Sabbath, Part the Second: Wendell Berry Poems

Since moving to Burundi, we have come to enjoy the in-country presence of the Miller family, who live in the capital and work with the same medical school as we do.  They are extremely gracious hosts, who continue to house us when we visit, but always in a way that we never feel like we are being a burden.

Joel and I enjoy talking books.  Several months ago, he loaned me “A Timbered Choir” by Wendell Berry, a poet/author from the American South who, for decades now, has spent his Sabbaths wandering through the rural hills around his farm and occasionally writing poems.  These are bound into a couple volumes.  He’s an old man now, and the aging process comes out in the progression of his poems throughout the years.  But with that kind of ritual, Sabbath walking for over 30 years, he has a lot of wisdom to share.

He speaks of trees, friends lost, the passing of time, birds sitting on high branches, invisible in the “at-home-ness”.  He speaks of the songs he hears all around him, and his own song that he tries to sing.  He speaks of rest, and his attempts to practice it.

Sabbath observance often feels frustrated by the imminent demands of parenting.  But Rachel and I usually understand one another’s need, and try to carve out a little time for solitude each Sunday.  

So lately, that’s where one could find me during that brief interlude, sitting outside on a log with a copy of the psalms and Wendell Berry’s “A Timbered Choir”, slowly reading, savoring the words, watching the branches move in the wind, trying to embrace the image of a day to come, when our rest is made complete, thanking God for the way he continues to transform and lead our lives.

“And I, through woods and fields, through fallen days,

Am passing to where I belong:

At home, at ease, and well,

In Sabbaths of this place

Almost invisible,

Toward which I go from song to song.” (-W.B.)

Sabbath, Part the First: Resting and Rhythm

Never is the routine of normal life more appreciated than after traveling overnight abroad with three small children.  We are back from Greece, where we had a wonderful time working on credentialing, seeing friends, and enjoying my parents’ company.  And now, the quieter, steady life here at Kibuye has returned.  Obviously there are lots of challenges to life here, but lack of routine is not currently one of them.  

Walk to the hospital, walk back.  Each day of the week has a set program, and they roll by reliably.  The kids know the routine for the most part, and that helps.

My enjoyment of this sort of surprises me.  Ten years ago, I would have feared that such a pace would be boring.  There are probably lots of reasons for that, and I imagine the greatest reason is that our phase of life includes three small kids, which certainly makes a quiet steady life schedule more desirable than the alternatives.

But there is another thing, which is my growing appreciation of the role of Sabbath.  I guess it began when Janet Tang gave us “Keeping the Sabbath Wholly” by Marva Dawn, back when we were in the US, and I read it around the time we arrived in France.

I think, prior to that, I would have said obedience to the Sabbath meant 1) having enough days off from your regular job and 2) going to church as often as possible.  Dawn challenged this by defining “rest” a lot more logically, as “not working”.  Shocking, I know, but to stop from all that is work (catching up on emails, catching up on housework, running errands, reading preparation for work or some other commitment...) meant something that I think I had rarely experienced, which highlighted how much of my identity rests on what I accomplish.

So we rest.  We stop.  And we celebrate.  Our family watches a movie together every Sunday night, while eating popcorn, pickles, and assorted luxury foods for an informal dinner.  The kids love it, and it separates this day out as special.

It’s been about a year and a half since we started this, and I think another element that Dawn mentioned is starting to come to pass:  the rhythm of life.  She argues for the importance of every seventh day, that it is a rhythm for which we are created, and that it’s observation will ring true.  As with any discipline, this grows with time, but more and more I’m coming to appreciate this.  Throughout the week, the sense of the Sabbath gone and the Sabbath coming inform the emotions of the moment.

More to come...

A Very Old Thesis

I'm taking four weeks of Tropical Medicine here in Baltimore, and last week was "Vector-Borne Illnesses in the Tropics" or "Disease You Get From Bugs".  We had a lecture on Lyme Disease, which, as you know, is transmitted by ticks.  It's not a tropical disease, so I didn't think it should have been in the syllabus, but a rather odd thing happened during the lecture.

