lost weeks, lost lives

the last couple weeks were dark.
in this pandemic i found myself cocooned in my tiny apartment, contemplating the value of my life. if people i thought were my friends and family could not be even bothered to wear a mask, how much does that say about how much they value the lives of us healthcare workers who have to take care of them when they invariable become ill? 
i was plunged into the realm of telemedicine, which initially felt like such a blessing, that i can remain employed, safe, and still helpful. as the weeks have drawn out and i've had to spend my time dealing with nearly invisible rashes and getting them a test so they can have a boob job or letting them come to the lab to check for allergies so they can decide whether or not they can get a dog -- i felt like a failure. it felt like i was failing to uphold the most sacred duty of my profession, which is to heal and protect.
my isolation, which i'm sure was echoed in other small apartments and rooms across the nation, became emotionally amplified because of this. not only straining against the painful physical isolation as a single person, but the emotional and existential isolation caused by observing the actions and attitudes of my community.
even work began to feel unsafe, with reports of tire slashing. an elderly staff member was assaulted in broad daylight and could have died. i saw more security and police officers in the last couple weeks than i had in the last several years.
in the dark, between moments of uncontrollable tears, i started to plan.
i knew this was wrong. so i reached out to crisis counseling.
my friends, whom i actually felt isolated against, risked their own space to come to mine. they helped save my life.

and reflecting on this now: though it was empty and vast, the only danger during this time to myself was myself.  i felt overwhelmed by the outside and the inside that i forgot my privilege.

never in my life, for example, had i ever thought a police man would kill me for nothing.

week 5/6

i think this is a rather common experience for those of us in outpatient primary care - the feeling of, what more can i be doing. i do feel really sheltered because of who i work for (large group), how i work (schedule largely laid out for me), and who i serve (higher socioeconomic class).  i think many of us may be experiencing professional existentialism - if i did not go into the job to serve and protect, just what am i doing? a struggle between required heroism and self-preservation.

week 4

this week i spoke with a very angry young man.
he was black (his photo was in his medical record). identified as being from west oakland. and very upset why he could not get the care he perceived he needed.
this is a common occurrence already. it mostly came from the privileged, entitled demographic. and to be fair, i did not know much about his socioeconomic situation. however, as we spoke, it seemed he had a profound illiteracy for his own health. i reviewed his last actual in-person visit with an urgent care physician a couple months ago. he was given recommendations and treatment. and two months later he is calling in for more treatment, somewhat inappropriately, because by his own admission he had failed to adhere to the first.
it would have been very easy, i think, to get in a battle of frustration with this young man. frustration on our part because he was not following up as recommended, and then barging in to the clinics, against all public advice to call in advance, ostensibly not wearing any type of protection because "coronavirus is a hoax."
i think after "discussing" his medical issues (quotes because, it was largely him being angry and not understanding/accepting my explanations), this was the thing that stunned me the most. i couldn't even be angry, i was so shocked that he would say that. "if it's real then tell me why they're all these construction workers around then"
it burst the bubble i've been sitting (very comfortably) in for the last few weeks. presuming that people would understand the "right" and "wrong" thing to do. as if everyone had a basic working knowledge of germ theory. and had the inclination to listening to the large institutions from which they are disenfranchised from in the first place. and even if they did, the resources to comply.
yeah, he was angry. he had every right to be angry.
what was i to do? tell him never to come and only accept treatment over the phone? "i'm paying so much money to you guys and i'm not getting xyz."
what is the individual primary care doc to do?

week 3

every day, i walk by a tibetian prayer center. in the front yard, obscuring the front entrance, is a cherry tree that in the last few weeks has been bursting into white clouds. i would sing a song in my head i learned in grade school about popcorn popping on an apricot tree. wrong fruit. the streets would be relatively still. it was often gray and rainy. no noise save for distance traffic and the click of my boots on the concrete. i would stand at a crosswalk waiting for the light to turn, only as a gesture, as a matter of course, because there was no one around to wait for them to pass.
i went to Oakland on wednseday morning to get onboarded. i rounded on a single person as practice. it came back quite naturally. the whole ceremony. gestures to walk through. standing at the door, quick chat with a nurse, coating my hands with hand sanitizer. walking up to the bed, introducing myself. the cursory exam. sitting back in the doctor's room, stumbling over the overwhelming maze of digital information to peel back the relevant bits.
one more patient testing positive. he went to the ER, and was obs'd.
one more week of waiting.
i am rather nervous for the future of my career. what is it going to mean to practice medicine from now on?
yesterday i noticed the intermittent rain pelted all the fluffy white cherry blooms of that tree into the ground.

