Not Your Last

Do not hoard me
As if I were your last breath.
You will only force me
To prove again I am not.

You know the feeling.
I rush from your lungs
And in your certainty you
Feel your world slipping away.

Flashes of regrets and hopes
Hurry past in black and white.
You try to watch them like
Some ridiculous tennis match.

Even then you can't decide
If you want to grab
Them and weep on their
Beating breasts or go alone.

When the flashes slow
Like the final pops of
Already burnt popcorn, you wonder
If that's all.

"Becasue it seems unfinished,"
You comment, forgetting to gasp
And sighing instead.
Because it is.



Written October 15, 2007
Barcelona

To Pronouce

"Oh, she died," this resident was always smiling, "Yeah."

I knew she'd been terribly sick and dying. I just hadn't heard that it had happened. Forty-two years old. Metestatic pancreatic cancer. Eleven-year old daughter. Husband. Parents. She'd been in pain for months and experienceing what we technically call "mental status changes" for the past couple weeks. What it means is that her brain has left; it can no longer make sense of this life or her diseased body which clings to its command center to tell the lungs to breath and heart to beat despite the pain in every mangled fiber.

Mental status changes. My new patient today has them too. He has not awoken yet from the intubation (tube down his throat) and sedation he got in the ER where they treated him first before admitting him to the intensive care unit. His body is covered in the bruises he gave himself as his mind raged against the bacteria in the fluid around his brain and spinal cord. His wife sits at his side and holds his hand.

"Oh, she died." I was giving sign out to another intern. We both paused. All three of us paused, to recognize the passing of the mother and wife and daughter and friend. "Yeah," she explained, "we extubated her after we started the morphine drip. They called me to pronounce her about an hour ago." "Oh," I repeat dumbly. And the other intern draws a straight line through her information on the sign out. "Flatline," she says, trying to be humane despite the three patients she has just admitted but has not yet been able to see or examine.

Pronouce. Another odd ritual. "I pronouce you dead." "I pronouce you husband and wife." "I pronouce you born." Pretty presumptive this pronoucing business.

Do I also pronouce your love, your happiness, your bare feet in warm sand, your quiet teenage moments when ideas fly toward you faster than you can catch them? I pronouce you joy. If I could I would. Pronouce blessings into the corners of your existance until you are filled with the gratitude of this "precious life."

But that if for you to pronouce.

You pronouce you alive.

I listen for silence in your chest when your breath has flown for the last time.

I pronouce you dead.

Sunbeams October 2007 | issue 382 (abridged)

If the doors of perception were cleansed, everything would appear to man as it is, infinite.
-William Blake


The most striking contradiction of our civilization is the fundamental reverence for truth that we profess, and the thoroughgoing disregard for it that we practice.
-Vilhjalmur Stefansson

In order to live with integrity, we must stop fragmenting and compartmentalizing our lives. Telling lies at work and then expecting great truths in meditation is nonsensical.
-Sharon Salzberg

Emotions, in my experience, aren’t covered by single words. I don’t believe in “sadness,” “joy,” or “regret.” . . . I’d like to have at my disposal complicated hybrid emotions, Germanic train-car constructions, like, say, “the happiness that attends disaster.” Or: “the disappointment of sleeping with one’s fantasy.” I’d like to show how “intimations of mortality brought on by aging family members” connects to “the hatred of mirrors that begins in middle age.” I’d like to have a word for “the sadness inspired by failing restaurants” as well for “the excitement of getting a room with a minibar.”
-Jeffrey Eugenides

We say, “Seeing is believing,” but actually . . . we are all much better at believing than at seeing. In fact, we are seeing what we believe nearly all the time and only occasionally seeing what we can’t believe.
-Robert Anton Wilson

You don’t see things as they are. You see things as you are.
-Talmud

Once, when a GI was visiting Pablo Picasso during the liberation of France, he said that he could not understand the artist’s paintings: “Why do you paint a person looking from the side and from the front at the same time?” Picasso asked, “Do you have a girlfriend?” “Yes,” replied the soldier. “Do you have a picture of her?” The soldier pulled from his wallet a photograph of the girl. Picasso looked at it in mock astonishment and asked, “Is she so small?”
-Richard Kehl

