Steinbeck's Texas

“I have said that Texas is a state of mind, but I think it is more than that. It is a mystique closely approximating a religion. And this is true to the extent that people either passionately love Texas or passionately hate it and, as in other religions, few people dare to inspect it for fear of losing their bearings in mystery or paradox. But I think there will be little quarrel with my feeling that Texas is one thing. For all its enormous range of space, climate, and physical appearance, and for all the internal squabbles, contentions, and strivings, Texas has a tight cohesiveness perhaps stronger than any other section of America. Rich, poor, Panhandle, Gulf, city, country, Texas is the obsession, the proper study, and the passionate possession of all Texans.”

John Steinbeck

mentors #2

#drredduke

mentor #1

communion

Time is a rarified commodity for me. Such is the nature of the beast of training to be a physician, both in the aspect of the hours demanded but also in the aspect of trying to stave off death for the patients. Caffeine and adrenaline are well known tools to any in the trade. Even relaxing involves an element of hurry. Hurry up and get home to furiously decompress. Always balanced against fatigue. Before it is time to go back and do it all over again. So even my beloved task of writing often takes a back seat to other more pressing matters, usually sleep. But one commitment I have kept is giving blood. I always make time for it. It has become a sacred ritual of remembering. It is a communion in the truest sense of the religious term. A communion with memories, motivations, unanswered questions, struggles, sufferings. Do this in remembrance.

pagers

There are few devices that trigger a more negative Pavlovian response than a pager.  At 3 am.  When you've been asleep for 30 minutes.  Because the last page was at 2:30 am.  When you are already sleep deprived.  And running on empty.  Apparently, there is no training on what is deemed a good, or appropriate page, what can be resolved with common sense or what can wait until the morning.  The hospital isn't Walmart.  You can't just walk in and get whatever you want.  At least it shouldn't be.

Good Page with Appropriate Response
"Doctor, the patient's heart rate is in the 130s and they are having shortness of breath."
"I'm on my way."

Bad Page with Forced Appropriate Response
"Doctor, the patient is requesting mucinex."
Silence..........."Mucinex?  At 3 am? Ok"  Click.  The patient wasn't congested when I saw them at 9 pm and asked them if there was anything I could get them for the night.  Again, not Walmart.

Worst Page with Restrained Response
"Doctor, I see you put in a prescription for lowermybloodpressure.  But I am looking at the patient's blood pressure and this is normal for them. Do you still want to give it?"

What I don't say, "no, a systolic of 180 is NOT normal NOR good.  And let us not forget another nurse, perhaps someone you may know since you're both caring for the exact same patient, paged me not 45 minutes ago to tell me about the elevated blood pressure.  Perhaps she can educate you about the dangers of elevated blood pressure since she seems to know more about it than you."

What I do say, "Yes.  It's ok to give the medication."
"Are you sure?"
"Yes.  I am sure that I want the medication I ordered to be given."
"What is your name, doctor?"
"It's the one on the order."  Click.

best line

Best line in clinic from a patient all week, hell all month.

"I'm gonna be your black mama.  Give me a hug."

what working nights is like

last resort

I walk in. Walk being the operative word. As I glance furtively about the waiting room, wheelchairs with their occupants of varying degrees of physical humanness sit close by their care giver. I don't belong here, here being TIRR. The Institute for Rehabilitation and Research. Or, THE Institute, I should say. When the congresswoman Giffords from Arizona was shot in the head, she was flown here for rehab. A bit of a reality check sets in as an internal dialogue begins. 

"I can walk."

"But some days, not so well."

"Yeah, but I'm not this far gone."

"Do you have a better idea?"

The voice is silenced as I truly am out of ideas. As are my other physicians. This pain management physician came highly recommended by my colleagues and friends in the palliative specialty of all places. How's that for dark humor? 

prescribed burn

Pack up all those phantoms
Shoulder that invisible load

Haunting that wilderness road
Like a ghost rider

Show me beauty but there is no peace
For the ghost rider

 

Shadows on the road behind
Shadows on the road ahead
Nothing can stop you now

 