everything depends on the red wheelbarrow.

week 2

this last week has been a lot of waiting. a lot of the initial fear and nerves are, well, not gone, but in the background. taking it day by day. ear to the news - getting called in, might be 24 hrs notice.
turning inward. small stuff. petty stuff. on one hand it's been a relief getting this gift of time to finish things in the office - reviewing charts, ie. but on the other hand, just a growing sense of dread for what will happen once people start coming to the office again.

week 1

things were relatively quiet in terms of the outpt world. a lot of time spent getting oriented to working in the urgent care/green zone setting, inpatient setting. nothing remarkable happened, except for a day where there was drama with one of the MAs and she threatened to quit.

the isolation is not helping much. i appreciate my girlfriends so much, letting me express my views and fears and doubts about what is going on. with my dance acquaintances it's pretty apparent that i don't fit in when physical presence is not required. i am making a choice to try to continue to insert myself in this group of people but ultimately they have no idea what i do, nor do they really care.

even though we are given this precious gift of time to prepare, instead of being very motivated and productive i find myself drawing more and more inward. i think i've already established my fear is not so much for myself. i think i am more afraid of causing more harm than good. i also fear for what the rest of my life is going to look like. if it is short, how will i spend this time? instead of plunging into work and work and work - should i be taking a different approach? instead of trying desperately to leave a footprint in others lives, should i just focus on "being" and becoming individually satiated?

I was trying to handwrite a will the other day. it is difficult.

the crown

in the last few weeks, i have thought nightly, in between burying my conscious brain in the sewage of youtube and social media, about my own mortality.
who could have predicted this reckoning? a plague, people are calling it.

i recently started talking to a complete stranger via video and phone. i disclosed to him, how unafraid i feel towards death. that i would rather die doing something meaningful than nothing at all. he was taken aback. he is only a couple years younger than me. "i don't want to die." neither do i (today) (dumbass), but if i were faced with it - well, i should like to think that i have been exposed to it enough to tamp down the insane fear of it. that is: if i were dying for a cause...i would go quite gently into that good night. i have an idea of what that journey entails.
until then, yes, i am terrified. terrified i will do a bad job. that i will harm, instead of help.

a new resolution. to blog something daily. to leave some trace of myself during this time. even if my physical body remains, i suspect this type of fire will leave me and everyone around me changed forever.

i think i would like to continue documenting the bad cases. as well as the good. the outpatient world has been rather mundane, with several notable exceptions. reading my old posts from the inpatient days (what a gift to myself, to have documented some - like a goldfish, i would never have been able to recall any of it), it really does seem like i made the right choice. wasn't cut out for it. and yet, here i am. on the precipice of being called back in to war. and suddenly i wish quite deeply for the mundane again.

some beautiful moments: on march 30, national doctor's day, someone bought ten pizzas for the entire clinic.
every other patient i talk or email to expresses their thanks, gratitude, and empathy for those of us in healthcare. i remind myself, i get the privilege of taking care of some of the most wonderful people in the world. (i also get the dubious honor of taking care of some of the worst people in the world, but never mind this for now)

tomorrow, training begins.

post-dc

i am appreciating clinic for its low key nature. it has bothered me at times, the feeling that i need to prove myself to a specialist, just to seem competent.  that never feels fun.  i know that overall i am vaguely competent.  but not excellent. that does bother me.
the rest of my life is such as mess that it feels overwhelming to strive for that excellence.  and what does that mean, anyway?  that i have to be on call essentially, available 24/7 for my patients, most of whom are about as privileged and well as i am?
i wish it was more clear from day to day if i am doing the right thing by these people.  of course real life is never as clear cut as a board exam.
day to day i also ruminate on my secondary boarding -- where do i want to go from here?  there isn't anything that i am doing that necessarily is above and beyond something a fourth year osteopathic student would do.  long gone are the days of shared meditations with my patients, working in the fluid, the ether, the embryonic zones.  a part of me scoffs, easily, at those times -- the idealism of an ignoramus.  the feeling is like a past lover.  you wonder how you could have been so silly.
but also, here i am willing to shell out hundreds of dollars for that treatment for myself.  i'm not sure what this represents for me and my journey in health and as a healer but i hope that someday it will lead to something good for the world.