There are very few human beings who receive the truth, complete and staggering, by instant illumination. Most of them acquire it fragment by fragment, on a small scale, by successive developments, cellularly, like a laborious mosaic.
-Anaïs Nin

If a thousand old beliefs were ruined in our march to truth, we must still march on.
-Stopford Augustus Brooke

Say not, “I have found the truth,” but rather, “I have found a truth.”
-Kahlil Gibran

The world is too dangerous for anything but truth and too small for anything but love.
-William Sloane Coffin

It was a day

“It was a day; only a day. You have a dark and troubled mind, My Lord.” The words float back to me in pieces. “It was a day.” I have just finished a thirty hour shift as the intern doctor in the intensive care unit. I smelled death this shift. It smelled like disinfectant they use to clean the bed after my patients die. I’d been the one to break the news to her daughter, Chandra, about her 60 year old mother dying. I persuaded Chandra to allow us to change the struggle to preserve life to an invitation for her mother’s death.

Initially, in the haze of shock, she did not grasp what I tried to tell her. “Your mother is dying,” I should have said. I learned it in medical school. Before that even I should have asked her what she understood about her mother’s condition. When faced with telling someone of her mother’s eminent death and with my own agenda of convincing her to let us withdraw live-preserving efforts, all I could say was: “She is very sick.”

“It is very serious. She is very sick,” I kept repeating like some scrub donned parrot paralyzed by fear of death and failure. I caught myself rattling off words like “pressers” and “breathing tube” in attempts to make her understand. Not yet ready to learn that she would soon be a motherless child in this world, Chandra ruminated her mother had felt well until yesterday. They live on the other side of the country. Her mom had recently been diagnosed with lung cancer and she’d been on dialysis for end stage renal disease for over a year. When asked, Chandra told me, her doctors at her home had told her to go on the “Dialysis at Sea” cruise. “Enjoy yourself,” they’d said. Chandra said her mom had always wanted to take a cruise. They’d just returned from the two week trip to Hawaii. She was trying to figure out if she should go get a hotel and start to arrange to have her mother med-evacuated to their home. She was still in denial, the first stage of grief. “You should probably wait here,” I tried to say it gently, “your mother is very sick.”

She understood that her mother was dying when I asked her if she’d like us to stop our failing attempts to rescue her mother’s body from following the likely already departed essence of her being. She began to cry. Alone here, without friends or family she repeatedly thanked me and put on a brave gaunt smile. She wore a soft black fleece; her body was as round as her mother’s naked cold body I’d just left with my fellow who struggled to find pulses and vessels to insert central venous and arterial access lines. I couldn’t tell if they looked alike, one was alive with small braids in her hair pulled into a high pony tail and dark round cheeks; and the other was ash-colored and dusky with her mouth gaping open around the breathing tube helping to keep her body’s metabolism limping along. The dying mother wore small gold earrings pressed into her ears in the shape of flowers.

I hugged Chandra, an awkward sideways hug in side-by-side chairs, made more uncomfortable for me by the fact that my resident had suddenly shown up to ascertain if I’d managed to establish that we were switching management to “comfort care.” When I glanced at his business-like dark eyes, blinking back the tears in mine, I remembered what he’d told me when we first heard about Chandra’s mother’s pulseless electrical arrest and three rounds of CPR in the emergency department: “Oh well. One less fat black woman who hasn’t taken care of herself.”

At the time, silently appalled that he’d said that, I turned away from him and buried myself in copying down her labs from the computer. If I ignored him long enough, he would go off in his whirlwind of action and jolting activity. I find it hard to maintain a sense of humanity and peace in places where people become so frigidly practical about death.