It is my first weekend off in roughly four months.  By this point in my journey, I am thoroughly lost.  There is no cell phone service.  There is no map.  So I settle in and listen to the woods.  Off in the distance I hear a woodpecker.  The loneliness of the ratta-tat-tat echoes softly through the forest.  While I'm sitting there, I am filled with nothing but frustration at getting lost on a dirt logging road.  And drops of rain begin to fall.  I am not in my jeep and my car is far from equipped to handle this road if rain begins to fall.  And I notice the strangeness of this area.  Where is the underbrush?  At closer inspection, the trees have that characteristic black mark on the bottom, or at least the trees that have survived, of what follows a controlled burn.  I am in the middle of nowhere, on a dirt road, lost, threatened with rain and I realize I need a prescribed burn.  To clear out all the tinder that results in uncontrolled wildfires resulting in the destruction of the entire forest.  The metaphor of putting out catastrophic fires the last years of my life is not lost on me.  I take a few deep breaths of the pine scented air, climb back into my car, and methodically find my way back to civilization.

scribes

On why medical scribes are money well spent, especially in the age of electronic medical records, which unlike my iPhone, makes things take infinitely longer. 

quackery, nonsense and utter bullshit

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

He hands me a stack of papers and says, "I was told to give these records to you."

Hey, a patient that brings their previous medical records! Awesome! I am about to thank them but my eyes quickly glance over the first page. It is a genetic test. Talking about theoretical drug-drug interactions. Ordered by his chiropractor. A confused look frumples my brow quickly replacing the smile.

"Could you please give me a bit information on these tests and why they were ordered?"

"My chiropractor ordered them for me. And he told me to ask you about the results."

"So he ordered them and charged you, but did NOT go over any of the results with you? Is that correct? I want to make sure I understand this properly."

"Yup. He said that you would know what to do with them."

I certainly did. I wanted to put them through the shredder but now they are a legal document and I am bound ethically to them. I glance over them for 5 seconds which is 5 seconds longer than the "data" deserves. I spent nearly 15 years in research and know firsthand the utility of this stuff.

I reassure the patient, "none of this is surprising or concerning. And it is not going to change how I manage your heart disease and diabetes."

And instead of shredding them, I dutifully scan them into our system to be added to growing pile of medical records that no one will ever be able to make sense of.

that which lacks words

If we make it through the night
If we make it out alive
Lord have mercy and pray for the dead
And you say that you can save me
Don't hope to ever find me
And I fear I'm too far gone
Pray for the dead
There is a hell
Believe me, I've seen it. 

I've never written of him. At least publicly. The words remain beyond my grasp. Or, is it that words represent a poor description. A mere charicature. But he left me songs to which to listen. After all, music begins where words fail. A thinly veiled attempt to bridge that chasm of pain. To communicate that which lacks words. 

nurses

"Hey, doctor. Have you eaten lunch yet?" a nurse whispered to me.

I stop typing orders and look at the time on the computer clock. It's 11:37. "Hell, I haven't even had breakfast yet."

"We have a bunch of leftovers in the break room. We had a breakfast pot luck. Want some?"

This is what happens when you treat nurses as human beings.

atlas

The twisted and rusted iron well represent the Muscle, Sinew and Will. A Will which struggles against the load which threatens to crush him.  Down on the right knee.  The left leg unbalanced and straining but with the foot dug in to regain a position of strength.  Metal rust bleeds down onto the concrete base.  And what gives blood it's red hue if not rusted iron?  How many times have I passed this sculpture?  First, as a candidate for medical school.  Now, as a physician......the metaphor of Atlas has deepened with experience in ways I suspect I will never truly comprehend. 

listening for nothing

I place my stethoscope onto the chest and reflexively bend my head down.  It could be mistaken for supplication.  Maybe it is.  It also pulls the ear buds on the stethoscope snuggly into the ear canal.  Sometimes there are electronic noises from beeping IV pumps to vital sign alarms.  Sometimes there are crying family members.  But what I am listening for is silence.  No heart beat.  So I mentally block out all the noise, as much to give a moment of silence to the recently departed as anything.  A heaviness is present in that silence.  Soon it will be broken by speaking with the grieving family members or speaking with the nurses to fill out the paperwork.  But in that moment, there is nothing but heavy silence.