A jumble

sometimes it feels like everything is scrambling, scrambling, scrambling, on low heat.  if you're gordon ramsay, then also with tons of butter.
today was just a jumble of cases.  i don't think i felt good about any of my discharges.
every day makes me glad that i wont be doing this anymore.
jaime tries really hard to make me feel better about the work here.  he inspires me sometimes to be more likeable.  always, until i realize i will never be likeable.
another holiday season working. alone.
here we go again!

i am definitely listening to the DMX/reading rainbow remix on repeat.

another one i guess

so yesterday, it was deja vu all over again.

i can't help but think it was the exact same thing.  patient with cancer, liver. unclear etiology. presenting with abd pain, nuasea, vomiting, distension.  she'd already been treated with NGT.  surgery'd already signed off.  and yet things turned from bad to worse.  she coded.  i was present, standing in the corner, impotent as the code leader, looking towards the intensivist who was already in the process of intubating her as i arrived.  and today, she died in the ICU.  i heard the wails of her daughter at the other end of the unit.

i wonder if i shouldn't have dropped an NGT tube.  I wonder if i should have been more persistent in getting surgery to come back.  i wonder i wonder i wonder.

part of the reason i feel i am not fit for inpatient is just this.  the tendency to ruminate.  i could have done all those things and the outcome would not have changed; this woman was fragile, a cirrhotic from drinking so many years.  and yet, i can't let go of the what-ifs.  and certainly, i am not the first person that this (sudden and rapid outcome) has happened to (arguably this has not "happened" to me, but i am choosing to put myself in the center of this scenario). but i can't help but feel ashamed, a little disgusted at myself, scared, angry.  like, an unwitting murderer.

one thing that bothers me about this case is how unaffected i feel, in comparison to patrick.  his death devastated me.  and i had only known him for less than a day.  i had been rounding on this lady for a couple days at this point.  i am not sure what the difference is.  maybe after the first couple deaths, one starts to get "used to it?"

if that is the case, then i surely am in the wrong field.  i don't want to get "used to it."  i don't want to be so jaded (as a defense mechanism) that i stop caring about the human side, the family side, the meaningful side. 

her death, i will carry.  as i have patrick's.  even though my shoulders are around my ears as i'm hunched over the computer, stressed, walking down the hallways as if trying to make myself like a mouse, like a ghost...their deaths weigh on my neck like elephants.  reminding me with every breath, that for some reason i am here and they are not.

horrifying

i forgot who i was talking to, but someone mentioned that for terrible/interesting cases, one should document it for posterity and future reflection.

yesterday i admitted a 28 year old man with past history of alcoholic pancreatitis, complicated by a pseudocyst.  his belly was soft and not particularly distended.  i thought this would be a quick few days of managing his pancreatitis and withdrawal and sending him on his way.
today i get a call from the radiologist, that on the follow-up CT i ordered he was noted to have a 12x10x14cm complex mass where his previous pseudocyst was, with possible solid components, hemorrhagic components, and intraperitoneal hemorrhage/ascites.  that morning, his hemoglobin had dropped from 11 to 6 without hematemesis, hematochezia, or melena.

it was so completely overwhelming.  i was just thinking, well i have to get surg, IR.  then i couldn't reach IR, the operator had the wrong number.  i was so despondent by the fact that this guy could potentially bleed out into his stomach and die, and it would be because i couldn't find someone smarter than me to handle the situation.

i think i will be forever grateful for the GI specialist.  he gave me some reassurance about the case.  he even told me that he himself reached out to a surgeon he knew at a nearby hospital for advice! and ended with some feedback to always call him with this type of complication.  he didn't think the patient was actively bleeding into the pseudocyst, that it was old, and that urgent imaging/IR/transfer was probably not warranted right now.