During the course, one of the "students", an Infectious Disease Doc from Mississippi, asked about STARI or Southern Tick-Associated Rash Illness.  The expert (who was quite a good lecturer, actually) said that the problem with STARI is that only one person had every isolated a Lyme-like bacteria from that kind of tick, a species called Borrelia lonestari, and no one had every been able to replicate that isolation.  Thus, most people thought that those southern ticks (a species called the lone star tick) caused a rash, but did not transmit bacterial infection.


Well, that was where I got quite excited.


And, if you don't know the rest of the story, you may be incredulous that I could get excited at that precise point.


But others of you know that, over 10 years ago, for my Honors Thesis at Belmont University, I did my one bench science project.  It was titled "The Presence of Lyme-like Bacteria in Sumner County, Tennessee".  Basically, I had heard about this new bacterium (though I thought 2 or 3 people had isolated it, even then), and went out to a Boy Scout camp outside Nashville and collected hundreds of ticks.  The methodology of that I won't go into, but suffice to say that, yes, in the process, I had a lot of ticks on me as well.


I took them back and ran a series of molecular tests on them to look for Borrelia lonestari.  And it was there.  I wrote my thesis.  I presented it a couple times.  Someone at another university offered to continue the work and maybe publish an article, but at the time, I saw that as only vain ambition, and it wasn't interesting to me.  It never occurred to me to think that anyone would find that information helpful in trying to figure out if STARI actually existed as a legit disease.  I left the results in the freezer at Belmont, and the two copies of my thesis on a shelf there.  I don't even have a copy myself.


So, after the Lyme lecture this week, I went up to the lecturer and told him that, over 10 years ago, I had isolated Borrelia lonestari.  He said, "Wow, so you were the one person?"  I said, "No.  I never published it.  I must have been the second person (thus showing that it could be replicated, that it likely did exist)."  He said, "Really?  You did?"  "Uh, yeah."


So he gave me the name of a tick-borne illness specialist in New York, and recommend that I let him know about this.  I sent him an email, and we'll see what comes of it.  I let my adviser from Belmont know, and he assured me that he still has a copy of my thesis.  I can't imagine that they still have the specimen in the freezer.


Lesson:  You never know how various strings of your life are woven.


Lesson:  Try to find out if your information or idea might be useful to someone else before you discard it.

Profile of my Job

For those curious for a little nuts and bolts of daily life (or for that matter, any update at all on this blog, sorry about that), I thought I would give a little info on my job.

This is a picture of Lakeland Regional Medical Center, where I have been working since late January, and where I will be working for a bit more, until the first week of April.  It has about 160 general medical beds, plus a big ICU, Labor and Delivery, a huge ER, and a small peds ward. 

I am working there as a hospitalist, which means that I only take care of patients in the hospital, without doing any clinic practice.  The hospital employs quite a few hospitalists, and most days (8a-8p), there are between 10-14 of us working together.  At night, there are 2 or 3 covering.  We take turns admitting patients into the hospital, and generally direct and coordinate their care until discharge.  I am like most of the hospitalists, in that we are doing block scheduling, so I work 7 days on, and then 7 days off.  This is good from the standpoint that it has allowed Rachel and the kids to stay some in Ann Arbor, where they know more people, and I join them on my weeks off.

The hospital was interested in hiring some extra hands for this time period, because on February 25, the entire hospital switched over to an Electronic Medical Record, which was a huge undertaking.  So, the good news for us is that it created an employment opportunity for me.  The bad news was that I had to learn the old, complicated system just in time to ditch it for the new one.  Oh well.

The size of the hospital is interesting to me.  Almost any specialist is there, and almost any service or test can be performed.  Thus, I have only transferred one patient to another hospital for reasons of needing a service we couldn't provide (which was a heart transplant).  Nevertheless, it's not a real big place, and the number of doctors and nurses are pretty limited.  I've enjoyed this, because even after a couple months, I feel like I know the majority of them pretty well.