I wondered if he uses those thoughts and words a protection or a mask, or if he truly feels that way. I wonder if I am overly sensitive to the struggles of the loved ones left behind by those who die in oblivion on our wards. After all, I don’t know these people. I never knew them in life. I don’t know why her mother chose to wear those flowered earrings this morning. I don’t know if, by taking this cruise with her daughter, she accepted that this lifetime neared an end. I make up stories of their lives in my head. I extrapolate facts into a brightly colored and meaningful picture of lives. And of deaths.

And so I hug Chandra as she cries. I turn my face from the resident and look out the window toward the ocean they have just crossed together only to part on this shore. He tries to rush me along. “We’ll give you a moment,” he says. I have learned that when he says this it really means, “I have more important things to do now.” I don’t want to leave her alone. I offer thin comfort by promising to try to get her a phone and contact social work to talk with her again. I wish I could do more. I could have, but I chose not to sit there with her longer and instead let myself be pulled back to the storm of line insertion and dialysis machine and catheters and ventilators. “So, comfort care?” my resident asked as soon as the door shut Chandra behind us. “Yes,” I said.
As soon as he communicated that information to the ICU fellow, the medical frenzy began to subside. We called for a morphine drip to replace the five pressers keeping her heart barely pumping. Once the morphine arrived, the respiratory therapist removed the breathing tube, the dialysis nurse unhooked the huge rectangle dialysis machine that tried to duplicate what her kidneys would never again do, and the ICU nurse cleaned up the bloody hairy mess we’d made. When they removed the ugliness of our attempts to perpetuate her body, the nurse covered her with a clean white blanket.

We walked Chandra in to sit with her mother and pulled the curtain to leave them alone together. For her, I imagined, sitting there in the subsiding flurry of activity and loud voices and beeps and alarms, her now peaceful quickly dying mother must seem surreal. I found myself hoping they believed in God, thinking that might make Chandra feel less alone as her mother slipped away in this ultimately tangible episode in a lifetime of hellos and goodbyes. The greetings and partings had come before her mother died; they will continue after her heart stops. For years after, perhaps until the end of her own life, I imagine Chandra greeting her mother in moments of celebration. She remembers her at weddings and on holidays, with a sadness eventually eclipsed by the joy of having grown from her.

Her heart stopped at 4:25pm. Her nurse came to get me. “Asystole on the monitor,” she explained, “Flatline.” Flustered again and feeling shy and emotional and ashamed, I wrestled to get my stethoscope out of my white-coat pocket before entering the curtained room. To “pronounce” her dead, I needed to listen for the absence of breath sounds and heart beat. I needed to hear silence and see stillness.

No rise and fall of the chest greeted me as I placed my stethoscope to the left of her breast bone and glanced covertly at Chandra still sitting at the bedside now watching me. I don’t know if she wanted me to hear anything or not. She already knew why I listened. She knew, but still, when I finished this doctorly ritual and heard only silence, she asked, “So, she’s gone?” The resident and I both nod, “We’re sorry.”

Again we leave her. This time to get the requisite paperwork to record that her mother died. So many papers to prove she exist suddenly canceled out by the small stack to state that she died. I call the Coroner’s office to report the death and see if they need to do an autopsy. “Yes, hello, this is Dr. K---,” the words become more unfamiliar and distant to my ears, “I’m calling to report a death.” The woman on the other end asks for facts. “Name? Date of birth? Social security number? Address? Past medical history? Circumstances of death? Cause of death?” She concludes that it sounds like a natural death and gives me the waiver number to cancel the autopsy.

Chandra appears to hold up well as she calls the donor hotline to agree to donate her mother’s eyes for a research study. She stands by the phone across from me “yes, yes, yes, no, yes” to unheard questions, “Uh huh, yes, Okaaay,” she draws out the end and increases the pitch in just the same tone she did when I explained her mother’s dying to her. I can only imagine her numbness. Awareness of her mother’s death will seep into her over the next weeks and years, for the reminder of her life. But as knowledge of death trickles in, so can knowledge of life.
She already savors the time spent going to Hawaii with her mother. Her mother enjoyed the cruise, she tells me. I am glad of that. That is life.