i remember my first really memorable case working here.  an elderly japanese-american woman coming in with AMS.  the next day, i happened to be there the same time as the ID doc.  he had enough gumption to roll the patient over, which i did not do.  and lo and behold, along her midline lumbosacral area following a dermatome, she had a vesicular rash.  her csf later tested positive for VZV.  my first zoster meningitis.

i remember a near-miss.  a lady with history of renal transplant, then subsequent colon AND lung cancers.  coming in with UTI.  i was about to send her home on her regular home meds when the renal specialist noted her pancytopenia and said, you have to call her transplant team before you let her go.  and that's how i learned that transplant medications should be changed depending on certain situations.  oh boy, i was so angry with myself that i didn't know even the basics of transplant medicine.

and another near-miss!  an older man with history of renal transplant, with ESBL UTI whom i had to send home on meropenem, forgetting that i had to discuss with his nephrologist prior to putting in a PICC.


oftentimes, i feel that i am not cut out for inpatient medicine.  compared to where i trained, the cases at this institution are so complex, and then i've never done inpatient onc in my life, and it seems like every other person in this goddamned town has cancer.  this week alone i had three patients with brain masses.
this has been an important learning experience.  sometimes, i justify quitting, telling myself "it's my personality, i take things too hard, too much to heart, as opposed to thinking through them in a calculating fashion."  or, "i am just too stupid to do this."  there was a click-bait article that i clicked on, "amateurs vs professionals."  one of the items on the list is,

• Amateurs give up at the first sign of trouble and assume they’re failures. Professionals see failure as part of the path to growth and mastery.

i sure hope this is what a natural path feels like.

trauma based care

i was just thinking about some things i've seen on social media: white people complaining about being called racists, the apparent "resurgence" of the KKK and neo-nazis, the accusation that the BLM movement is the "same thing."  wondering how it all came to this.

this week i took care of a 90 year old patient who was diagnosed with cancer for the third time.  his family wanted everything done, and then proceeded to verbally shit all over the physicians, nurses, case managers, and social workers involved in his care. they were hostile, pugnacious, and even arguing amongst each other.

i think i get it.  it was really hard to take.  you do what you do hoping to make a positive difference.  all of us are doing our best, navigating a broken system, to provide health for our communities, because we believe it is the right thing to do.  we lose sleep, lose touch with our loved ones, get behind on self-care and life in general, because we believe in it so strongly.  and then to turn  around and get that kind of treatment from the people you are trying to help -- that is difficult to bear.

but, i'm beginning to realize, the moment you make this about yourself, and not the person at hand...you've completely missed the boat.

i have no idea what kind of experiences have led this family to this point today.  poverty, emotional and physical trauma, here, abroad, access to care....i have no idea.  and even if one of them calmed down enough to talk to me, and even if i had the time to listen, i would still have no idea, never truly understand.

that doesn't mean i stop being their physician, and just dump the case. we all keep trying, morning into afternoon into evening into morning, putting on a pleasant face, providing constructive data and options even though we know they will all get shot down immediately.  because there is no other alternative.  because we have to keep trying to work as a team. or things will never get better.

i took care of a 60-year-old woman who was found down in the field and near death from DKA. as she came to and an entire team of people began to piece together her history, it because apparently she had a history of psychiatric illness, polysubstance abuse, and was in a poor/dangerous social situation.  as she became stable and more with it, as part of a cognition evaluation i half-jokingly asked her if she knew who the president was.  "Trump, and i'm glad i voted for him," she said with a smile.

of course, inside i raged, because it was so easy to take personal offense to this.  a person for whom it is become more apparent by the day that she is reliant on public resources, proud to defend a man who is by all accounts a sociopath.  a man who poses a danger to the very systems she relies on just to live her life.  but of course, i have no idea what she's been through to make her feel this way.  our systems ARE fundamentally flawed.  i've heard the struggles first-hand from the patients i took care of through the county clinic during residency, patients who despite living similar traumas are thoughtful, decent, and making the "right" decisions about their health and well-being.... and are still struggling.  the minute i made this about myself, about my own opinions about politics, my own judgements of this woman's life choices, i was blinded by indignant hatred for this lady.  and that is not helpful.