end of the rope

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     Every month I am a different doctor.  One month I am a family doctor managing patients in the hospital.  One month I am an ER doctor.  Next month I am a surgeon.  And you have to embrace that because they each approach problems very differently, and deservedly so.  But underneath it all, I am still me.  On this particular day, I was a surgeon, more specifically, a colorectal surgeon.  That may sound like a big stretch but not as much as it could be. I am one of those rare family docs who is also learning colonoscopies.  And if one is going to learn colonoscopies, learning about colon cancer comes with that.  It is my way of saving someone from having to experience bone metastases as without colonoscopies, we usually find colon cancer once it hits the bones.  And if you have read my blog from a few years back, you can imagine what bone mets feel like.  It ain't pretty.  And so on a day where the clinic day is colorectal patients, one can imagine a fair share of them are there for colorectal cancer appointments either as follow ups after surgery or to be assessed as surgical candidates.
     This particular patient had been referred by their medical oncologist to assess whether they were a candidate for surgery after they had completed chemotherapy.  A common scenario.  In fact, I had dealt with it two times already that morning, neither of which had any hope of surgery improving those patients' quantity or quality of life.  But the third one of the day.....they had completely mistaken notions of the results of the most recent CT surveillance scan.  Their cancer was not in remission.  In fact, it was back with a vengeance.  And I simply could not do it.  I could not bring myself to tell a third patient that day that their results meant that surgery held no hope for them.  Maybe it was it was because I was exhausted.  Maybe I was tired of playing the surgeon.  Maybe consoling two before lunchtime had left me devoid of any further ability to empathize.  Maybe I had reached the end of my emotional rope because of my own baggage with cancer.  Regardless, I let the attending tell them. 
     I felt horrible afterwards.  I apologized to the attending.  I felt as if I had let the patient down.  That if a family doctor can't console someone then what the hell is that doc worth?  The attending looked at me and reminded me it wasn't my job.  It certainly wasn't expected that an off-service resident should be able to interpret a CT scan and interpret whether surgery was off the table or not.  But for me, it was not about being able to make the medical decision.  It was about being able to be there emotionally for the patient.  I left that day feeling worse than if I had made an actual medical error.

ghost

Pack up all those phantoms

Shoulder that invisible load

Like a ghost rider

Just an escape artist

Racing against the night

A wandering hermit

Racing toward the light

- ghost rider by n peart

my mixed heritage

On one of the few opportunities where I was driving during daylight hours, I noticed this billboard. Someone in the Dutch company of Heineken marketing gets the Texas mentality.

obstetrics summarized

god has a horrible sense of humor

I am signing an order that needs the date and time so I ask the nurse. "May 22nd". Of course. Why else would my very first patient in the ER be one suffering from the horrific pain that bone metastases inflict? At the end of my shift, I was able to get them admitted to the hospital. And got a thumbs up from the patient. I will not elaborate upon what Herculean (and self alienating) measures were required to get to that point where a thumbs up is the best possible outcome one could wish for as a doctor. Instead, I look down at my left wrist, my familiar and well worn Mala beads rolled comfortably around my wrist. I roll one unnoticeably in between my thumb and forefinger, close my eyes, and become grounded to these ancient words which arose from my memory five years ago on a Sunday morning at 3:30 am. 

Through many countries and over many seas
I have come, Brother, to these melancholy rites,
To show this final honour to the dead,
And speak (to what purpose?) to your silent ashes,
Since now fate takes you, even you, from me.
Oh, Brother, ripped away from me so cruelly,
Now at least take these last offerings, blessed
By the tradition of our parents, gifts to the dead.
Accept, by custom, what a brother’s tears drown,
And, for eternity, Brother, ave atque vale
‘Hail and Farewell.’

an old man

     You can barely see them.  The four little dots of a band aids on my lower right back.  They represent yet another round of poking needles into my spine all in a desperate attempt to bring some modicum of relief from pain.  Most people can't tell I am in pain nearly every day.  I have become very good at hiding it. 

     When I check in at the front desk of the doctor's office, everyone has to fill out a form saying they will not drive and that someone can drive them home after the procedure.  But me?  I don't drive.  I walk.  I go back to work.  Besides who wants to know their doc is human?  We are supposed to be Superman, after all.  But my doc, who is incredibly talented with an amazing staff, can see the pain and the exhaustion it brings with it in my eyes today.  We both know we are reaching the end of what procedures are available to me. 

     "Am I even helping?  I want to make sure that I am actually helping you."

     "Well, since ablating the nerves on the left side, I can check my left blind spot a lot easier.  That's something.  But my pain?  The worst is deep down in that joints of that extra vertebra and with all this rain....it's bad....and I know there's nothing you can do about that......and I know there is nothing a surgeon can do about it."

     "I'm not going to lie to you or feed you a line.  Besides, I'm sure you've done your homework as always,"

     I interrupted and chuckle, "Yeah, I've done my homework.  I know that surgery realistically has very little to offer me."

     The sadness in her eyes told me everything I needed to know, "I know.  I could send you to one if you want but you already know the answer....you're one of my youngest patients....on the outside you look great, but on the inside...your spine looks like an old man."

     I remembered back to when I first started down this road of pain with my family doc.  He took an x-ray and we counted an extra vertebra.  I recounted it to her, "I asked him if I am like this now, what am I going to look like when I'm in my 60s?  He said, let's not think about that right now."  She chuckled in agreement.  And we went so she could stick more needles into my spine.

my old life

I sometimes miss my old life.  Wait, let me be more precise with my words lest I get lost writing all the things I miss.  I sometimes my days in research.  A project of mine from years back that was shared with another group within the company was recently presented at an endocrinology conference.  It felt good for our data to be included as most of my work ended up going into patents rather than publications.  And in the biological sciences world, publications mean more when it comes to hiring time.  A full publication should be following soon.

PP30-2 Fads1 Knockout Mice Are Lean with Improved Glycemic Control and Decreased Development of Atheromatous Plaque

Program: Abstracts - Orals, Poster Previews, and Posters
Session: PP30-Regulation of Body Weight Via Adipose and Brain Poster Preview
Basic

Sunday, April 3, 2016: 11:30 AM-11:45 AM

Room 258 (BCEC)

Poster Board SUN 600

David R Powell^*1, Jason P Gay¹, Melinda Smith¹, Nathaniel Wilganowski¹, Angela Harris¹, Autumn Holland¹, Maricela Reyes¹, Laura Kirkham¹, Laura Kirkpatrick¹, Brian Zambrowicz¹, Gwenn M. Hansen², Kenneth A Platt¹, Isaac van Sligtenhorst¹, Zhi-Ming Ding¹ and Urvi Desai^1
1Lexicon Pharmaceuticals, Inc., The Woodlands, TX, ²Lexicon Pharmaceuticals, The Woodlands, TX

Delta-5-desaturase (D5D) and D6D, encoded by the fatty acid desaturase 1 (FADS1) and FADS2 genes, respectively, are enzymes in the synthetic pathways for the omega-3, -6 and -9 polyunsaturated fatty acids (PUFAs).  Although PUFAs appear to play a role in mammalian metabolic pathways, the physiologic effect of isolated D5D deficiency on these pathways, and the potential value of inhibiting this enzyme to treat metabolic disorders, is not clear.  After generating >4,650 knockouts (KOs) of independent mouse genes and analyzing them in our high-throughput phenotypic screen, we found that Fads1 KO mice were among the leanest of 3,651 chow-fed KO lines analyzed for body composition by dual energy x-ray absorptiometry, and were among the most glucose tolerant of 2,489 high fat diet (HFD)-fed KO lines analyzed by oral glucose tolerance test (OGTT). In confirmatory studies, we used quantitative magnetic resonance spectroscopy to show that chow- or HFD-fed Fads1 KO mice were significantly leaner than wild type (WT) littermates; when data from multiple cohorts of adult mice were combined, body fat was 38% and 31% lower in Fads1 male and female KO mice, respectively (P < 0.001 for each). Fads1 KO mice also had significantly lower glucose (P < 0.01) and insulin (P < 0.001) excursions during OGTTs along with significantly lower fasting glucose (P < 0.05), insulin (P < 0.01), triglyceride (P < 0.05) and total cholesterol (P < 0.001) levels. In additional studies using a vascular injury model, Fads1 KO mice had significant 62% and 57% decreases in femoral artery intima/media ratio after 16 days of exposure to a copper-containing silicone vascular cuff (P < 0.01 for each independent experiment), consistent with a decreased inflammatory response in the arterial wall of Fads1 KO mice. Based on these results, we bred Fads1 KO and WT mice onto an ApoE KO background and fed them a western diet to create an atherogenic environment; after 14 weeks we collected the aortic tree of each mouse, stained it with Sudan IV to identify areas of atheromatous plaque, and found that the aortic trees of male and female Fads1 KO mice had 37% and 44% less plaque, respectively, than did those of their WT littermates (P < 0.05 for each). Importantly, 1) analysis of the arachidonic acid/dihomo-gamma-linolenic acid and the gamma-linolenic acid/linoleic acid ratios in brain and liver phospholipid fractions of Fads1 KO mice were consistent with the combination of markedly decreased D5D activity and normal D6D activity, respectively; and 2) our Fads1 KO mice did not appear to have decreased survival even on diets low in arachidonic acid.  We conclude that these Fads1 KO mice exhibited a beneficial metabolic phenotype, and that this beneficial phenotype suggests that selective D5D inhibitors may be useful in the treatment of human obesity, diabetes and atherosclerotic cardiovascular disease.

