packed, heavy, wet snow covering the hayfield, it looks like Thanksgiving. It also looks like a few of the Halloweens of my youth when the end of October mistook itself for the beginning of winter. With a fire softly burning (thanks, JD, for the image) in my study...by the way, we didn't have a fireplace when I was growing up, have I told you?

Our house was small -- three bedrooms, one bath, kitchen/dining and living room, all heated electrically. The closest we came to a fireplace was a small wood-burning stove in our unattached garage that my father used as his saddle shop for several years. Hardly a stove, it was a twenty-five gallon oil drum turned onto its side with a door cut into one end and four welded feet. How he worked out there, winter after winter, is a testimony to a father's love and determination.

I split firewood for him. I remember grousing about it at first, as any kid might, torn from afternoon cartoons to trudge out to the woodpile near the barn. I'm supposed to play, not work, I thought. He overlooked my complaints and taught me how to set up a block of wood, take aim for the middle, and swing without missing. It wasn't long before I began enjoying standing there in the snow with my axe and carrying armloads of split logs into the shop, losing myself in a "living-on-the-ranch" reverie. Writing about all this, I recall a day when I grew up a bit, realizing how my "work" kept him going. I must have been around nine or ten, but I began appreciating my father more than I had before.

Shared tasks, working together, those were his values and he passed them along to me. He was raised in a time and place where everyone had a task and everyone contributed to the family's welfare. He and his siblings had chores, a word one rarely hears anymore and tends to be associated with black and white reruns of old western television shows like The Rifleman on AMC. When used now, it's often in the pejorative sense, life is a chore. And some of his were all of that, especially when he was too young to ride after the cows and had to content himself with milking them, instead. Reality fails to imitate art every now and then.

He wasn't heartless about chores, though, and perhaps that comes from his own experience. One afternoon after school, he'd been too busy to cut wood into sections as he usually did, leaving them for me to split. So I started in with my axe, intent on doing both the man's job and the boy's. He came out a short while later and in a gentle tone he reserved for just such moments, told me I could stop, he had enough wood for now. I was hesitant -- the wood box was nearly empty as anyone could see -- but he assured me he was fine and to go on into the house and get warm, The things dads do.

A person has to wonder where the desires of the heart come from. I still love fireplaces and going out into the forest to cut wood. The axe of my youth has been replaced with a splitting maul, five pounds of steel at the end of forty inches of Ash. There is a sectioned tree trunk, well over a hundred pounds itself, sitting in the garage, the legacy of the doctor who lived here before me, that is our common chopping block. The open rafters are high enough for a full-armed swing.

Sheltered from the weather, it's not the barnyard of my childhood. Nor is my work that of my father. But the appreciation for a warm fire on a cold morning we share, as well as the effort to bring it to life. From whence comes the desires of the heart? I can't always say. What I know with any certainty is, I can't plunge my maul into a block of wood without thinking of all those afternoons, splitting wood in the snow, and my father who taught me how.


(Creative Commons image by Gadget_Guru via Fkickr; "a fire softly burning," Back Home Again, words and music by John Denver, copyright 1974)

First Assist

More years ago than I like to advertise, I was flat on my back in a hospital bed, awaiting surgery for kidney stones. It all began on a typical July 4th weekend in northwestern Colorado, visiting family and fishing in the high country. A delightful lunch of cutthroat trout cooked over an open fire was followed by nausea, vomiting, and abdominal discomfort that puts the P in pain. The local ER doc diagnosed a renal stone and I began seeing a urologist in Denver the next week.

As we say in medicine, my initial treatment was conservative, i.e. reduce calcium intake and drink water or cranberry juice like it's going out of style. At that time the theory was, my kidneys were less adept at eliminating excess calcium, so by flushing them with clear fluids, we'd rinse them of the offending chemical. It was a good theory; the problem was, it didn't entirely work, resulting in my first exposure to surgery coming from the patient's side of the operating table.

I spent this past week, and will spend the next five weeks, on the surgeon's side and believe me, that's a whole lot more fun. Not that I minded being a patient, but the lessons I learned have stuck with me. For instance, there's nothing like being at the mercy of the healthcare system to teach future doctors to pay attention when their patients speak. It's one thing to get report of 522b's requests for morphine and quite another to have been 522b, in severe pain, and have to wait -- in pain -- for the hours to tick away like days before the next round of medications arrives. Thanks to the gravel pit that collected in my left kidney, I know what this is like.

What makes the surgeon's side of the table more enjoyable -- apart from the absence of pain -- even for this incipient psychiatrist, is the fact that you're delving into live anatomy. For all the times you may have laid scalpel to preserved, leathery cadaver flesh, when you insert your fingers into the warm open incision of a living person, you've got to experience a mix of awe and fear. Fear that you'll do something harmful and awe because you're in a position to do so, probing where no one has gone before. It's enough to make the crew of the Enterprise envious.

My week, as do most, began with Monday -- orientation, a meet and greet with the staff, butterflies in the stomch. The next four days were spent in the OR from near dawn to mid-afternoon, when the surgeons head off to do office work and I'm left on my own. This rotation is largely self-directed and I have the freedom to pick and choose the procedures I find most interesting to scrub-in on. Since I'm working in a community hospital, I won't see cardiac or severe trauma cases -- we don't have the ICU facilities for major surgeries like those -- but I'll definitely see the kinds of things most of my future patients will experience and that's what matters. Naturally, I'll scrub-in for all those performed by my primary instructors, but I can also work with any other surgeon who's willing to have a student along for the ride.

It was the latter that led to another first this week, an opportunity to act as First Assist, the individual who stands opposite the surgeon, ready to offer whatever assistance the surgeon requires at the moment. Ordinarily, First Assist is a trained nurse, PA, or another physician. Under the right circumstances, however, it may also be a student. Yesterday the tumblers clicked into place and I was in the right place at the right time.

Now, before this begins to sound "important," in point of fact, I didn't actually participate in the sense I cut this (aside from sutures) or pulled on that (aside from retractors). Still, having an extra set of hands can be helpful and mine were eager to be put to good use. From a student's perspective, you're assisting, even in small ways, and that's always better than observing or merely standing by, all scrubbed up with nowhere to go and nothing to do when you get there.

And the word gets around. You've done the job once, you were attentive and diligent, you didn't screw up, the doctor seemed to enjoy your company; he'll tell other docs and you'll get to do it again. The more often you do, the better you'll get, and sooner or later, someone may hand you a scalpel, which to your inexperience feels like a Bowie Knife, and say, "You make the first cut."

Are my hands ever eager.


(Creative Commons image by Army Medicine via Flickr)

Noticing

When the dogs and I stepped out of the house this morning, the lane was littered with oak, elm, and magnolia leaves so thick our feet (my feet, their paws) barely touched the blacktop as we walked along. It rained last night, not a gentle, soaking, spring-like shower I imagine makes the trees lift their limbs and whisper to one another, "Psst, pass the soap, will you?" This one was intermittently wind-blown and down-pouring, scattering leaves and drenching the countryside. It was the kind of rain that rinses the air clean as a whistle and whets sunlight sharp as a tack.

As we walked up the road, morning business on our minds, something unusual caught my eye. A single leaf, a tiny piece of oaken gold, hung spinning in mid-air, its stem caught in a single strand of spider web, like an arboreal ballet dancer dancing as though her moment had come and never would again. I'm reminded of the line by Mark Twain, Sing like no one's listening, love like you've never been hurt, dance like nobody's watching, and live like it's heaven on earth? That's what she was doing, drifting and swaying to music beyond my hearing. I was mesmerized.

Some people never notice the things that render life more than a matter of getting by, those side-long, fleeting instants when eternity opens a window, reaches through, and taps us on the shoulder. Sort of like what happens in the film, Babe (1995) with James Cromwell as Farmer Hoggett, a man who notices. Hoggett lives on a sheep farm in Queensland, Australia, and to his family, he seems a bit odd now and then. They're solid, ordinary people who are nevertheless, completely unaware that eternity has not only opened a window, it's climbed through the frame, unpacked its bags, and taken over the guest room.

Hogget knows something is happening. He can't explain it, neither does he bother to try; some things you try to explain and their significance gets lost in the details. He simply lets it all in and follows its lead. Presented with possibilities others would dismiss, he can't help but take them seriously,

For instance, when he notices how Pig interacts with his sheep, he allows the little guy a chance to prove himself. Hoggett sees what no one else can or will, and while he's a man of few words, his actions are as pregnant as a woman at nine months who;s about to pop. Only he doesn't just notice things, he responds to them, opening a creative space in which they can unfold at their own pace. We're often in such a hurry to find out things will turn out, perhaps because we're in doubt they will, that we forget about everything that comes before. Hoggett's efforts are ridiculed, of course, even by his family. But then comes the final scene, when the crowd that jeered goes crazy, cheering its heart out over the little pig that could.

Hoggett knew what Pig was capable of because he'd witnessed it. He noticed something unusual and instead of blowing it off as nonsense, he did what most of us are too afraid or too embarrassed to do, he gave it credence. He did the hard thing and in the end, he wasn't disappointed. It really all begins with noticing.


(Creative Commons image by Lord Mariser via Flickr)

Missing Megan Fox

I really like Megan Fox, but not necessarily for the reasons you might think, me being a guy and all. Sure, she's drop-dead gorgeous -- I'd have to be blind as a bat not to have noticed and trust me, I've noticed. But what I like about her so much is her role in the first two Transformer films. No, I'm not talking about the cutoff jean shorts she wears in both, though I noticed them as well. I mean her character.

Megan (if she's reading this, I hope she doesn't mind the familiarity) plays Mikaela Banes, a pretty young woman with a past. Her father has a prison record for grand theft auto and she, a juvenile record for having been his presumed accomplice. She has another liability, however, and that's her beauty and sex appeal. Like far too many women, she has a history of being regarded as a trophy.

In the first film, her boyfriend is a muscular, good-looking, football player who treats her like a possession once too often. She knows there's something wrong with the guys she's chosen to date, she doesn't like the pattern, and she has sufficient inner strength to do something about it. As she's walking home, along comes the film's hero, Sam Witwicky. Sam is everything the other guys could never be: overtly insecure, honest, and down deep, utterly courageous.

In the first installment of the trilogy, Mikaela is not only a match for Sam, in some ways she is even more heroic. For instance, when they're attacked by a mini-decepticon, she grabs a power saw and goes to work, rescuing him. During the final battle against Megatron, she is determined to save Bumble Bee by hooking him up to a tow truck and then drives it backwards down a wreckage-strewn street while he shoots at the bad guys. I love that scene.

In Revenge of the Fallen, her character is a little more traditional and her biggest challenge seems to involve convincing Sam to tell her that he loves her. Sam, how crazy do you have to be to have someone like her around and dither about saying, "I love you?" Get a clue, buddy. Anyway, that bothered me, the fact that she wasn't permitted to be the totally gutsy chick she was in Transformers. Her character wasn't just beautiful, she was admirable.

Now we come to Dark of the Moon and there's no Megan Fox. Instead, we've got a blond babe whom Sam has decided is the love of his life. She flirts with other guys and then minimizes her behavior, she's essentially focused on the accumulation of expensive toys, and perhaps, worst of all, she has absolutely no idea what makes Sam tick. You tell me what's wrong with this picture.

If we wanted to get psychological, we'd have to ask why Sam hooked up with her in the first place. According to the story line, he and Mikaela had a fight, broke up, and rather than do what any man with a lick of sense would do, i.e. turn himself inside out to get Mikaela back, he lets her go. Sam clearly has far too much pride for his own good. It's what kept him from declaring his feelings in Revenge of the Fallen and it comes back to haunt him in Dark of the Moon. We could be Freudian and say the new girl is more like his mother, but we really don't have enough character development to go that route. We do know, however, that Mikaela and his mother are two very different kinds of women and that could explain a lot.

For whatever reasons the producers decided Megan's character wasn't meant to be a part of the last film, I miss her. I liked Mikaela's resourcefulness and willingness to take a risk. Her response to Sam's question, "Fifty years from now, when you're looking back on your life, don't you want to be able to say you had the guts to get into that car?" is one with which I, as an older medical student, can well identify. I also liked the fact that she wasn't squeaky clean. She had a past she was ashamed of but she refused to let that prevent her from something better. Her wounds made her human and more interesting. Best of all, I think, she didn't allow herself to be paralyzed by fear. She could be counted on in the clinches and was capable enough to be a participant in the action rather than a hand-wringing damsel-in-distress. Definitely the right kind of gal and why I'm missing Megan Fox.


(Image of Transformers: Revenge of the Fallen via RottenTomatoes.com)