when i see some of my dear acquaintances on social media become consumed with their own outrage, despondence, depression about what is going on in this country, unfriending/unfollowing every dissenting opinion, i get it.  i want to do the same thing.  but, to what end?  to take those feelings and turn around and channel them into hostility towards another, what will that accomplish? we have to work as a team.  or things will never get better.

resuscitation

life is motion, right?

many of us live in 2-D.  we stand up to awaken, we sit to work, we lay supine to sleep.  we hold a hand, one side's fingers interlaced with another. our time is linear.  point A to point B.
dr sutherland described the tide, a three-dimensional pulsation bathing our beings, an all-encompassing force greater than the to-and-fro within our vasculature, without which we could not exist.  dr jealous described the embryologic zones, a four-dimensional construct enabling him to describe why some of us are born and develop and live and die suffer and thrive the way we do in the physical world over the course of our existence.  the motion of development.  structure and function.  function and structure.

i always thought if i could have a superpower, it would be to fly and experience the world in three dimensions.  but on thursday, i discovered i had a different one.  it is the ability to experience it all in slow-motion.
i could hear my footsteps echoing much louder than they should for the soft shoes i was wearing, the sounds bouncing through my skull endlessly.  i could see in my periphery the bland walls moving by as i ran down the hall.  i could feel my heart stop as i saw the crash cart and ten million people in  my patient's room.  and then i could feel the entire world frozen, breathlessly immobile, as i saw them inside his room, standing over his bed, beating on his chest, yelling at each other, his feet flopping to and fro, keeping time.  his belly grotesquely distended. an impossible marionette.

and i saw, one by one, the faces of staff and family, as they crumpled in agonizing pain before all that was unfolding, in shock and disbelief.  i could see my patient's face as i remembered him when i saw him last night, wide smile, kind and forgiving eyes shielding his physical pain and the inner pain of the unknown, the known, and the realization he was too late. i could feel the soft warmth of his hand as i shook it for the last time.  i could feel the same hand gripping my throat and dragging my spine down into the floor as, after 45 minutes of cpr, he was pronounced.

what have i done.  what could i have done for you, P, that i did not have the knowledge or foresight to provide earlier?  could i have saved you?  could i have bought you precious time during which at least your family could come to your side and say their final goodbye?  have i robbed your family of that joy and sorrow and closure?

outside, the clouds moved briskly through the blue sky, and people toiled in the fields, and why am i still here and you are gone?

i feel you at my back.  i carry you with me always, as i do the faces of your loved ones.  it is heavy. and endless.

running

i stepped out of that cave of a dance studio around dusk.  the air was heavy and cool.  the clouds were backlit with brilliant yellows and pinks, and with smokey greys.  i hadn't heard anything out of the ordinary, as i was concentrating on stepping around the deep pools of water in the parking lot to not get my shoes wet.  then i noticed nails on the pavement.  and suddenly, there it was.  short hair, caramel, long pointed nose.  lean, with mouth open and tongue lolling about.  uncollared. unafraid.
it looked me in the eye, then trotted towards another dancer walking to her car, as if it belonged to her.  i was startled, but i figured someone just let it off its leash. i turned and got in my car.  as i was backing out of my space, i saw it dart across my front, then out of my line of sight.  i was irritated. the last thing i wanted to do was to kill a dog on accident after dance class.  i braked and rolled slowly to avoid crushing it, if it was still there.  then, i saw it loping away from my car in my rearview mirror.  relieved.  went down the driveway.
as i started picking up speed down the street, i suddenly saw her again in my rearview, running after my car and going into a full on sprint.  it was not the face of a rabid dog, nor a playful one. her eyes were piercing and dark.  as if to say, i am running too.  take me with you.