After Chandra leaves, the man with the metal gurney and the white canvas rectangle tent comes to get her mother, now wrapped in a white bag and zipped up. He asks for help with sliding her over. They use some of the same techniques we use to move sedated or anesthetized patients. He wheels the now heavier gurney to the place in this hospital I have never visited, though I remember it from my medical school hospital. That room is metallic and cold. It smells of disinfectant.

The same disinfectant they use to wipe down the mattress after they remove the dead woman’s sheets from them. As the housekeeper wipes, the cleaner glistens for minutes on the plastic mattress before it dries. The room smells of sanitized death.

“It is a day.” I remember the words from a past life, as if they are spoken to me by the dead. “Only a day.” From a book I read, I think. The memory starts to return. Steinbeck, perhaps. “You have a dark and troubled mind, My Lord.” King Arthur. Why do those words return to me as I walk down the hill to my car in a haze of fatigue? The rest of my thirty hours had been filled with managing diabetic ketoacidosis, maintaining tact with another resident venting to me negatively, fighting down the constant nag that I am making mistakes and I don’t know enough to do this, bolusing fluid to hypotensive patients, adjusting ventilator settings, attempting insertion of an arterial line, performing my first thoracentesis, answering my beeper, and sleeping precious little.

In the midst of death and sickness and life, I struggle to keep peace with myself. If I do not anxiously expand doctoring to unmanageable proportions, this job is not so technically demanding. I gain experience and learn the routines and science. I no longer feel faint when I have to put in central lines or perform lumbar punctures. I know I can do this. I know I can witness death. I can live among the sick and try to guide their bodies and minds back toward health. I know I can witness life.

And, as I did with Chandra and her mother, what life I only peripherally witness, I imagine into existence. For her mother, I imagine Hawaiian sunsets and buffets at sea and time spent laughing with one she loves. For Chandra, I imagine denial and guilt transitioning into peace and celebration and acceptance. For myself, in my exhaustion, I imagine a “dark and troubled” mind. I grow tired sometimes of imagining others’ lives instead of living my own. I can do this job; I imagine I can. There are times, however, when I cannot imagine why I chose this over sunsets and real joys of my own.

"...but to love more."

"There is no remedy for love but to love more."

-Henry David Thoreau

"A successful marriage requires falling in love many times, always with the same person."

-Mignon McLaughlin

"Memory is the enemy of wonder, which abides nowhere else but in the present."
-Michael Pollan

"Openings"

This is what we are given:
soap and bees and dark tea,
coyotes calling on August nights,
milk and mist and the amazing nub
of a brown nipple that stands up
when it gets cold, the subtle smell
of earthworms tunneling soil, eating dirt.

This is enough
and still there is more.

Today I saw the black face
of a dog lean out of a truck window
to sniff the air, his pink tongue flapping
in the wind, and I knew he could taste the sun,
the snowmelt, the earlly gnats and pollens,
his nostrils swelling with the cold silver scent
of car bumpers, grocery bags filled
with sweet yellow peppers and deep red meat,
even the lushness of a single shoestring, mine,
dragged down damp streets and along ripe forest paths.

The dog seemed satisfied,
his body pure contentment
beyond gratitude, which like grief,
doesn't last.

I don't know where that black-faced dog
is now. But the sun is smearing its white light
over us as it does every day, and tonight
the cold moon, as always, till turn
its blistered cheek toward us whether we see it
or not, and all of this is enough.

-Kimberly Pittman-Schulz

Bigger Elevators Needed

I have returned from Spain. It was beautiful. It was my life.

That is a reference to the book, Nicole Krauss' "History of Love," which I read while I was there. It was the perfect literary compliment to a amazing thoughtful, beautiful, healing, renewing journey.

In the book, the parts I like best are about his love being the "happiest and saddest" at the same moment. And at the end, it says "He was in love. / It was his life." The context is lovely if you'd like to read the entire book. On my journeys through hostels and Barcelona and Valencia, I kept meeting up with it: in Spanish in a bookstore "La Historia de Amor." And then on a rainy night in Dutch read by a fellow hostel companion stuck in the storm.