The other unique thing is that this hospital hosts a number of doctors from Southwestern Medical Clinic, which is a Christian group practice, with a commitment to international medical missions.  This is not all the doctors, but it's enough of them that it changes the overall feel of the place noticeably.  For example, when they hear that I lived in Kenya for the last two years, I don't get one of the normal responses, which is "So, are you with Doctors without Borders?" or "Did you take your kids there?"  Instead, I get "Oh, do you know Mike Chupp?" And I say, "Yeah, he lived across the yard from me."

Seaweed Glue?

My job description got a bit stranger today. I got a page at lunch and called the number.

Daktari? We are trying to pick out an agent to treat the cockroach problem in nursery.

Well, that sounds like a good idea.

Could you come up and give us your opinion on the safest chemicals to use?

Hmm... (I have no idea.) Sure. I can come up in a bit.

--See, the issue has been around for a while, really everywhere in the hospital, but recently a family in the nursery has complained, and thankfully, a solution is being sought. The only trouble is that I have no idea which chemical might be problematic for 2 lb preterm infants. Probably all of them, I guess.--

Daktari, thanks for coming. Here is the man.

(She introduces me to a very young man in a black suit who is apparently the sales rep for the insecticide company.)

Nice to meet you, daktari. Can I show you one of the products?

Sure.

(We go down the hall, and he pulls out a small purple container with a couple of air vents on top, with a distinct smell of lilac. It is, to my eye, an air freshener.)

This gets rid of cockroaches?

Yes. It is a repellent.

(I read the label. It talks only of how it will emit a pleasant odor for the next 2 years. I read the ingredients. It includes a few things that sound very non-insecticidal.)

You see this ingredient, "seaweed glue"? It chokes cockroaches, mosquitoes, and something else that I can't remember.

It chokes cockroaches?

Yes, but it doesn't hurt people.

--At this point, I advised the nurse in charge that anything that was airborne and choked cockroaches was probably not advisable for our NICU. She agreed with me, and therefore told the rep that we would buy some for public areas, like the restaurant, but not for patient care areas. And I guess having pleasant-smelling public areas is not a bad thing, but I'm not thinking we're making a lot of headway on the cockroach problem. I went and googled "seaweed glue" and, not so surprisingly, only found references to it as... glue. So, I think I made the right choice for the NICU, but I haven't figured out whether I should tell the proper people that I think the air freshener rep is seriously trying to pull a fast one.--

"Are You Jewish?"

It happened twice today. So I'm blogging on it.

I went to the pharmacy to see if we had a saline nasal spray. (We had one. And I prescribed it. And now we have none.) The Kenyan pharmacy tech says, "You know, you look Jewish. I have a video with Jesus in it, and every time I see you, I think you look like him." Not 2 hours later, I head to the nursery, and the nurse asks, "Are you Jewish?" I say, "Did someone tell you to ask me this?" "No," she says. "You're saying that because I look like Jesus in the movies, right?" She smiles, just a tiny bit self-conscious. "Yes." "Well, I've known a lot of Jews, and I don't particularly think Jesus in the movies looks Jewish."

This was not at all the first time I've gotten this since moving to Kenya. I think the reasons are multifactorial. First, they really haven't met any Jews, with the notable exception of a Messianic Jewish dermatologist who came to visit earlier this year.

Second, they've all seen The Jesus Film, which actually is the most viewed movie in cinematic history, according to The New York Times. Personally, I think he looks like Don Chaffer.

Truth be told, I actually got this prior to coming to Kenya. My friend Jenny was serving as a med student/translator for me in clinic in Ypsilanti for some of my Latino patients. We left the room, and she broke into a smile. "I've got to tell you a story."

"When you left the exam room for a minute, the patient turned to me and said, 'You know, I feel like I've gotten to know you, so I'll share something with you. I think my doctor looks like Jesus, and when he came into the room I thought: The Lord is my doctor and he has come to heal me!' "

There are worse things in this world.

Lord Jesus, we are all being transformed into your image...

The End of Residency

After 12 (or 11 for Eric) years of post-secondary education, the end has come. This is a momentous reminder that time does, in fact, pass, and things come to an end, despite good reason for feeling like it never will.