swing state

I have been thinking about my grieving process.  What constitutes healthy, mature reactions? How do I prevent unhealthy reactions?
My lack of resilience gives me great anxiety, ironically.
But I think this time will be different.
I am nearly crossing the line over which women are designated "advanced maternal age."  Aside from my inconceivably crushing debt, I have nothing holding me back - house payments, children, involvement in politics.  Though I am sure the future ramifications are far more serious than I imagine them now...how can I stay silent through these times?
During morning report last week, the director felt it was appropriate to comment on the election.  He said something to the effect of, "so, all those minorities who are saying they are scared for their lives, they should quit their bitchin and moanin, because that isn't really a thing." 
Right then, right in that moment I saw my shackles, my shame.  Because as I knew instantaneously I should say something, I saw my future fellowship taken away from me, my name slandered from ever practicing in the area...career ruin.
If I could go back in time, I would say something.  Anything.  Just, something to let the room know that this is not right.  This is not okay.  This is the type of attitude that should be a crime to perpetuate amongst future healthcare providers.  This is a gentleman who is so completely ignorant of his bias that he can't see any other worldview than his own.  We CAN'T let this be normalized for doctors in training.
See something, say something.  See something, say something.
What do I have to lose?
Everything.
Say something.

meta

i have a friend who can be....how to put this gently....strongly opinioned, about our mutual friends.
more specifically,  strongly negatively opinioned about the life choices of others.
having known this person for so long, knowing the family background and traumas, i think i get it.  i think i get where the feeling is coming from.
at the same time, it makes me very nervous.  "but for the grace of god," you know?  all that.
i want to think i am the kind of person that loves my friends for who they are at their core.  whether fiercely ambitious, emotionally damaged (and/or damaging), or happy to be a shadow.
if feminism is the idea that both men and women have equal freedom to make the choices they want, and i identify with that, shouldn't i extend the same courtesy to our most close and important friends?
i've often wondered if it would ever be a good idea to share this with her.  how would you put this, without sounding like you are judging someone for being judgemental?
who am i to say anything?
but sometimes...when it comes up....all i want to do is throw my hands up and say, give her a break.  she's living her life. let's just be there for her.
i dunno.  is that so wrong?

it is never as bad as it could be

it felt right to tell you, at that very moment, the thing that was on my mind.  even though in my heart i knew it was not wise.  even though i had not carefully considered the consequences.
there was a beacon, dim over the dark hills, but we continue along the shore, the wind whipping at our back.
maybe it will be warm again, but for now it's only me in this eddy, swirling, contained chaos fucking with my train of thought.

what it is

the first thing that comes to my mind is the softness of his arms.  the way they formed around me, perfect, tailor-made.  solid.  when i rested my lead-heavy head onto his chest, becoming enveloped by the warmth, vibration, heartbeat.  the hair and air and skin and muscles and tendons and bones melting away into nothing.  becoming distilled into something primal, living in the seconds between the seconds within the seconds.  civilizations born and rising and dying on the outside and it would not be bad or okay but just be.  a transcendent mediation that would only be broken with a human sigh, or a gentle borborigmo, or perhaps the start of soft, soft snoring.

dive

the van stopped at the end of a dirt road, off the main highway, by a chain link fence.  i remember getting out of the vehicle, towel in hand, breathing in the muggy, amniotic atmosphere.  we slipped through a chain-link gate, haphazardly shackled, and into the jungle.  the path was narrow but well-worn, darkly muddy, plastered with rotting black leaves.  i tried to focus on protecting myself from the myriad of mosquitoes that descended upon us hiking the path like starving children.  keeping my eyes to the ground, i noticed that the leaves were all uniformly angled...black triangles.  it was several meters before i realized they were hundreds of thousands of single butterfly wings.  i picked one up in curiosity.  the body was completely torn off; only the wings remained, black as obsidian, streaked with shards of iridescent blue.  no idea what species this was.  the macabre path was paved with them.  What was eating these butterflies, i wondered outloud.  The question hung in silence.  The guys didn't seem to care much.  They were as foreboding to them as the carpet in a casino. We hiked, the sunlight oozed through the canopy in patches, and the jungle rustled. Despite the humidity, a shiver went up my spine.
The path eventually broke into a small, picturesque cove, with crystal white sand.  Straight out of a postcard. Not a soul within shouting distance.  The clear sea was as hot as a sauna, the air above the waterline shimmering with energy.  I followed them down the sand to a large pile of boulders that lay at the base of the cliff and we started to climb with hands and feet.  The tall, slippery jet-black rocks interrupted the path with gapes so wide it seemed we would fall through and end up like James Franco in that terrible hiking movie.  We all slipped more than once, with a cry then a sigh of relief.
At the top, through the dense brush was a human-cut path.  And at the very edge of the cliff, the precipice: the cove, the ocean, the glittering horizon.  the heat of the land beat from below, and the sun from above.  a hundred feet or so below, you could see the rocks and fish below the blue surface.
i stood a foot from the edge, taking in the horizon.  At that height the world stretched out before me, endless, mysterious, wonderful.  time stood still.  there was neither the regrets of the past, nor worries of the present living within my head and heart.  only the infinite blue sky, and the kingdom of the sun, the lush forests, and the shimmering heat of the ocean water.  the humid air like molasses.  the infinite scenarios racing through my minds eye.  striking the rocks on my way down crept into my mind. perhaps never coming up after hitting the water.