I wrote pages and pages in a journal I kept there; many pages of sorting through half thoughts and emotions I must have been storing up since at least the diagnosis of lupus in May. And some even from before that. There was mud to be sifted for the lotus to grow. To be sure.

I may include some of that at a later date.

For now, I am back at work. In the medical intensive care unit--the ICU.

My re-aclimation to the United States of America was frought with travel frustrations. My plane in Philly was broken so I was stranded there for a night, though at least I didn't leave my wallet in a taxi like my part-time travel companion did on his way back. It was a good think I had that peaceful Spanish vacation aura about me. It, along with a peace I've been working very hard to regain and grow, kept me calm through all the travel hassles. I kept remembering the Hanh talk we'd attended and his book. Take time when you are stuck somewhere to meditate in your mind. Enjoy the space and time and cherish that peace. So I enjoyed the airport floor and the fact that my cell phone worked again and I could reconnect with friends I'd dearly missed. And I could sleep without my legs cramped in the middle seat on the plane. It really wasn't so bad.

The second day after I was back, I returned to work in the form of an eight hour test with 340 multiple choice questions about medicine which I hadn't done in 6 months. It was an utterly painful day. By the end, I wanted to quit this job.

The contrast between that day and Spain was stark. I realized that I don't even like thinking about that stuff that much. I realized how much I enjoyed writing and considering and letting my mind wander through my memories and jump through the futures and connections as my feet wandered through the freshly washed streets of Spain. I thought I'd quit and become a writer. I'm still thinking about that.

I came home and stared out my screen door and cried on the phone to my mom. I wanted to go back. I wanted a hug. I didn't want to feel like the out of place dreamer in a world of practicle thinkers. I don't want to still. I want to read and think and have time for three hour meals with friends and be surrounded by people who look for, and find, the good and share that with each other.

I felt better when I'd rested the next day. Sleep is a beautiful thing. Siesta or otherwise.

I continued sorting through my pictures and putting them in my Espana srapbook. I liked to fold up the random pieces of paper and cut out the pictures and glue stick them down as I remembered the place and pasted down my memories of it. I needed to process the magic and the fact that I was returning to a reality that I hadn't been sure I'd wanted for months.

My mom flew down the next day to make me a belated surprise birthday. My favorites: her homemade lasagne and apple crisp. So good. So good to see her too. I worked on my scrapbook for much of the time she cooked. It was good energy and time to share. She's feeling much better and it was good to be with her and see her so happy.

Still, I had to work the next day. I was worried.

The ICU is full of the sick patients. The ones who die. I'd had sign out already that one of my patients was brain dead and my task when I came on service would be to talk to the family about withdrawing care (she ended up dying before I got in the next day, though). Then I'd heard at the test that the ICU fellow that month was the one I'd had the worst month with the previous december on my cardiac critical care month. He was a pompus, loud man and we clashed badly. He disturbed my inner peace badly. I felt like crying again when I heard it was him I'd be working with all month.

It took me a little while to get to the mental state of seeing it as a challenge and a second chance with him. I've been through a lot and learned a lot since we'd last interacted. I would not take things personally from him. I would learn as I could and do my best. Maybe I could even try to repair some of the damage we'd caused each other before. Maybe. Survival would come first, though.

The first day went well. It was good to see many of the nurses again, and they were glad to see me, too. There was good energy among the team--or perhaps it was good energy in me. either way; it felt positive for once. I felt immune to the familiar power struggles and hiearchical games and hiding behind imagined knowledge.

One of the patients I picked up is a lupus patient. She is very sick. I cringed and felt my heart fall when the previous resident told me about her. "42 year old female with lupus nephritis, intubated, sedated, abdominal bleed from a liver biopsy looking for hepatitis." Indeed. She is very sick. She could die.

I try most of the time not to think about my own lupus in that catergory, hoping instead that I will be one of the ones who doesn't develop renal disease or need hip transplants from chronic steroids, or is unable to have children, or gets brain inflammation, or any number of other complications. But sometimes it hits too close to home. It could be me.