Last Friday, the paper chain that Rachel made to countdown the days she was separated from Maggie for work purposes was torn at its final link. God willing, her next patients will be in Kenya.

The week prior was Eric's gradution, and though he doesn't finish working until June 30th, the honors and certificates have been bestowed, and great thanks to Tim, Sami, and Jonathan for coming up and sharing the evening with us.

Last Friday night, the OBGYN gala was on, and Jean, Sharon, and Tim all got to come, in addition to Karen Selle, Eunice, Jason and Heather Fader, and Charlie and Maryann Leland. Rachel won her classes' Academic Achievement Award, and her class kept up the tradition of spoofing their senior residents with a video of Rachel built around the themes of bikeriding, working up to one's due date, and The Lion King.

Rachel's Brain Brings Home The Bacon

This being her last year of residency, Rachel has completed her research project, "The Implementation of Standardized Treatment of Patients with Gestational Diabetes Mellitus." It reads like a John Grisham novel, I assure you.

Now we all know that Rachel is a smart one. Or as we say in our house, according to the Wooster fashion, "she eats a lot of fish" (now that she's not pregnant). Yet this world in which we live is not always one that rewards such brilliance.

So we were extra delighted when she beat all other contenders at her home hospital for her research project, and an extra little check made its way to our burgeoning family. This success also made her the hospital's candidate for the regional research presentations and competition.

So, last week, we headed out to Rochester Hills, a northern Detroitland suburb, to a place called Meadowood Hall. We had no idea a place like this existed in our general area. It was built in the 1920's by the widow of John Dodge (of auto fame), after the style of various historical British manor homes. It was absolutely idyllic, and after sitting in a gazebo in some perfect weather for awhile, Rachel went into her conference, and Maggie and I walked around the grounds for a bit (well, she didn't actually walk), and found a pint-sized building, that was a gift to the Dodge's 12-year old daughter. A fully functioning house to teach her how to run a household. Then we joined in for Rachel's presentation, where she wowed the crowd, and Maggie behaved perfectly and earned many adoring fans. After another monetary prize, we headed home, but thought we would share the sites with you all.

Where Disability Comes From

I have a short list of the 3 things I dislike the most about doctoring:

1. Narcotic pain med management
2. Reviewing my dictations before signing them
3. Filling out disability paperwork

I had a bit of an epiphany regarding disability a few months ago. It is (in my opinion) an unfortunate part of our jobs that we certify disability. I prefer the forms where I just get to write what I see/know from a medical standpoint, and someone else decides whether that means they can hold a job, but often times I'm the one making the call, which is always with a large degree of uncertainty.

My epiphany came when a women came in for an annual examination. She is in her late 30s and is in a wheelchair due to a genetic condition called spinal muscular atrophy. The important point is that she has very limited use of all her extremities. She also was born without an essential enzyme to help with everyday energy production, and certain amino acids will make her incredibly sick. It's called phenylketonuria, and you can check out a warning to her and other with her disease in the small print on the back of your Diet Coke. All this, and she's just here for an annual exam. No worries. She has a husband and kids and runs a small business just north of the Ohio state line.

Later that day (maybe the next day), I saw a woman about her same age, sitting in the room with her daughters, neck rigid with debilitating pain that has gone on for over 4 years. I (and numerous other specialists) have tried and tried to find anything wrong with her bones, muscles, nerves, or any other part of her body, and all of it appears totally normal. No medicine helps. No therapy helps. I wish I could say this case was unique. She came in that day to get forms for disability filled out, so that she could get some cash assistance. So I filled them out. "What physical findings support this disability?" Well, none. "What tests and exams support this?" Also, none. "What is her diagnosis?" Just 'neck pain'. "Can she hold any job at all?" Now, why did they have to go and ask me that? Taking it all together, I would have to say that no, she can't. I don't know why, but I know from interacting with her that it's not going to work.

So, what makes for disability? I'm convinced that emotional well-being is really where it originates. The first lady taught me that almost no physical disability can't be overcome is the rest of one's person is well-functioning. And the second woman (and dozens like her) just reinforces that nothing may be physically wrong, but the emotional/social/spiritual health of a person is easily enough to push them into a state where even a basic job will probably not be doable.