i remember the end of the falling.  it was like a roller coaster, the inertia of my internal organs finally succumbing to gravity and pulling my nerves and veins and fascia down, down, down to the core of the earth, dragging my stomach with it.  everything became a blur of green and blue.  then, hitting the water, as warm as my blood, and feeling the salinity in my nasal cavities, feeling myself curve into a fetal position, the bubbles of my entry into the sea pushing me back and back towards the surface.

then, surfacing. gasping.  treading. buzzing...

getting back

as my training period in central california comes to a close, i've realized that a lot of my unhappiness and unrest comes from being so tunnel-visioned.  the "light at the end of the tunnel" certainly puts most of these struggles ("struggles") into perspective.

i want to think that i will come away from residency a little bit more kind.  even though i've had jobs and some (albeit very unique) life experience prior to choosing this profession, i realize that some of the baggage of my past that i'd refused to address turned again and again into small fires that smoldered behind me, dissolving bridges into smoke.  but as i learn to forgive and to nurture, i experience that universal, cliche-sounding truth: that you cannot love others until you love yourself.
my heart is so full at the moment.  i have never felt more content.  even reacting to things like not getting along with people at work, or doing something for my patient that was not evidence based, or feeling like i am just never enough -- these seem to fade more and more.  the storms that one creates in their minds, completely driven by nothing other than self-criticism and self-loathing.  to be able to step back, let all that go, immerse oneself in love and creativity.  like the entire world is open to me (even though i know it is but a fraction of a fraction).  how privileged i feel....!
i am grateful to live in a time, in a geographic location, where people can feel safe to explore their personalities and preferences, where they can feel empowered to speak up for the benefit of their families and communities. 
i am grateful i have the resources, physical and not, to drift seamlessly between cultures, cliques, environments.  daily i meet patients who were not and will never be living with that type of privilege.  i feel deep humility.  who am i to deserve these wonderful things?  (and i can't even get some diagnoses straight...)

i heard one of my pregnant patients, at 9 months, was in an MVA and had a pole go through her chest.  both her and her baby boy are alive.  incredible.  i live in an age where an event like that is not a death sentence.  that is mind-blowing.

i had my heart broken in the worst way (the worst way in my own limited personal experience, haha).  but from there i had the courage to continue my training and to pursue a second boarding.  everything about this career has been humbling, but in the best way.  it's given me meaning.  it's helped me realize that though others strive for fame, fortune, reputation...that's just not me.  and that's okay.  people need the background players as much as they need the visionaries and the leaders.  and there is nothing shameful about being the harmony to someone else's melody.

i think the difference about what's going on lately is getting to connect.  Connecting with people with whom i have no doubts, no worries about judgement, no shared past negative events.  sparks of joy  in the most mundane.  getting to dance again.  exploring medical knowledge and ideas with little fear of repercussion.  it is never the same as the friend-cocoon i grew up with....though in a way, it is far more freeing.  i used to be so resentful about not having that safe friend-family.  it took me a while to realize that permanence is not a prerequisite for family.

i don't want to analyze too much, just enough so that when the next rough patch comes, i can read this and remember: yes, yes life is good.  and if i am kind, i will be enough.