little m, little d

     The overhead page declared the need for a doctor to be present at the final moments of birth.  Again.  I excused myself from the woman in triage, who's need for medical attention just became much less urgent than the woman about to deliver.  As I trotted down to the delivery room, out of the corner of my eye I noticed EMS bringing in another pregnant woman.  Judging by the screams, she was in no small amount of pain.  And judging by the size of her belly, she was pretty much full term.  I entered the delivery room but was beat there by the OB resident.  She asked me to go check on the new one in triage.
     Back down to triage I go, consent already in hand knowing this woman was going to be delivering tonight.  As I approached the triage desk, the nurse already had her arm outstretched with her finger pointing back down the hall telling me she was already in a delivery room.  Back down the hall I go, my back beginning a litany of curses.  I enter the room and the delivery nurse, who has been at this much, much longer than I have, orders me in a firm voice, "gown up, this baby is coming now."
     And she was correct.  I got my sterile gloves on and she started pushing.  Not wanting her to tear, I quickly forgot about the gown and gained control of the head and the situation.  The amount of blood and other fluids that would be on my scrubs didn't seem to matter at that point. The baby was out within minutes without any complications.  As I turned to have someone help me with the cord, usually another resident or at least a med student to deliver the placenta, I realized I was all alone as far as MDs.  Just as I was finished the cord and placenta and began to make sure the uterus had stopped bleeding, the OB attending popped in.  "Everything ok?"  I don't think they like to look in the room and see only a family medicine resident without one of their own present.  "Just fine."  The delivery nurse confirmed that everything was under control. 
     My wife jokes that until I finish residency, my MD is a really a lower case md.  I have to earn that the right to capitalize it.  I think I earned a bit of that uppercase that night.

cleanliness

I walk into the call room, enjoying the mild muffling of the constant noise that a hospital brings. It's not a complete silence but it's close enough. I open the door to the bathroom and I am greeted by this scene.

I'm not even sure where to begin with this. I've been to the ER multiple times and hospitalized once forcing me to miss an entire rotation necessitating the need to repeat it. One ER doc suggested frequent irrigation of the now mostly healed wound. This is a hospital. Cleanliness ought not be a goal on par to the task of the Mars Rover. But when a toilet occupies the shower, words escape me. Specifically, a flow of four letter words escape my mouth. What maintenance person does this?

I move the toilet only to find the handle does not work. It slides on and off as easily as a toilet fits in the shower. But it fails to turn the water on or off. I pull a pair of rusty old pliers out of my backpack (don't ask) and use that to turn the shower on and off. 

I finish my shower hopefully thereby avoiding another ER visit but not without wondering about trying to keep one's sanity in a hospital such as this. 

iron therapy

writer's block

A photo posted by theoatmeal (@theoatmeal) on Apr 11, 2016 at 10:45am PDT

bravado

http://www.smbc-comics.com/index.php?id=1130

surgeons

I'm on my surgery rotation this month. I have a whole new appreciation for why surgeons are the way they are. Each pager represents about 10-15 patients. 

off

I've not been at my best of late. Which is to say, that when I say I have been struggling it is akin to saying that in June when the cicadas start their humming, it is a touch hot and humid. Two ER visits in three months for the same condition for which landed me in the hospital in November are certainly of no help to the matter either. The demands of residency are not little and having one's body refuse to cooperate compounds the struggle to put one foot in front of the other. But to rationally list my woes as if it were a To Do List, seems to reduce them to banality, nothing more than a math problem rather than a human experience. I decided I posted enough less than flattering pictures of others when they are less than optimal so turn about is fair play as this picture my mom snapped clearly demonstrates, I am not well. 

burn'em

How can this structure cause so much stress and pain in me? I pondered this while waiting to be seen by my interventional pain specialist. I get my first real chance at some pain relief by burning off some nerve endings in the left side of my spine on March 31st. After that, I start going through the process of getting the right side done. One would never think that "sticking a scope into my spine and burning nerves off" would sound so very appealing. But I look forward to like a kid on December 1st. 

Valentine's

"You sure you don't want a rose, child? Says a lot if you come home with a rose Valentine's mornin' after workin' all night."

I love the late night cafeteria ladies. 

things I've learned from the ER

Tworkocet - (noun) a patient who comes to the ER with some vague non-emergent complaint who wants a turkey sandwich, a note excusing them from work for said vague complaint, and a Percocet.

the many emotions of chronic pain

the many attempts to make the pain less

These are band aids from where I had a doc stick a wire into my spine not once, but 4 times. Then went back to work. 

how many doctors does it take to screw in a light bulb?

For anyone who has been in the hospital, you know the drill. You see the doctor for maybe 5 minutes once a day. At an academic hospital, you get residents. And you're lying in bed wondering what in the hell is the doctor doing? And why hasn't he or she written that order for the new medication? What exactly is taking so long?

Just how many doctors does it take to take care of a patient? It takes 5 residents to care of 8-12 patients 24/7, 7 days a week. And these are highly complicated patients. Some of them are worthy of a Dr House episode. 

We sacrifice our families to take care of our patients. We live at the hospital. We lose sleep over the ones we are losing. We even dream about the patients as it is so all consuming. We go home and read about our patients to see if there is a new and better way to help them instead of sleeping. We are doing things far beyond what a doctor normally does. We are scheduling appointments for them when they get discharged so they don't get lost to follow up. Sometimes we see them ourselves in the clinic. We are on the phone with specialists or other hospitals. We are on the phone with the pharmacists and nurses. We walk miles during one day making rounds throughout the hospital. We age ourselves at least a year in just one month. And at the end of the month, we are left smiling and proud of the work we have done.  Believe it or not, there are doctors who truly care. I just had the privilege of spending a month (it felt like six months) working with them. 

the many colors of pain

These are lidoderm patches. They are just one weapon in my armament of living with pain. Clearly, I cannot put these on myself. So I rely on my wife who does it best as she's had a LOT of practice. Other times, I rely on the kindness of nurses.

finding beauty

Pack up all those phantoms
Shoulder that invisible load
Keep on riding North and West
Haunting that wilderness road
Like a ghost rider

Carry all those phantoms
Through bitter wind and stormy skies
From the desert to the mountain
From the lowest low to the highest high
Like a ghost riderKeep on riding North and West
Then circle South and East
Show me beauty but there is no peace
For the ghost rider
- n. peart 

During a dark night of the soul, pleasurable things often drop to the wayside. Slowly, one begins to touch those old parts to see how they feel. First, with hesitancy and a quick withdrawal. With time, one grabs the thing, flips it over in one's hands, gets the weight of it, the texture, the smell. Photography is one of those things I recently started exploring. At a time, I could capture beautiful scenes while backpacking. But as backpacking fell off, so did photography. Now, by chance I've noticed my new iPhone has quite phenomenal optics. I still could do more with my old SLR camera but I'm learning to find find beauty in that around me. Sure the framing is off, the composition and lighting could be better. But it's early on. Here is a water wall of the McGovern Center for Humanities (proud alumnus) which I pass on the way home from the hospital. 

stress

     I've never been a great sleeper. I figured working long, grueling hours would make sleep a pretty simple proposition. After all, it's one of the top three priorities of residency, along with food and showering. But I wake up with nightmares. I wake up thinking about my patients. I have trouble falling asleep despite being exhausted. So, I fall back on to what I've used ever since my brother was diagnosed. I lift heavy things and set them back down. It transforms the anger and as a consequence, I fall asleep eating. This hand is what stress looks like. Mala beads as an ever present physical reminder of where I've been, who I am, and to never lose my humanity. Chalk covering my hands to keep the bar from slipping. The spiritual and the simple physicality. 

beginning the day

At 0:dark thirty, my day begins. The heels of my boots echo off the walls as I stride down to a computer and begin assessing the patients. 

Christmas lights

I rarely saw the sun, or even daylight in December, but I loved driving by this waterwall every evening. It graces the McGovern Center for the Humanities, of which I am a proud almnus. 

Impossible boots to fill

     "That man....do you know what he would do? It didn't matter where I was. He would walk straight to the back of the cafeteria if he had to and give me a hug.  Every day. This man was BUSY. How many doctors you know do that? Most don't even look their patients in the eye." Her eyes were starting to well up with tears. She was of course, referring to Dr Red Duke. Whether the person was the president of these United States, a cafeteria lady (or a med student), he treated everybody the same. 

     "If I turn out to be a fraction of the doctor he had in the tip of his pinky finger, I'll consider myself a success."

     "Uh-uh," she shook her head no back and forth. "You got to be BETTER than that. You've got some mighty big boots to fill. And you'll fill'em. You have to. We need docs like that."

     "Well, I know I ain't him, but I'll be the one to start giving you hugs."

     And a wry smile cracked her face. "You better live up to that. Don't make promises you ain't gonna keep."

     So I hugged her like my cousin taught me to.