I knew before I left for Spain that I had fear of something in me. Something deep that I hadn't seen or known or uncovered. I cried at the church service about forgiving yourself. I cried when Hanh talked about seeing your fears and challenges as a baby, and holding them close and examining them before letting them go. And I didn't know why I cried. Something was sensitive and touching me deeply. I'd feel my throat constrict and my eyes start to swim at the some very inexplicable times and with thoughts that I couldn't complete.

I think now, after sorting through some of these emotions, my fear.

I was afraid that I would die. Or that I might still. Soon. I could still.

Today I had to pull a groin line on my lupus patient. She has been bleeding badly and I knew I'd be sitting at her bedside holding pressure for longer than the requisite five minutes. I brought a chair with me and adjusted the bed to the right hight so I could sit without aggervating my own lupus reactive arthritis in my knees. I told her mom and best friend that they could stay if they wanted. The actual pulling of the line takes only a second, though they hovered over me as I did it. The rest of the time I sat there with my hand on her femoral vein, trying to keep it from bleeding too much. Hoping for a clot to form from the factors from her damaged liver.

As I held her vein, her friend wiped away a tear from the patients' eye and held her hand. Later she would wipe tears from her own eyes and I would hold back my own as I tried to not think about our shared disease. And as I thought about how her life had changed. She'd be diagnosed only three years ago and here she was intubated, likely afraid, with her friend and her mom at her bedside telling her, "It's okay." She could die. No one wanted to talk about it; it's hard to talk about.

It's true, though. We all die. We're just not sure when. And the question becomes how to we want to spend the time we did have. I wondered what she wanted to do with her time. If we could save her.

I wanted to be the one holding her hand, not her groin. This doctor thing is difficult. Much of the time it pulls me away from my center. It used to anyway. It still tries, but I'm stronger now. I don't let it if I can help it. Still, the pulling creates a struggle.

This career is consuming. It leaves me little time to think and read and write and explore this big wonderful world and the people in it. And I don't know what time I have and if I want to spend it like this.

Sometimes I do, though. There are days I love my job; that feeling of usefullness and impact it brings. The smiles I can share and the rest I can bring to suffering. It is a position of privlage and power to effect the most vital and basic elements of life--and death.

While these world burns around me and over 700,000 people are evacuated from their homes and the fire-fighters who tried to save them are burned and intubated five floors below me, I work. Because I am "essential personnel." Schools close. Businesses close. When the world burns, there are those of us deemed "essential." It is a privlage. Yet there are time when I wouldn't mind being less important. When I would like to join the evacuees and offer what I can--even if it isn't medical care. Because it might just be time.

And there are times when I don't want to give my time so much to others. When I'd like to have some time left over for me. Time not snatched in the seconds in the empty elevator, nor the tired drive home. But real genuine time, whole days stretched out before me like a cloud. My own cloud.

When I came back from Spain, I wrote to my friend that I felt like I was coming down from a cloud and that my wings didn't quite fit in the elevator.

If you Ain't Got Love-Mason Jennings

On the train ride to Paris
Or from sunny Barcelona
We rose up through the mountains
As the sun started setting
And the sea came out below us
As we rode through a village
We passed ten feet from a little porch where a man was serving dinner
And our window was open
And we could hear them laughing.

I’m never gonna give you up
What do you got if you ain’t got love?
If you ain’t got love.
What do you got if you ain’t got love?

At nine in the morning
After nine months of waiting
You were born and I saw your face
And you looked up at me
But before I could hold you
The doctors raced you from me
They told me that you might not live
your heart was not healthy.
And with wires coming from you
I sat beside you.

I’m never gonna give you up
What do you got if you ain’t got love?
If you ain’t got love.

What do you got if you ain’t got love?

Someday, someday soon,
You and I will both be gone
And lately I can’t help but think
That the love we feel will live on.

At a little wooden cabin
Up in northern Minnesota
We ran together down to the dock
And you jumped right off it.
And from out in the water
You called me to join you
And I said “baby, I can not swim if I jump I’ll surely drown you.”
You said “life has no limit, if you’re not afraid to get in it.”

And Oh, baby I jumped to you,
Since then there’s nothing I can’t do.

I’m never gonna give you up
What do you got if you ain’t got love?
If you ain’t got love.
What do you got if you ain’t got love?

Someday, someday soon,
You and I will both be gone
But lately I can’t help but think
That the love we feel will live on

Email to US from 16 Octubre

Just back from my walk around the city. I did indeed make it to the music hall, looked around the outside, but decided not to go in. I sat on the steps and read about Gaudi's education and growing up in the book I got at the Sagrada Familia yesterday. Then wandered to the Gothic area again and found the cathedral. Also a little house over to the side with a fountain and a courtyard in the sun.

I found a craft fair where they had wooden keychains. They also had books that looked too beautiful to be written in. Ceramic clocks that I may one day wish I'd bought but that I was afraid would break on the trip home.

I must be looking more like I know my way around because people are friendlier and when they ask me for directions I sometimes know where to point. Returned to the Ramblas and took it all in for a bit. Also back through the food market that is reminiscent of Pike's Place in Seattle if you've ever been there. I got a euro's worth of fresh figs and ate them on my walk back to the Rambla de Raval where I seem to always end up by the lumpy black cat which I think is so strange and kinda creepy.

I felt joyful and whole and secure on the way back. Navigating the city becomes an art which I have just begun to grasp. Things begin to look familiar just before I change. I got my voice back a few days ago so I was singing to myself as I found little out of the way ancient buildings turned gallery where I was the only one in there and my voice echoed off the walls. I was singing Angel at that point. Later Do you want me. Gulf Coast Highway. I wish my love was a red red rose. And pieces of others here and there.

Musicians sit in the close stone streets making music that echos around the stone walls. Today there was a man with a round metal instrument I didn't recognize but sounded beautiful around the corner from the cathedral. Also a lovely young cellist girl with blond hair. The workman yelled pelo rubio at me today. I smiled. Wonder if they see the strawberry, too.

Got a kebab then went to find Jamie packing at her place. I'm supposed to be packing now, but wanted to upload some pictures from today and say hello first. I'll go out to Sangria with her tonight at the only non-smoking bar in the city. Well, they have a non smoking section that is blocked off. and they have Sangria on tap. key.

It is sort of sad to have this time coming to an end. I turn my sights toward home and the re-entry into my real life. I'm still not sure this is the real life that I want. I know I'm not going to be ready to do clinic on Thursday, eight hour test (which I will likely bomb) on Friday then I think I might start off on call in the ICU on Saturday. I'm afraid of the ICU. It will be okay. I just want to get it over with more than anything. I still don't know how I feel about adult medicine. I like the kids for sure, but the adults. Well, it's been a while so I'll see if it is better when I don't have my head full of clots and it hurts just to smile. Has to be better!

Plus I'll have Spain inside of me. And new friends. I feel like I'm back to sucking it up and just getting through this phase of my life and that feels wrong in a way. Because if I get sick, is this really the end I would want? Just have to make everyday have some sort of magic in it. I can make a difference in lives. Patients see that. I've had them tell me they feel better just after talking to me. Have to maintain my peace and play with the space between to be effective and to make this whole thing worthwhile and sustainable for me.

I feel like I'm coming down off of a cloud and my wings don't quite fit in the elevator.

Arrive where we Started

I'm leaving for Spain today! I'll be gone for a couple weeks. It will be a great trip. I've oscilated between extreme excitement and suppressable anxiety and melancholy. Change is always hard for me. I'm better at it, but it stretches my comfort circle. Good for me. And Barcelona! I think it's still not completely real to me. I'll be meeting a friend there and hanging out with her. Staying a hostel for the first time and renting a car for a trip for a while. It looks beautiful. My mom got me the ticket for my birthday. Regalo fabuloso!

She was down here yesterday briefly. J., J., mom and B.S. went to a peace lecture and medidiation by Hahn. "Peace in Every Step" is his book. About mindfullness in the moment. You take it with you. You take your peace with you. I'll take mine to Spain. There is beauty and peace everywhere if we look--rather if we choose to perceive it that way. If we remember that we breathe and in breathing unite our mind and body and become aware of our present. We only life in that moment.

It is always only ever now, after all. I've said it before...somewhere in these ramblings.

In preparation for the trip, I've been thinking about books to read. Some of them not for now, but someday. Spent some time at the book store. I'd like to read "My Antonia." J says that Les Mes is a must. I'm taking "Man's Search for meaning" and a few others. Sill working on a few here, also. Richard Bach has been a favorite lately. He writes a lot about releasing your mind to allow yourself to be. At least that's how I'm thinking of it in this moment. Have also been missing my poetry some. Writing and reading. I was looking up Dante the other night when I couldn't sleep at 3 am. Sent some to S. He got a kick out of that. "You're nothing if not interesting," he wrote back the next morning.

I've been mostly on the night shift at work. Had a couple day shifts these last few days. Sewed up some lacerations. Lots of ortho stuff. Belly pain in a very patience-trying patient yesterday. They were there they entire shift and wanted everything and I kept my cool with them pretty well I thought. Kept going back to myself and reminding myself to smile and take it in stride. It's not so hard. It was a good opportunity to practice it, too.

I feel out of the depression for a while now. I remember it enough to know it's still there, but I also see it and am aware of it and so can leave it where it sits.

Hahn said you have to hold your anguish and sorrow and recognize it so you can move thorugh it.

He also said that "the lotus does not grow without mud." Wish mud as a metaphor for the challenges and pains of life and the knowledge that the flower will bloom out of that and because of that in the end.

I wonder if I'm seeking out these things more, or letting them touch me more, because I was afraid that I was going to die.

Once you are no longer afraid of death, it has no hold over you. He told stories of people recovering from "terminal" cancers.

Medicine is really supportive care for the body to heal itself much of the time. I told J. that the other day. We do our best to guide it toward healing, but really it comes down to the body and the person. Cellular level be damned.

Of course, as a doctor, this is a struggle for me--this balancing act of science and mindfullness. I accept whatver works for that person. I accept whatever works for me.

My INR was 4.3 yesterday. Too high again. I got to skip a day or eat a salad. I ate a salad. Will be better for me to be a little high with a long plane trip ahead anyway. Course clotting in my legs wasn't the problem. It was the head they were after.

They? Who? Why? Random? Lesson? Growing. "What is to give light must endure burning." I don't know why this happened. Or if there even is a why. Or if the why matters. Or sometimes what does matter.

Balancing between living like time is limited or pouring the present into plans for the future. It's odd that I titled this blog what I did when I did. Before a lot of this had happened. Of course everything is a balance. It's the fine line between self and other--between now and then. It's the line that I try to expand. Make it a beautiful path to walk along and enjoy the red glow of the setting sun on the hospital I saw as I rushed to the lecture yesterday.

It's appropriate that I'm a Libra. The scales.

There are four of us living here with birthdays this month. And one who just moved out so that makes five. Maybe that's why the vibe around here is so good and close. BK is the 16th, J is the 17th, JL is the 18th, B is the 8th, then there's me on the 14th.

Twenty-nine this year, four of the five will be turning the same age.

Dad sent me a card the other day. I hope it means that he's finding himself again and getting out of his depression. It was a picture he'd taken with a quote inside from T.S. Eliot

"We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time"

That makes me feel deeply now. Maybe from Dad in transitions and the promise of something circular and knowing.

I remember when I read "Sidhartha" in high school and wrote an essay about the circular nature of the book. The thought for the thesis of the essay came to me like a flash of insight and I was on fire writing the essay--mostly with the thoughts I wanted to get out with it. I remember making the first thesis and conclusion echo each other so the essay itself was an expression of the meaning it was trying to convey, coming back to itself and seeing more with every revolution. J says that "100 years of Solitude" does something similar. I'd like to re-read "Sidhartha."