The next step would be then to work more towards this model of holistic health for people. Unfortunately, I don't really think we're all too good at that. Not in medicine. Most of that health has to come from elsewhere.

Wisdom

I started a post today, and it ended a bit longer. Since I don't want the baby news too far down on the blog roll, I'll just put a brief excerpt here and you read the rest:

A 35 year old lady with 3 kids at home and no dad anywhere around comes in because she has terrible headaches. She's also overwhelmingly anxious and doesn't sleep well. She has plenty of reason to be anxious, since her oldest son just ran away, she fears her 13 year old daughter may be pregnant, her boyfriend gets abusive sometimes... (read the rest)

Wisdom

Here's a scenario oft repeated in our daily lives, which I'm writing about now for an emotional outlet as much as anything:


A 35 year old lady with 3 kids at home and no dad anywhere around comes in because she has terrible headaches. She's also overwhelmingly anxious and doesn't sleep well. She has plenty of reason to be anxious, since her oldest son just ran away, she fears her 13 year old daughter may be pregnant, her boyfriend gets abusive sometimes, and she is inches away from not being able to cover her heating bill next month. She wants to sleep. She wants to have her head feel better. She wants her life to be much different than it is, in a myriad of ways.


I think I saw variations on this theme at least 3 times just this morning. After asking some questions and examining her to ensure that these headaches aren't from something more dangerous than painful, we're down to figuring out how to control her symptoms. There are a number of medications that can aid in control of head pain, back pain, any kind of pain, but sometimes patients say they don't get any or enough benefit. Sometimes insurance doesn't cover them either. For anxiety, there are some pretty good, cheap medicines, but they don't act right away, and many patients want to feel better now. (n.b. I totally agree with those who want to utilize non-medicine solutions to the above problems, but that's another discussion.) So often it comes down to narcotics for pain and benzodiazepines (valium, ativan, etc) for anxiety.


She's tried lots of things in the past, she says, and feels that these last options are all that works for her. I pause. True, I think, for some people, they are useful. However, these medicines are in the control of a prescriber like myself for some reason, and I can only assume it's because of my experience. Because I've seen what she hasn't, which is people ten years down the road, taking truckloads of narcotics and still not feeling better. In the meantime, the side effects pile up and they get sicker. I've seen women beaten up by the boyfriends in order to take their anxiety medicine and sell it or share it at their next party.


And so I've come to conclude that our desire to get benefit now sometimes results in harm later. This is driven by docs and patients alike, because neither of us, unless totally empty of empathy, want these terrible experiences to persist any longer. So we look for the quickest relief. And often the quick-relief medicines don't continue to work as well as they once did, so we use more and more. I've been trying to explain to people that our eyes ought first to be on long-term function and success rather than on short term fixes and patch jobs. This isn't received well.


Why isn't it received well? Is it just our human weakness? We don't want to put up with anything? Maybe. In fact, that's my first thought and maybe still my primary thought. But then the other day, these issues washed over me again... 5 years from now? 10 years? How does one focus on those goals when you feel you'll never make it into next month? Maybe I'll be a wreck in 10 years, but at least then my kids will be out of the house, and not depending on a mom who's a nervous wreck and incapacitated by headaches... This line of thinking isn't human weakness. Maybe it's wisdom, wisdom to spend your health today, since the future isn't guaranteed regardless.


And I don't have an answer. I don't have an answer, and it matters terribly to lots of people, and lots of families. God, help me. I'm convinced you alone have the answer, and without your guidance, we will continue to walk in darkness.

Trailer Medicine

Every summer and fall, my (Eric's) residency program staffs a migrant clinic. Every Thursday night, a few people drive out ~50 minutes or so from Ann Arbor, down a dirt road on the DuRussell Potato Farm, to a couple of trailers, one of which houses the clinic. There the Latino migrant farm workers have a chance to get some convenient health care during the time they're here in Michigan instead of Texas or Florida. Some speak English, some don't. Some have insurance, some don't. Last night was my turn to make the voyage, and I loved it (again). Here's why:

1. It's in a trailer on a potato farm. Anyone who wants to open a clinic in a trailer on a potato farm, please let me know.

2. It's casual. My goal is to practice medicine in a t-shirt. I don't know if I'll accomplish this, since Africa maintains a professional decorum with its traditionalism.

3. HIPPA is... elastic. The faux-wood panel walls between the two exam rooms don't really offer any sound-proofing anyways. The casual nature of the clinic means that the conversation about birth control or your kids' ear infection may continue out into the hallway and all the way to the door of the trailer. And no one (seems to) mind. It reminds me of Africa. Confidentiality can be a boon, and at times, is essential. The flip side, seen here, is that there is a collegiality in a shared experience that is also valuable.

4. The staff is excellent, and are incredibly well-versed in the logistics of what is and is not possible to accomplish for their patients.

Viva la clinica en la trailer en la potato farm!

Medical Literacy Research

Funny how some things can take large parts of your time, but you never deem them interesting enough to share with friends.

But in order to give our "real" friends a chance to "really" know what's going on in our lives, I (Eric) will mention my research planning. I'm not by nature or desire a researcher, but every resident in our program has to do a senior project of some kind, and a couple years ago I got fascinated in one particular question in the field of medical literacy. "Do patient's understand medical jargon?" Even more interestingly, "Do physicians know what medical words the general public understands?" My theory is that docs are so far within their realm of work that they don't even know what they knew before they entered medicine, and thus simply telling them "You should avoid medical jargon in talking to patients" is a lost cause, since they don't know what that is.

So I've developed a survey (i.e. quiz) that will be distributed to patients and to physicians, with a goal of then comparing the actual patient responses to physician estimates of how they would do. All of this, of course, if I can get my project approved by the IRB. I don't really feel that I'm posing much risk to my patients with this survey, but we can never be too sure...

Click here for the questions, and test your own jargon knowledge!

Nights

Both of us are back on nights. This will be Rachel's last month (!) and Eric's last extended stint. He's only on for the first half of the month, and gets to take most call from home, when possible.

Munchausen's Syndrome

There was a fascinatingly awful patient care experience last month that I've been waiting to say something about. Maybe it would have been interesting to see what I would have said in the heat of the actual experience, but I'm trusting that a little emotional distance will provide some better perspective.

Late one night during my shifts last month, a woman was admitted to the hospital with trouble breathing and chest pain. (Obviously, this woman's name and any identifying info will be omitted or changed.) As I looked into her medical record, I found something that I had only heard about before, namely Munchausen's Syndrome.

This syndrome was named after the good Baron von Munchausen, pictured in a bust above, who apparently was famous for telling wild adventure stories from his travels that all turned out to be lies. The medical diagnosis that bears his name involves patients that have no underlying medical problem, but desparately desire to be a patient. Often, they will do some ill to themselves in order to be treated for something, and many times the more severe the treatment the better. They often have a medical background of some kind, travel from hospital to hospital, show up with wild problems, and always desire some very invasive treatment plan. You hear stories about this diagnosis in medical school, but obviously it should never become a label unless it is very well substantiated, since it will dramatically affect how future care is provided. Note that this is different from "I have lots of pain, doctor, and I need narcotics." Narcs can make you high and you can sell them. There is no secondary gain for a Munchausen's patient except to get to be in the "patient role".

So my patient was admitted to our hospital 6 months ago with abdominal pain and found to have air inside her abdomen, usually a very ominous sign of a perforated bowel or something equally dangerous. She was taken to the OR, where surgery found no source for this, but did evacuate out acetone-smelling fluid that, after much investigation, was concluded to be some cleaning solution that the patient had injected into her own abdomen. She got better. Then the story broke, through her husband, that she had multiple underlying psychiatric diagnoses (all of which she denies to this day and refuses treatment for) and had been to many other hospitals with bizarres stories in the past.

So for the next several nights, I would be repeatedly paged with reported problems from this patient, for all of which she desired something to be done to her. She "vomited over 200 times" (none of which were witnessed or have made her at all dehydrated by our testing), so she "really needed an NG tube (tube through the nose to the stomach) and a PICC line (super IV that goes into the vena cava)". She held her urination until we were forced to catheterize her, lest her bladder burst, and then she asked for a larger bore catheter. On and on it went. We tried to discharge her, and she petitioned Medicare to let her stay until her case was reviewed to see if there was any reason for her to stay in the hospital. They said no, and she finally went home.

The bizarre nature of this is probably evident to everyone, but the hardest part for me was a suppression of every instinct that I've garnered since starting medical training. We are trained to seek out problems as clues to some disease or malfunction of the body, and to never ignore a patient's problem. Here, these very instincts will contribute to making the patient sicker and sicker and perpetuating her problem, when what she really needed was to go home and be out of range of some medical intervention.

I don't know if this rings of a lack of compassion. I hope not. Patients most often have a quite notable instinct as to what they need for their own health, but there are unfortunately many people (not just people with impossible-to-treat psychiatric disease) who think some thing is what they need, when I am convinced that it just adds to their problem. These are always difficult times, since I must act for their best interest, whether they believe it to be or not.

Rushing in where angels fear to tread? I pray never. God, give your grace, your light, your healing.

The Last of a Long Line

Our human condition has an amazingly innate resistance to the idea that time does, in fact, pass. Anything difficult seems that it will last forever despite repeated assurances (even from yourself and to yourself) that "this too shall pass".

So tonight is the last of my night shifts, and tomorrow I start back on days for the next several months. Rachel has been doing all she can to spur me on to endurance, but I've still felt it dragging. Now, at the end, "good riddance" is definitely the prevailing thought. However, I did find some unexpected encouragement this morning in the Psalms (#134):

"Praise the Lord, you servants of the Lord, who minister by night in the house of the Lord. Lift up your hands in the sanctuary and praise the Lord. May the Lord, who made heaven and earth, bless you from Zion."

As Eugene Peterson asserts, if worship was ever to be slovenly, it would be by the priests at 3 a.m. And maybe our hearts will be sagging, and maybe we can't help that, but we do have control of our limbs, so raise your hands and praise the Lord.

Late Night Phone Medicine

During my present night shifts, I field calls from the answering service for our clinic. Last night I had a series of phone calls that make for a retelling that is, at least to other physicians, humorous. I recognized the name from a couple nights previously. It's a schizophrenic patient who (like many schizophrenics) smokes a lot and has some early emphysema as a result. Some of my favorite patients (not that I have favorites) are schizophrenics, and thus I have a special place in my heart for those who have to live with this mental illness. Anyways, last night 1:30 a.m:

"Hi, it's Dr. McLaughlin from the University of Michigan. What can I do for you?"

"Oh, Dr. McLaughlin, I know you from a couple days ago."

"That's right."

"Well, I ran out of my albuterol inhaler, and I need a refill. I usually use it once every 2 days or so. It's not really any worse, but I ran out."

(Thinking: Why does he need this at 1:30 in the morning? He doesn't seem short of breath) "Sure, I can call that in. To the Kroger pharmacy in Milan?"

-our phone call gets cut off. So I call in the prescription to his pharmacy and call him back.-

"I called in the Albuterol. Is that a 24-hour pharmacy?"

"No. Can they Fed-Ex it to me?"

"Uh... no. You'll have to wait until the morning."

"They can't Fed-Ex it to me?"

"No, no one is there at the pharmacy."

"Oh, could you find a 24-hour pharmacy for me and then call me back?"

(Thinking: This is getting ridiculous.) "Uh... sure. I'll do that." I hang up and search google for awhile until I find a 24-hr pharmacy about 20 minutes away and call in the prescription.

"Hi, sir, I found a 24-hour pharmacy and called in the prescription."

"Will they Fed-Ex it to me?"

"Um....no, you'll have to go and pick it up."

"Oh! I have transportation issues. I don't have a car."

"Oh! (Thinking: why did he think this plan was going to work, then?) Well then, I really can't think of any way to get this to you before the pharmacy opens."

"Oh. OK."

I hang up and shake my head and smile. