It’s Not Always Like This

Once Upon a Time I was a new nurse. No. It’s true. I had the uncommon good fortune to start right out in the ER for my first job. That’s not the case for everyone and I’m thankful it worked out that way for me. I’m still in the ER and sometimes I have the honor and privilege to shepherd a new nurse into our group.

Not too long ago I was chosen to orient a nurse who I had often heard mentioned outside the context of the hospital. She is an acupuncturist and has worked with my wife for several years in the birth community. In the ER we do just about anything we can to avoid delivering a baby in the department. We really will muster a sudden burst of energy and drop whatever we’re doing to redirect that imminent labor upstairs where that is what they do…what they expect to do and what they are trained for. Sometimes though it does happen that a delivery in the ER cannot be avoided and having a nurse who has attended births and is comfortable with the the perinatal milieu is a great asset.

This nurse is not just new to the ER.   She is a new grad as well, just out of nursing school like I had been. One of the benefits of working with students and new orientees is that it brings me back to the beginning.  It forces me to think about why we’re doing what we’re doing…why one thing is prioritized over another. During twenty years in the ER one develops shortcuts and workarounds to keep up with the pace of things. But this is a time to go back to basics and model correct methods, doing everything exactly as it is meant to be done, remembering pitfalls and pointing them out to someone who hasn’t yet been exposed to them… maybe keep her from stumbling.

Reflecting on where I started and where I have come I realize there is a lot to keep track of.  Luckily starting out you don’t know what you don’t know so it’s not too intimidating. Her whole career is ahead of her and now is the time to establish strong habits that will serve her as time goes on. Am I really the right person for this? My mind is kind of like a corkscrew. Not linear and methodical. Not by nature anyway, but I can squeeze myself into that mold when it becomes necessary. May I tell you a secret I have discovered? I think a too linear, methodical mind may be a liability in the ER. The way a day descends into barely controlled chaos lends itself to the person with the corkscrew mind. (I tell myself that).

You never know what to expect going in to work in the ER. I have probably said in the past that that is one of the things I really like about my job. It is one of the first things I stress with my orientee. Some days are Sunshine and Roses. Other days are … Not. Some days you have time to talk to the 75 year old children of the 98 year old woman you are taking care of. You can learn about where she grew up, what she did as a child and as a young woman living in a time so different than our own. You can hear about how it was on the family farm in South Dakota… how her husband had a farm accident and a suture was improvised from the E String of a violin by a neighbor who had the ingenuity and the nerve to close the wound with it.

You can learn about the soul damage of a Viet Nam Vet still broken and tormented by events that took place when he was just a kid of 18, now 50 years ago. That’s almost three quarters of his entire life defined by that time and place. The shock of the experience has chiseled deep and disturbing graffiti into the bedrock of his existence that he will never heal. It’s something he carries as a sort of sign saying “Keep Out”, and it works, because, to a large extent people don’t come near him…for better or worse. Guilt and pride for one’s service can be so fatally conjoined for some men I have spoken to that they can’t separate them and remembering either is a minefield they will not enter.

Having time with people brings gifts wrapped in lifetimes of emotion that you must open carefully. If you open them at all.

Some days there is no time for talk. No time to get to know the human side of the person you are caring for. The relationship can be so thin it is frustrating. You can feel like you are running full speed just to stay several steps behind and still lose more ground while doing the bare minimum… so much less than you know you are capable of, so much less than you know the person deserves. You would happily give so much more…but there’s no time. You just hope you don’t miss something important in times like that. Consequences are real and the weight pulls at you.

When I started the first day with this new nurse, as her guide and resource person, I never imagined that what had happened to me would happen to her. On my first day here we had a patient who died. It hadn’t occurred to me we would be dealing with the many tiers of issues that come with a death in the ER. The vast majority of shifts go by without a loss of life. But we heard the voice of the paramedic over the radio. It was a Code-3 ambulance… a cardiac arrest at home. Resuscitation was well under way, CPR was in progress. A tube had been placed for ventilation. Epinephrine and Amiodarone (Potent Cardiac Drugs) had been given through the IV. They had defibrillated the patient. (Delivered powerful electric shocks through the chest) to try to trigger an intrinsic heartbeat. They had repeated the process again…

-Nothing-

Was the patient alive when he got to us? Legally yes. Physiologically? I believe not. We heard the report of what had happened at the house…what the paramedics had done and what response there had been, how long the man had been without a pulse. We asked the questions about past medical history while assuming responsibility for chest compressions. My orientee did them. It was her first time. We asked about medications the man takes while we started a second IV and drew blood. Respiratory therapy took over manual ventilation. Between cycles of compressions the heart rhythm was analyzed on the monitor. Asystole (No activity). Pupillary responsiveness was assessed. (Non-reactive and Dilated). Compressions were continued. Another round of Epinephrine was given…

This procedure…following ACLS (Advanced Cardiac Life Support) protocols for pulseless cardiac arrest can bring a person back. When you hear a person say they were dead for 2 minutes, or what have you, but they were brought back, this is what they are talking about. They were successfully resuscitated after their heart had ceased to beat. That is actually the miraculous success story of a friend of mine who was brought back after sudden cardiac arrest. But that is the exception. That is not what happened this time.

This time the patient died. He had a large family. Several people were on their way to be with him in the hospital. Thankfully we were not too busy at the time and we were able to give the family time to grieve …time for the people on their way to arrive and be together with the others. Time for it to sink in that he was gone. It is a small mercy, but can mean a lot.

It was sinking in for our new nurse too. She had never done CPR, had never felt the sensation travel up through her hands and arms to her own heart of how violent an act a cardiac resuscitation is. It is physically, mentally and emotionally demanding. A hell of an introduction to ER Nursing, having to figure out on the fly how to master your emotions in a hectic situation and keep your focus where it needs to be so you can do your job. And it’s all new. The team chemistry where everyone has isolated tasks and a practiced way of communicating and performing their role so the person you’re working on can have a chance at life. She had never been a part of any of that.

It’s interesting to be made aware that the person you are helping learn about her new workplace has just been closer to a dead body than she has ever been before. She has never touched the lifeless body of another human being. Thinking about it, most of us probably have not. I have. Many times. It is not easy, but there is a certain getting used to it in the context of the medical setting. It is a fact that one must be ready for. We weren’t.

She had lots of questions. Naturally. We have a checklist to help us remember all the important steps to be taken when you have a death in the ER. I guided her through all the things we do. We didn’t yet speak of what was going on below the level of our brains. What was rattling around untended in our hearts would just have to rattle there for a bit. We went down the list: Call the California Transplant/ Tissue Donor Network. This is required for every death in the ER. They have trained staff who take the calls, gather information on the person: age, sex, prior medical conditions, “Is the patient on a ventilator, or had they been during their treatment?”, is there family with them?, are we able to provide contact information of the next of kin?, will this patient be a coroner’s case?. The Donor network contacts every family at some point to see if there is any interest in donating any organs or tissues for transplantation to give hope to another person. That is a job that must take some finesse.

Contact Next of Kin (If that hasn’t already been done). Call the Coroner and give them information so they can determine if the Coroner’s Office will require an autopsy… Any time there is a suspicion of foul play, or if the death is unexpected and the person has not been under the care of a physician within a set time period an autopsy will be ordered by the Coroner and they will dispatch an officer to pick up the body.

Find out if the patient or their family have a prior agreement with any local mortuary for their funeral services. If so we will contact them on behalf of the family if that is their wish. Notify the Nursing Supervisor of the death. Make an inventory of any valuables or personal effects on or with the body. Offer for the family to take any effects with them at this time, or they can collect them later according to their preference. Contact Security. Any effects not taken by the family will go with security for safekeeping. Also at this time we will enshroud the body in a post mortem bag. Security often helps with this. Then the body will go to the hospital morgue awaiting disposition, either to a mortuary, to the coroner or with donor services.

File an event report on-line. This is something that goes to the corporate Risk Management Department for follow up, just as a matter of protocol. I’m sure deaths can easily turn into a potential for litigation. Crazy world. That about does it for the checklist. Quite a few tasks and contacts most of us will never have to give a thought to , but my orientee did. On day one. I should say she was strong and professional. That is how you have to be. I was impressed.

Things got busy in the ER. We had a group of other patients to take care of, though none of them stand out in my memory now. You just keep working. Especially when it’s all a new experience for you, you have a tendency to try to find something to hold onto, that will steady and balance the surreality of what you have been part of. At the end of the day I told her she had done well and asked if she needed to talk about any of it. We did have a conversation about what was coming up for her. She said it wasn’t as hard as it might have been because she felt no life in the gentleman when he came in. She said she just felt his spirit had already departed his body before he ever even got to us. So she didn’t have the feeling that we might have been able to have saved him but didn’t, or that he died in our presence…he was already gone. That helped her somehow.

She has a supportive husband who she will be able to talk things through with. Each of us has to find our own way with this part of the job. We all come from different traditions, religions or spiritual practices that may help us have perspective on death. Maybe we don’t have any such thing. To give her hope and minimize the dread of facing another day like this tomorrow, I told her, “It’s not always like this”. “In fact it’s rare”.

We had a little chuckle over that and went our own ways, to come back tomorrow.

The next day started out slowly, as they thankfully often do. A lot of mornings feel like we’re running a pediatric clinic. Babies and toddlers who have fevered in the night, or coughed or vomited keeping their parents awake are brought in to be checked out. Most of the time these are reassurance visits for the parents more than medical visits for the children. We meet a lot of beautiful little ones this way. It’s one of the sweet parts of the job. It was a nice way to begin again and put the darkness of the day before out of our minds.

It wasn’t long before the course of the day veered hard away from sweetness and accelerated us back again to our post on the portal between life and death. On this, her second day in the ER, this new nurse had to face the very situation she had said would have been harder than what she had done the day before. (And is maybe the hardest situation we do face). We had a patient who was alive when she came in. She was very ill though. A child with terminal illness. She was very weak and her degenerative condition had worsened to the point she could no longer carry on. Her parents knew she was dying. Their faces and posture were like stone. This day, which they had known for so long was coming had arrived.

When our efforts to sustain her proved futile and she ceased her struggle, her little body relaxed. Who knows if she had ever, in her brief time on Earth, known comfort and ease? Her parents were so quiet. Sometimes there is wailing and an angry defiance that death has come, a sharp and bitter refusal. But here, there was resignation and letting go. We were witness to a stoic acceptance of fate borne with dignity and grace by this silent couple saying goodbye to someone they had loved so dearly and who had needed them so completely. I wonder how much they needed her too, how much their lives had become about the dailiness of her care, how would they move on?

What can it mean that your first two days as a nurse are like this? Your training is definitely focused on the interventions you do to keep people alive and to make their lives as full and functional as possible. Very little Nursing School instruction addresses how you cope with death or how you’re supposed to help others with their loss. So this? Sure it’s got to be part of the Nursing experience, but maybe you could ease into it over time? This is sort of an assault to be greeted by your profession in such a way. I wish I had some stabilizing and comforting wisdom to share with her at the end of day two. She called me out on having told her, “It’s not always like this”. She asked if I meant it, if I really meant it, or if it really was going to be like this every day. “Hardly ever”, I tried to assure her. Tomorrow would be better. She would see.

So much comes at you in a day, and so much more in a week, that even if you try to remember everything, you just can’t. I should say I can’t. Some things I remember in detail, others not at all. By the end of a day I couldn’t recount every patient I had cared for that day. So when I’m trying to piece together the events of this first part of working with this new nurse a lot is lost. Mostly what I remember is the overall feeling of the days. By the third day I was ready to show her how a normal day in the ER plays out… a day where you take care of your garden variety patients without wishing them bon voyage over the River Styx. She was ready for that too. That’s what we had in mind as we started our third day together.

Oh how I wish we had been able to end that day as we had envisioned it. Maybe a bloody. nose, some sutures, someone falling off a bike or a horse but not much worse for the wear. Maybe a bunch of kids with fevers or asthma or ear infections. Maybe an abscess from skin popping – oh I mean from a spider bite- . Maybe poison oak or passed out drunk or closed their finger in the door. I’m talking about people who come in, you work with them and they walk out the door. That is the day we wanted (and which I had tacitly promised). Not the day we had.

We’re given to a few superstitions in the ER. One is that you are Never to say the “Q” word. SShh. (It rhymes with “Riot”). Say that and your co-workers will be all over you in an instant. And if something bad rolls in, or if it gets really busy you are to blame. You opened Pandora’ Box. As for myself, I’m not given to that particular superstition. I think that when it is not horrendously busy you ought to be able to gratefully acknowledge that. But I’m an outlier on that point. Another superstition (and I am an adherent to this one) is that things come in threes. It has just happened too many times for me to say it’s nonsense. So it was for us. We had our third.

Code-3 ambulance…respiratory distress…Paramedics were giving nebulized Albuterol and had put the patient on CPAP. You know those forced air machines heavy snorers use when they sleep to prevent sleep apnea? They’re used for respiratory distress too. When a person has been working really hard to breathe for a long time they can become fatigued and the work of breathing can tire them to the point of respiratory failure…they just can’t keep working that hard any longer. So the positive pressure of the machine does the work. When they arrived the patient was sitting straight up, restless with the CPAP blowing oxygen into his face. His fingers and toes were becoming bluish. His blood pressure was very high also. There was some obstructive airway process, Air wasn’t getting deeply into his lungs where the Oxygen can trade places on the hemoglobin with the CO2 he needed to get rid of.

The patient needed to be intubated. A breathing tube would have to be inserted and the patient put on a ventilator so he could continue to breathe and stay alive. Since he was awake and alert we would have to use RSI (Rapid Sequence Induction). This is a procedure to rapidly induce anesthesia and paralysis so the patient can be emergently intubated. This is a stressful thing to do. You have a person who is awake and breathing on his own, thought not adequately. And what you have to do is knock him out and paralyze him so he will relax his muscles and you can insert the EndoTracheal Tube. It is a moment of truth when you push that paralytic. It is derived from Curare, the Amazonian blowdart poison that paralyzes the prey so the hunters can bring home food. The only thing is, if you can’t sink the tube once the person is paralyzed you’ve got big problems.

Once the person is paralyzed you have got to be able to provide ventilation, since their diaphragm is immobile. If you fail to insert the ET Tube you can still fall back on forcing air through the nose and mouth with an Ambu-Bag to get oxygen to the lungs, But this doesn’t protect the airway and puts you in a worse position than when the guy just couldn’t breathe for himself. You 100% have to get the tube in place or your patient is going to suffocate right in front of you and you will be, to no small extent, responsible.

The intubation went fine. A portable chest x-ray showed the tube was about a half centimeter too deep, so Respiratory Therapy backed it out and re-secured it. Breath sounds could be heard in both lungs but his oxygenation was still not good. The ventilator was set up, but the patient started to fight it as the meds wore off. This is normal. He needed sedation. So we got out the Propofol and started an infusion, advancing the dose to try to get him relaxed again. He was a large man, so it took a lot to begin to work. We got his Blood Gas results and he was still not getting enough O2 and getting rid of enough CO2 and he was severely acidotic. The ventilator settings were revised to compensate. The other blood tests revealed a dangerous excess of potassium. His blood glucose was sky high, his lungs were full of fluid and his kidney function was failing.

It’s a high adrenaline scenario with a lot to do immediately and no wiggle room in getting it done. Even when all goes well and you’re accomplishing all your treatment goals, to counteract the list of emergency conditions you are aware of, there may still be others you don’t know about and the patient may still deteriorate. Maybe he has massive pulmonary emboli (blood clots in the lungs), occluded coronary arteries, DKA, MI, ringworm. (Alright we’re not going to sweat the ringworm). So even though we were doing everything we could he was getting worse.

Maybe if he had gotten to us sooner? It was her second time doing CPR. But harder this time because this person had been alive for her. She had known him to be a living human being and we had swum against the current to try to rescue him as he went down, but we lost him.

1-2-3 days, beginning to wonder if this career move was such a good idea. “I don’t know if I can take it if it’s going to be this way every day”. “You said it isn’t always like this. But it is. Why did you say that?”. I knew it was true, what I had said. It isn’t always like this. Thankfully I knew that. She had yet to see anything else. What was she to believe? I couldn’t fix it by talking. She would just have to experience better days. We had a few days off after that to try to shake some of it off.

When I first started working as a nurse I had three pairs of scrubs, all Forest Green. A rotation of three pairs is a decent start. My orientee started out with a few pairs, all of them black. After this day she questioned that choice. Was wearing all black inviting trouble? Before we came together again after our days off, she got some colored scrubs and has never worn all black again.

When we started off our fourth day I went out on a limb with her, because I figured,”Why should she believe me”, when I said it, but I told her again, “It isn’t always like that”. (It was probably beginning to sound like a worn out joke) “Most of the time it is nothing like that. It is going to get better and your patients are going to walk out that door like they’re supposed to”. She gave me a hard look. She had seen my quirky side, but she had seen me solemn as well. I believe I am a pretty transparent person and with that penetrating stare I think she could see it in my heart, I meant it. So she trusted me as we began another day.

Nearly a year has passed and she has never seen a stretch of consecutive days like those first three. She made it past that and has it as a foundation in her practice. Trial by fire has formed her and branded an indelible mark that speaks about Life and Death and ER Nursing. With that as a frame of reference, I should think the rest of the job looks pretty good.

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Sweetened Condensed Prose

Come on Miguel where do you get that Goat Rodeo stuff and how do you get it out of the can?  It seems too thick  to just pour right out.  So what do you do to get at it?

I’ve been spending more time wandering through the fields of growing stories, inspecting their progress and examining which ones are filling out nicely and which ones are calling to me.  They grow quite a bit on their own and usually just need a little pruning and shaping   At some point I have to harvest an armload of material and bring it into the kitchen.  I’ll start the prep with some idea in mind of what the flavor should be  and I’ll just start working, tapping a bit out , fast or slow and then I’ll taste it.  I work by taste and I adjust it as I go.  Every bit of advice I have ever read about the craft of writing advises against this approach.  “Don’t edit as you write”, they all say.  “It inhibits your free flowing creativity”, they say.  “Just get the story down and then go back and edit it”… they …say.

I might as well jump into a swamp and try to balletically traverse its mires.  I have tried the approach the Experts propound and ended  up with an unruly patch of brambles. I started with a good idea and good energy, liked the flow, but in coming back  have hacked and chopped the poor defenseless words into a stuttering, prickly shrub that is unbalanced and will not flower. So I have been finding my own way.

I nurture the tempo and tend the choice of words turning them over in my head, walking up and down the rows, weeding as I go and trying their feel in my mouth to achieve the aesthetic while also delivering the goods to market, telling the story. Maybe I’m right. Maybe I’m wrong. Either way, I have found I don’t write enough. I don’t dedicate the time to writing that I think it deserves.

That’s why I have joined a writing class, and the method is definitely “Just get it out and onto the page without engaging the “Editor”. And I am learning the value of that…. letting that uncensored part of the creator free to run wild. Loosen up and put the person who wants perfection in the penalty box during this initial phase of the process. That bastard is wiley though, used to having his say when he wants it.

Now I am trying both ways of writing… the slow word tasting, Bonsai cultivator and the open your seed-bag and scatter them in every direction, flying on the wind to surprise you with their arrangement and their beauty when, later on, you stop and assess what you have done.

You hear about being on this Earth for a limited time and how it is important to share your gifts, not squander them. If it is a gift or not is for you readers to say. But if it is I may well have been squandering it. When I think I set out to be a writer after high school almost 40 years ago and have let the fields of ideas lie fallow for that time… well, you see what I mean.

On the other hand one must pluck the fruit when it is ripe, and by gosh, I’ve got some harvesting to do before the crop spoils! The thing is you don’t want to let time pass you by and never do what it is you are meant to do, but neither do you want to rush and puke out some not yet ready rubbish just to have it out there. So as I see it I should be about nicely ripe at this time of my life. The impatience and laziness and unwillingness (or inability) to be still that characterized my younger self have softened and given way to … to what? It feels like a more forgiving and tolerant person lives in my shell now. I mean forgiving and tolerant of myself. I’m not cool. I don’t have to look good or be the best at something. I can just be me. And enjoy it.

When I share that in my brand of writing it feels good. If there’s a way to twist some words out of the air and get their fresh tang onto the page… What else is there? That is me.

That is how I do it.

I Knew I Was in Trouble

Oliver Enzo has an amazing talent. It comes from something innately embedded in his nature but developed by him and honed to a high degree of skill. He is 15 years old now and has his own business in drone video work. At the age of 13 I bought him his first high quality video Drone. At age fourteen he took his talent to Burning Man and was approved for one of just 30 Drone Pilot Permits out of 70,000 Burning Man participants. While there he Shot some drone footage for a You Tuber with over ten million subscribers to his channel. Ollie’s footage can be seen in the You Tube Video the guy produced. His flying skill is impressive. It is matched by his eye for the shot and his ability to edit moving images and music together into a beautiful final product.

I know I already said it, but he is a really good pilot. But he is also a fifteen year old kid. Under the rules for Small Unmanned Aerial Systems (Drones) you have to have an FAA issued Commercial operators certification in order to do commercial work. To be eligible to get the certification you have to be 16 years of age. What’s up with that? Well, the FAA controls all the country’s airspace and drones are just one of the users of that airspace. Actually They’re the new kids on the block in terms of airspace users.

Though many view drones as a nuisance or as as irritating toys, or unwanted invaders of their privacy, Drones occupy a respected place in aviation and provide an impressive array of services beneficial to society. They can also pose a danger. That’s why the FAA requires commercial users to take a test demonstrating adequate knowledge of the airspace regulations to operate safely and in a coordinated manner with both manned and other unmanned aerial vehicles. Within the language of the FAA Part 107 regulations (That’s the rules governing drone use) there is a stipulation that every mission must be under the control of a Remote Pilot in Command. That is the person holding the Certification. But the person doing the actual flying need not be the RPIC (Remote Pilot in Command). The person actually piloting the drone is referred to as “The Person Manipulating the Controls”. This person is under the supervision and direction of the RPIC but isn’t required to be FAA Certified. The RPIC just has to be able to take control of the drone should an emergency arise.

Here’s the little dance with words that has allowed Ollie to operate commercially: I am the RPIC. As a gift to Ollie for his fifteenth birthday I studied the regulations, completed an in-depth online course and took the FAA Proctored exam and have received my Part 107 Certification. This allows me to be the Remote Pilot in Command and Ollie to be the person manipulating the controls. He is a much more skilled pilot than I will ever be. In fact I haven’t even flown one of his good drones before getting certified. You don’t even have to demonstrate competency flying the drone in order to become a certified SUAS Remote Pilot by the FAA. I expect they will tighten that loophole pretty soon. But for now it has worked out for us.

I have since begun to learn to fly drones and how to shoot still images and video with them. Nothing spectacular. When our family were on an annual camping trip to Mono Hot Springs last Summer there were fires in the mountains and some of them were said to be getting within a few miles of the campground. The Camp Host, Jen had been in contact with Cal-Fire who were keeping her updated on the fire status and making contingency plans with her for how to evacuate or lock down the campgrounds should that become necessary. She said evacuation would be unlikely given the nature of the terrain, the woods, the abundance of water in camp and the limited capacity of the roads to facilitate a quick exodus. Also she said that if fire fighters were needed in the area the roads would need to be clear for them and their equipment, so anyone trying to leave under those conditions could get into trouble for obstructing an active firefighting effort.

There were days with helicopters circling for hours, trailing buckets that they were filling in a nearby lake and dropping on the fires. One day, after Making sure the choppers had ceased their activity several of us went on a hike up to a ridge to see if we could see any nearby plumes of smoke. Over an hour had passed since the last sight or sound of helicopter activity was registered. Ollie let me use his Mavic Pro drone to take up in the air and see what that vantage point could afford me. It is strictly forbidden to fly a drone anywhere near where aerial firefighting operations are in progress, and for good reason. You could cause the crash of a helicopter and endanger the lives of the crews in the air and on the ground. So I waited until there was absolutely no other air traffic for an extended period before I launched. From atop a granite outcrop I ascended straight up to a height of 200 feet, through an opening in the trees. Using my iPhone as a monitor the drone was sending me real-time video of the surrounding area. I did a 360 degree rotation and could see no nearby smoke or fires. That was a relief. I buzzed around above the tree tops for a few minutes shooting some video of Thule Lake with its high vertical granite wall standing from the smooth surface of the water up over a hundred feet high. I tried to spy the other hikers who had come out on the adventure with me, but I didn’t get a glimpse of them. I could hear them calling out like peacocks from below, I just couldn’t see them from the air.

After I landed and reported the fire status to the group we hiked back toward camp. One of the group asked if there was any interest on a side trip to Doris Lake for a dip before returning to camp. I wanted to go to get a shot of the lake and of Eagle Rock, which is a granite promontory rising some 45 feet or so above the lake and is a popular spot for thrill-seekers to jump off and enjoy that brief moment in the air that stretches out time, but compresses space into a tiny concentrated point while the experience lasts.

Sarah, her Labradoodle Charlotte and I broke off from the others and ambled the twisting, rugged trail to the top end of Doris. We scrambled over the bouldery stretch to the spot where access to the water is easy. There Sara and Charlotte went in for a swim. The surface of the lake was as smooth as I had ever seen it. The skyline was beginning to blush as the Sun arced toward the place where it would intersect the profile of the peaks to the West. The quiet added to the beautiful stillness of the scene… It would be a majestic shot. I was excited and nervous as I unfolded the arms of the compact flying camera.

I went through my pre-flight procedure: Pairing the drone to my phone, making sure the drone and the transmitter were functional, removing the brace and cover that protect the delicate camera and gimbal assembly. My heart was pounding and my hands a little shaky as I lifted off. Sarah and Charlotte were just past halfway across the lake, already on their return leg of the swim, making a smooth wake of ripples as they plied the serene water. I flew toward them shooting video as I approached the midway mark of the lake where I intended to hover in place and rotate the drone 180 degrees to frame up the shot of Eagle Rock with the sunset bursting behind it. Instead of rotating the position of the drone though I mistakenly rotated the camera into a downward position, straight at the surface of the water. No big deal. I could edit that glitch out later.

I corrected that and drew the aim of the lens back to the plane I was after, pivoted into position and enjoyed the way I was able to arrange the shot. The smoke from fires brought out all the glory of the Sunset backlighting the scene. There was still more than enough light so the lake and the face of Eagle were fully exposed though. It was as lovely as I had hoped. There is a dynamic way of enhancing a scene like this when making video with the drone. What you do is line up the shot and then fly upwards and backwards, away from the subject. I have seen Ollie use this technique many times and thought it would be the perfect way to record the splendor of nature and preserve that moment. So that’s what I did.

Up and away, the field of view enlarging as I drew further from my side of the lake. Nice. Very nice. Another second or so should do it. Better get a visual on the drone to be sure I’m above the trees on the opposite bank. Just a quick glance up. Oh Fuck!

The drone was close to a tall Pine tree growing out of the rock right on the edge of the far shore and only about halfway up its height. I reversed the stick to full forward in an effort to avoid hitting the tree. But the drone was going fast and its momentum couldn’t reverse instantaneously. My heart landed in my stomach, maybe even my small intestine as I watched the little Mavic Pro impact the needled branch of that High Sierra Pine so close to the water’s edge.

My first worry was that the thing would bounce off the tree into the lake and sink. That would be the worst case. If it went into the water, of course the electronics would be fried and the drone would be ruined. Ollie has it insured, so if I could retrieve it we could replace it. But the water is deep and dark under the limbs of that tree. My heartbeat stopped while I waited for it to tumble down the limbs and splash. My breath caught high in my chest as I awaited the worst. One, two , three seconds passed and the red and green lights signaled that the drone remained high up in those arboreal clutches. Thank God! I moved the two control sticks into the down and inward position shutting down the motors to keep them from burning up unable to spin as they were.

This is Bad! I have to get that drone out of that tree before it falls out! Before the Sun goes down. I can’t leave it there overnight. “Sarah, I got Ollie’s drone stuck up in a tree on the other side of the lake. You and Charlotte don’t have to stay with me, but I have to go over there and try to get that drone back. I can’t leave it in the tree”. “Oh my God Miguel!”, Sarah responded, “Where is it? “. It’s right across the lake about 40 feet up a tree”, I told her. “How am I going to get over there? I could swim, but then I’ll be across the lake having to climb that tree in just my shorts. That won’t work. I’m going to have to hike around the back of the lake, up and over that high rock and down to where the tree is.” “Of course we’re going to stay with you. There’s no way we could let you do that by yourself. What if something happened? What if you fall out of that tree? I think you should just leave it. You’re never going to be able to get up there and get it back”. “I may not be able to get it, but I have to do my best to try. It’s Ollie’s drone and I can’t just give up on it without trying”. Sara was doubtful, “I don’t see how you mean to get at it. It’s way up there. You aren’t going to be able to climb that tree are you? How do you know you won’t fall?” I was feeling desperate, “I am not going to take any unreasonable risks. I need to get over there and see if the tree is strong enough to climb. The Sun is getting pretty low already. I hate to drag you through this, but I have to get moving or it’s going to be dark.” Sarah was obviously not comfortable with any of this, but she is too solid a person to abandon me to my stupidity and misadventure. She was picturing me lying under that tree on the bare granite, fractured and unable to help myself. I felt terrible putting her through this.

We set off retracing our steps around the back of the lake. “How are we going to get over to where it is?”, Sarah asked as we pounded out a brisk cadence. “I’ve been over there with Ollie before, one of the times we camped out up here”, I told her… “the year before we did it with you and Noah”. There’s a trail that goes up and over those rocks and that big humpbacked hill, down to the other bank”. Continuing to walk fast she confided in me, “I should tell you my depth perception is not good once the light is low. I may have a hard time picking out my footing as it gets darker. And also I don’t care for scrambling and off-trail hiking. Jeanie LaPage always wanted to do hikes that way when we would go hiking and I never got comfortable with it.”. “I’m sorry Sarah. I really appreciate your willingness to stay with me. That means a lot. Let’s try to get over there quickly and I’ll see if I can even get into that tree. If I can, then I’ll go up and try to get Ollie’s drone back. If it looks like there’s no way up to it we’ll be able to say we tried and we’ll go back to camp”.

We made pretty good time humping through the back country. Sarah, her caveats acknowledged, had no difficulty arriving on the far side of the lake with sunlight to spare. She didn’t come all the way down to where the tree stood. I think she didn’t want to be that near if I should fall. She did sort of run a monologue of how I might fall. I couldn’t get all the way up there. The limbs probably wouldn’t hold my weight. Though I did appreciate her concern and especially her presence I had to say to myself, “To Hell with that!” I was resolved to get up into that Pine, figure a way to reach out the 8 feet or so from the trunk where the drone was suspended and safely retrieve that thing! I can get very determined and willful when I have to. This was one of those times. I had flown my son’s drone into a tree on the far side of a lake and I could not go back to camp without doing my absolute damndest…without pushing my limits to their utmost so I could to return it to him.

Sarah and Charlotte sat on a naturally formed granite bench about 50 yards up the slope from where I stood testing the the strength of the lower limbs. From ground level it looked promising. The limbs started only about 4 1/2 feet up the trunk and were about 5 inches in diameter. That should be strong enough. The spacing of the limbs appeared to be such that a climber should be able to reach from one to another without having to be a contortionist. I shouted to Sarah, “The limbs seem strong enough. I’m going to give it a try!” “Just be careful Miguel!”, came her reply.

I turned my cap around with the bill toward the back of my head, reached out gripping the dry rough bark of the first branch and hung my weight from it. 200 pounds is a lot to ask of a tree limb to hold. No problem. No crisp crackling noises like the wood was going to pieces. No sagging down. So I put a foot against the trunk, leaned back and pulled myself up into that pine. Once I was standing on that lower limb I could see there was a little issue. There were going to be spots where I was going to have to use little dead limb stubs to transition from branch to branch. That could be a problem. “If I’m going to fall that’s how it will happen”, I thought to myself. Better just test one of them now, while I’m still only a few feet up to see what happens.

These stubs are just about four to eight inches long. They are dead-wood with no bark and many of them are cracked and look to be just dangling from the trunk, waiting for the next breeze, or chipmunk to knock them onto the rocks or into the lake below. 200 pound chipmunk…Jesus Christ, what am I doing? I’m not ten years old anymore. My best tree climbing days are clearly far far behind me. Do I really have any business at more than halfway through my fifties assaulting this dignified, centuries old sentry of the mountain lake? Stop it Miguel! Those thoughts are not going to help you get all that way up there and complete your mission. It is time to simplify your thoughts and refine your focus. Take a few breaths and become one with the tree. Envision your success and then perform the physical steps that bring you to it. You still have that ten year old tree climbing aficionado inside you. Access him and bring that drone safely down.

Upward I continued, testing each branch, each stub, with first a little weight and then more, satisfying myself that that would not be the one to give way. By the time I was fifteen feet up I was crawling with ants. They were everywhere! At first I thought there was just a line of ants in the lower branches and once I was higher I would be out of them, but they were in every inch of the tree. I tried brushing them off. There were just so many! I got the ones off my neck and face and carried on. Every few feet I had to swipe some more off, the most distracting ones anyway. You have got to be kidding me! This is how it’s going to be? “You have gotten yourself into this situation Miguel”, I chided. “These damn ants are just going on with their lives. You go on with yours”. Refocus. Calm. But “Shit!” They’re getting in my nose and mouth! Fuck it! I’ll just have to my best to ignore them until I get back down.

Let me just say that the bark of this old tree is really sharp and jagged. It is scratching up my skin something fierce! It’s beginning to burn on my arms and legs. At least it almost gets my mind off the ants. Am I breathing this hard because I’m exerting myself at 7’000 feet elevation, or because I’m nervous I wont be able to get the drone back safely, or because I fear I may fall out of this ant farm? Not sure, but I certainly am not used to breathing this fast. Just slow down a bit. Not much further to go. Make your movements deliberate. Now is not the time to rush.

I can’t say how much time I’ve spent in these prickly, ant crawling pine boughs, but I’ve finally reached the level of the drone. The red and green lights are at eye level. Looking down I’d say at least 40 feet up. In against the trunk as I worked my way to this point I haven’t had any real reason to worry about falling, but now I am faced with the problem of how to reach the drone that looks like it’s more like ten feet out the limb than the eight feet I had guessed from the ground. There’s nothing I can use to reach for it. That means I am going to have to go out to it, hang myself ten feet out these limbs. Their diameter isn’t as broad up here as it was below. Hmmm, the branch the drone is in is pretty strong looking. I can put some weight on that one, but not all my weight. I wouldn’t trust it for that. About five feet down there’s another decent sized one. It looks like my best bet is to distribute my weight between the two of them… stand on the one below and hold onto the upper one, not putting too much weight on either. That should work. Hopefully. If one fails, I will need the other to do all the heavy lifting and keep me this side of the River Styx.

A few inches at a time I test the competency of the two limbs I am suspending my life from. Away from the safety of the trunk, where the branches are thick and strong, I continue outward. There is Sarah with Charlotte up the slope a ways. I don’t really know her that well. We have camped together up here with our sons, away from the rest of the group that once. We have shared carpool driving from Bonny Doon to Santa Cruz where our kids are in school together. Her husband, Sam and I are in the same loose-knit group known as the Bonny Doon Gentlemen’s Leisure Club. (Great group by the way!) We have been at numerous social gatherings where we have friends in common… that is what it is to be a Dooner. Everyone knows everyone and everyone helps each other out. Now she’s standing by me in this harebrained photo op come off the rails. She didn’t have to stay. I wouldn’t have blamed her if she had left. Would I have done the same for her? I would. Without hesitation. Does she know that? I hope she could guess.

Just a few feet more to go. At this point there’s a fair bit of dead material in the branches between the drone and me. That doesn’t reassure me. I want these to be the healthiest, most verdant goddamn pine boughs I have ever seen! Nothing to do for it though. This dead stuff is in my way. I have to remove some of it to be able to reach the drone. So I snap off a few little twiggy bits and drop them. It doesn’t occur to me that Sarah is going to hear this and think I’m falling. I’m just honestly not thinking about that right now, okay. Who are you to judge? Almost there. I move out a little further. Really. Not. Digging. This! A little further. What if I stretch? Can I reach it? Balancing as best I can I extend my arm as far as I can. I don’t want to test the good nature of these branches any more than I already have. But I have to. I can’t reach. Out I shimmy. Just another half a foot. Reach. Got It!

Unbelievable! I don’t believe it myself! I really, truly don’t. I have Ollie’s little Alpine White Mavic Pro drone in my hand. It appears grossly intact. I powered down the battery. I haven’t fallen. I am going to have to tell him what happened. When I get back to camp I shall have to confess what I have done. It is totally my fault. I did not maintain awareness of my surroundings. But I have rescued the drone. Well almost. I still have to get down from this high pickle, but compared to the climb, when I didn’t know if it could be done… the descent should be easy. Fold the arms and props into their compact positions. Stow it into the cargo pocket of my shorts. (It fits!). Get back in toward the central column of the tree trunk and down I go.

Once I felt my feet back on the ground I let out a grateful sigh. The worst had been averted. The drone wasn’t in the lake. It wasn’t in the tree. It was in my pocket. I couldn’t be sure it wasn’t damaged. It has some delicate parts I had no way to assess at that moment, but it wasn’t obviously destroyed. Now we just had to get back down to camp. After I get these ants off me. I was actually lucky. The ants weren’t too interested in biting and the tree was strangely absent of sap. The scrapes from the bark were the worst I had suffered.

The Sun had fallen below the horizon while I was up the tree. It would be dark before we saw camp. We still had to scramble off trail for a good distance, then it would be a mile hike over rugged granite down to the the streamside campsite where our families would be, worrying over what had become of us. I thought they would be anyway. But Sarah had called them. Her cell phone got reception all the way out there! So much for remote back country experience! She had already told them what had happened and what I was attempting. (That took some of the sting out of the confession I was going to have to make to my son). She called again to let them know we were headed back down.

It was difficult going at first, skirting over, around and sometimes through thickets of wild roses. The major feature of these flowers is not the flowers. It is the thorns. An unreasonable abundance of them. What function can that many thorns serve? Half as many would be twice what’s needed to deter any creature from wanting anything to do with them! I tried to hold them aside, or down for Sarah when I could. Even so this was the worst part of the hike. There was no rhythm and we had to invent our route, since there was not trail on this stretch. Charlotte didn’t seem to mind.

She guided us enthusiastically once we were back on the trail. We had to watch our step. Luckily no rattle snakes had encamped in the trail. They are common up there and enjoy stretching out in the evening. We never heard a buzz. No-one tripped as the twilight deepened.

Before long we were back at camp, where the others were finishing dinner. There was some saved aside for us. The confession I thought I was going to have to make was never needed. Ollie, mindful of the stipulation that I am to supervise him when he flies a mission relished this opportunity to tell me he is going to have to supervise me when he lets me fly his drone in the future. That little turnabout filled him with a certain pride and gave him a good natured way to show he had the upper hand on me. Fair enough. He wasn’t angry. He doesn’t really get angry. (I’m not sure how he does that.) He was gracious enough, not forgetting that he, too has had mishaps in the air. Nothing was lost. The drone wasn’t even damaged we determined. The trouble I was in had trickled away down over boulders and up into the air. I learned through heart pounding adrenaline to maintain awareness of my position relative to potential hazards. Best of all, now I have this tale to tell.

What Day is it?

What is that thing? That thing inside your head? That thing supposed to house your consciousnes?.  That thing from whence your intelligence is said to emanate?  That big morel or gyromytra suspended in syrup within the vault of your cranium?  That fragile friable sulci strewn blob?  It sure doesn’t look like much.  What is that thing?

Why, that is your brain.  A magnificent organ of electric impulses which is the one thing that sets us apart from the other animals, so they say.  No offense to the opposable thumb intended.  Nor to the form and function of our jaw, mouth and vocal chords that facilitate speech.  Let’s give the brain its due.  It coordinates the basic functions of life, but at the same time stores your memories, produces original thought, is capable of logic and reason and abstract imagery.  For some wizards it is capable of higher math. (Leave me out of that club).  For some, beautiful art. For some the stringing together and juggling of words that inform and move the reader. Imagination is the juicy stuff that your brain is capable of. It is where you gather the ether that emanates from nowhere and everywhere and manipulate it according to your own impulse and inspiration.

When you injure that thing, that brain of yours, all kinds of bad things can happen.   To varying degrees, depending on the nature and severity of injury and the area injured, your ability to process information can be disrupted, even annihilated.  Your ability to coordinate gross and fine movements of your limbs.  Tactile, visual auditory senses can be affected. Access to language can be lost. Emotional regulation that protects you from ungoverned outbursts can be utterly washed away.  You may not be able to comprehend what is said to you.  Or you may know exactly what you want to say, but be unable to produce the words.  There’s something called “Word Salad” where a person is speaking, thinking they are conveying clear thoughts, but what the listener is getting is a jumble of random words and sounds in no particular order and with no discernible meaning.

Concussion to penetrating trauma to cerebrovascular accident, they alter your mental functioning.  One of the first questions you often hear asked in assessing neurological function is, “What Day is it?”.  I rue this question.  And I’m not the only one.  But we still ask it. We’re trying to establish the person’s orientation to time (the way we gauge it anyway). Here’s the irony, and it comes from working a nurse’s schedule.  I never know what day it is myself!  So when I’m asking a patient what day it is in order to assess their neuro function I don’t know the answer without checking!  Doesn’t that just bugger all?  I mean it.  It’s embarrassing!  Does this make me a charlatan? I like to think not. I know where to instantly find the answer to the question, which is as good as knowing.

There’s a range of questions to answer and actions to perform that paint the clinical picture of what and where the problem is, what part of the brain is affected. But the imaging studies CT Scan, MRI, MRA really seal the deal, provide a picture of that brain of yours and pinpoint the anatomical , structural insult. Maybe your high blood pressure went untreated for too long. Maybe you were riding your bike or your skateboard without a helmet and stacked. Maybe your blood thinner worked a little too well and you just bumped your head ever so lightly. Maybe you have had a vascular malformation since birth, a slight defect in the vessels supplying blood to your brain that suddenly reached its terminal limit and ruptured. Maybe a bullet entered your brain, and maybe you chose to put it there. Maybe it was meant for someone else. It’s so easy to lose so much so fast without warning and be completely changed. A different person. But the same person. Who is that person?

When our brains are healthy, how much are they like each other? We each project our imagined reality based on our experiences and sensory inputs don’t we? Is it not true we each inhabit a world of our own creation which intersect the worlds of others as they are creating theirs simultaneously? Or are we all jumbled and crammed into one reality? Who makes that reality then? And do we, as individuals have any power, any authority to alter its velocity, its speed and direction?

As I write this there is a humming bird zipping from Salvia, to Peruvian Lily, to Jasmine in the courtyard where I sit. It’s making tiny rapid clicking noises as it sips nectar and with each short flight it makes that familiar Light Saber sound with the beating of its wings, that humming that , even with my limited hearing I can enjoy. The air feels slightly cool as we enter the middle of September and my mind wanders to the little stack of firewood I have outside in the yard and to the thought that I will need to get more. It would be nice to get it split and stacked and covered before the rains begin. My mind goes to my friends who also heat with wood and have trees down in their yards who have offered to get together and split it and divide it up so all can be cozy and warm this winter.

That’s the way my mind is wandering. Is that what is happening in the minds of the people around me drinking their espressos? Where are they coming from and where are they going…in their minds? And how about that Humming Bird? How much intersection and mingling of our perceived realities is going on right now?

Don’t ask me.

I don’t even know what day it is.

Do you?

What’s Your Thing?

Back in nursing school I had a teacher who, during a lecture on respiratory care revealed to us that she couldn’t stand phlegm.   “Phlegm is my thing”, she said.  She took a little tangential off-shoot, spontaneously (I think) to tell us that the thing that grosses her out is phlegm.  That is the one thing in the realm of the nurses job that makes her cringe, makes her skin crawl, makes her want to gag and leave the room.  She went on that, in her view every nurse has a “Thing” and hers was phlegm.  I could tell she was telling the truth, because she became jittery and and her body language said at least as much as her words about the way it physically affected her, even just thinking and talking about it.  These side tracks Margaret took and the physicality of her delivery made her lectures more memorable.  Interesting that it was not the material itself , but the personal divergence from the straight lecture that made it stick in my head, even to this day.

Every nurse has a Thing?  Probably true.  Could there be that one tank of an individual though that can keep on rolling through the worst of it unfazed?  Could be, but not likely when considering the broad spectrum of grossness we encounter.   So what’s my “Thing”?  It’s gotta be eyes.  If you could see me right now as I’m writing this, you would see it’s true too, because my posture has just changed and my face has gone sour.  I’m as transparent as glass.  More transparent.

Think about the eye for a moment.  What is it?  It’s kind of like a jellyfish… in the shape of a marble.  It’s just a bunch of flimsy, wet, filmy layers of material in a gelatinous glob all contained within some kind of membrane.  It’s not very strong but we lead our way through the world with our eyes right out front.  They’re pretty vulnerable when you think about it.  And what protects them?  Just a little row of hairs above and below?  Come on!  That and a bit of skin that closes over them?  Please!   It doesn’t seem like enough!  Not when you consider how heavily dependent we are on our eyes.

From time to time we get someone with an eye injury in the ER.  Most of the time it’s not too bad.  Something in the eye, or the sensation of something in the eye, that kind of thing.  But rarely we will get something more serious: Penetrating foreign body, ruptured globe, chemical or thermal burn, detached retina.  Most of my co-workers seem quite easily able to deal with these ocular emergencies.  Not me.

Before I was a nurse I was a bicycle mechanic for many years.  During that time there were several instances when I got fragments of metal in my eyes.  Two or three times I had to go to an eye doctor to get them taken out.  I still have a sharp memory of the pain.  There was no relief from it.  It was only bad and worse.  The unstoppable watering.  Blinking was torture.  Sleep was impossible.  Rubbing the eye, lifting the eyelid to try to get a fraction of improvement… there was no escape!  The eye doctor took out the metal that had gotten in my eye while I was cutting threads on a fork.  He showed me the offending material, the cause of my agony.  What a disappointment!  That tiny thing!  It was just the tiniest speck, almost imperceptible!  It was impressive the amount of suffering that could be produced by something so small.  My eyes are watering now.

Besides the foreign body I also had a corneal abrasion.  That eye doctor told me that that was why it hurt so much.  The surface of my eye had been scratched up by blinking and rubbing and had become swollen.  The good news was that although the cornea is exquisitely sensitive and painful, it is also one of the fastest healing parts of the body.  So after the crapola was dug out of my eye with a needle (He used a needle for chrissakes!) it did heal quickly.  In the range of possibilities, not a very significant injury, but enough to give me a heightened respect and strong aversion to eye injuries.

So when we get eye injuries I try to get someone better equipped to deal with them to take those patients.  I admit it.  But phlegm?  I’ll take phlegm all day long.  Blood, Barf, Melena, angulated long bone fractures… bring ’em on.  But please, no eyes.  That’s all I ask.  I’d have to say eyes are definitely my thing.

So, What’s your thing?

Open/Closed

It’s 6:30 in the morning.  I’ve just gotten to work.  I haven’t even put my bag down yet.  The knit wool beanie my wife made for me 11 years ago still keeps my head warm when an ambulance rings us down on the radio with incoming traffic.   The medics are transporting a mid 50’s male with a report of heavy ETOH (That’s alcohol) and they inform us the pt is very familiar to us.  

Take a deep breath

No sign of injury, they continue.  No complaints from the patient.  But he is difficult to assess due to the ETOH.   He is slurring his words and has been incontinent of urine.  There was an empty vodka bottle on the ground next to him.  He is being verbally abusive, but not physically combative…

I should put my things down and get a room ready.

– – – – – – – – – – – – – – – – – 

Next patient: a baby with a fever presents in the lobby.  She has been up crying on and off the whole night.  She has a runny nose and is teething.  Her eyes are red and puffy.  Her young parents haven’t slept.  This is the first time she has been sick.  They are full of Love for her but have no idea what constitutes Big sick vs Little sick and have no clue what to do.  Not their fault.  No-one teaches this stuff.  Maybe I can take the opportunity to begin a little education while they’re here …

– – – – – – – – – – – – – – – – – –

“Michael, your other patient is urinating on the floor and it looks like he’s going ot fall out of bed!”  It’s true.  The guy is kneeling, leaning against the bed rails and relieving himself onto the floor.  He does look likely to topple onto his head.

I swear because I care.

– – – – – – – – – – – – – – – – – – 

This exact scenario hasn’t played out word for word (Or maybe it has).   This is the kind of thing that can happen though.   This is a job that produces unavoidable interactions with other people.  Interactions I would never have under any other circumstances.  I don’t control who I will be interacting with.  Or When.  Or how they’ll treat me.  Or who else will be there enacting their own behavior at the same time.  I guess a lot of jobs have this in common.  I’m going to guess though that on the social, behavioral, functional continuum of individuals the difference between interactions one relishes and those one shuns stretches quite a bit wider in the ED than in most other workplaces.  That’s the premise I’m going with for this piece anyway.

It doesn’t take too much imagination to envision situations where a person in such a position will be in wildly different interactions at the same time, each with its own demands and challenges and requiring deployment of wide ranging, sometimes even opposite behaviors on my part in order to provide the appropriate” care” for each patient.  Each patient needs something different.  That brings me to the thing I do have control of.  That is how I will interact with each patient and family I come in contact with.  

Let me tell you it is not easy.   And after twenty years in the ER I still have a lot of room for improvement.  To that degree I have grown better at it, I owe thanks to my wife Cecile whose loving example has osmotically transferred some useful tools to me over time.  Through her steady and compassionate nature and her genuinely held belief that Love is why we are here I have been able to expand my capacity for compassion.  (A smidge)
Ideally I would be able to bring my same self to each interaction and have something of myself to give.  Doesn’t that sound awesome!  I would leave work every day feeling amazing if I could have meaningful engagement with each and every person I dealt with! 

But I can’t.

I have to know where to set the aperture for my heart and soul for each situation.  Sometimes a wide open setting is called for to provide the touch that will provide a spark and Healing will happen. When it does it’s sweet and the feeling can sustain you.   Maybe it’s just taking a little extra time listening when someone really needs that.  Maybe it’s just showing basic respect to a person who never sees it from others.  Maybe it’s sharing some of my own parenting journey with scared new first time parents and letting them know it will be alright in the end.   Opening up to the other person on a basic level can create a space where everyone walks away feeling good.

But

 Sometimes a total lockdown is required to protect myself from the damaging effects that could be inflicted on me if I let the wrong person too close in.  Usually it’s somewhere in between.  Make the wrong choice either direction and the things can get bad.  Fast.  I can, and have unintentionally hurt people’s feelings and angered them through slight misjudgment on my part.  Sometimes someone who really does need some help will abruptly bolt and I may not even know what triggered them.    I have been knocked out of my chair with a punch to the jaw I didn’t see coming when I let the wrong person get outside the field of my peripheral vision.  I have been yelled at, spit at, treated to sublime profanity and wretched propositions by men and women, young and old.  People have said they would kill me.  Over and over and over, but I think I’m still alive.  

 It doesn’t pay to be a perfectionist about this.  But I sometimes forget.  It is easy to fall into a trap of thinking I should have known how things would go.  It would be cool if I could just nail this!  If I could just snap judge it, Bam!  And get it just right.  Yeah.  That would make things a lot easier in the emotional dance we do with our patients.  I could be a better nurse.  I could be more balanced when I get home.

When I get home…  Oh my, I have 40 minutes of driving time to transform myself from the hardened gritty shit magnet or tattered soggy dishrag I have turned into emotionally, through the crucible of my 12 hour shift, into some semblance of an appropriate family man.  I use that drive as my phone booth to change, to shuck off the things my family never needs to know and deposit them somewhere.  I have to do this in order to be the person who is going to interact with a wife and three children who don’t inhabit the world of the ER.  If I don’t something will slip or bubble out in an awful way and everything will go silent and still and I will know.  Know that my costume change has not been complete and Nurse Michael is still not quite ready for listening and reacting to Kindergarten stories.  Nurse Michael is not quite equipped to help with high school homework or to show proper sensitivity when hearing about the difficulties of a Loved One’s day, which though valid, pale by comparison to what I have just slogged through.  Sometimes that 40 minute drive is not quite long enough to leave it all behind.

Sometimes though, on the drive I will try to remember each patient I interacted with during the day.  I want to be able to remember, so I can process things, or write about something funny, or reinforce the memory of something that went right so I can do it that way again.  But most daze it feels like trying to pull something whole out of a blender.  All the distinction of each individual interaction has been homogenized into a grey slurry and I can’t seem to access any of it. 

Usually though I can remember and continue to feel whether I had to be Open or Closed to do my job, and whether or not it had worked.


Feels Like Home

“Daddy, will you dance with me to go to sleep like you used to when I was a baby?”

Sure I will.   You know, just because you’re another year older now… just because you’re six doesn’t mean you’re not still my baby girl.  No matter how big or how old you get, you’ll always be my baby.

“I know that Daddy. ”

I have an important question for you now.  Are you ready, because this is serious?

“Oh Daddy!  You can ask me your question, but this better not be one of your silly ones.”

What I need to know is if you want your regular “Sleepy Time Playlist”, or if you want Norah Jones like we used to when you were a baby?  I don’t know if you remember, but we used to listen to “Feels Like Home” by Norah Jones.  That was how we started, before we added other music to make your regular “Sleepy Time Playlist”.

“I want Norah Jones.  That’s what makes me get sleepy with my head on your shoulder and you’re dancing, with just a little bit of light.  Is that how you’re going to do it?  Please Daddy.”

Oh yeah.  That’s the only way, if you want it like it was when you were a baby.  Do you remember I used to carry you all the way down the road to the mailboxes and turn around and come back to help you get to sleep?

“Well we should start dancing right now before I get too heavy.”

That wont be for a long time.

“How long?  When I’m nine or ten?  Because that’s coming too soon Daddy!”

It’s a long way away.  When you’re nine is still three years away and when you’re ten is four years.  That’s a long time.

“Well I’ve got a great big hug and a smooch for you Daddy, because you’ll still dance with me”
This is how the talking went as my youngest began to quiet down, needing extra closeness. and a little movement, gently swaying and the smoky vocals of Norah Jones easing her off into Dreamland with her head on Daddy’s shoulder.  And for me, I could feel her little muscles softening as her grip relaxed and I wrapped my arms slightly more securely around her.  Her breathing steadied into a rhythmic warmth in my ear.  That moment stretched out, elongating in a shimmer barely perceptible but holding in it all the memories we’ve made together and the cradlefull of possibilities unformed before us.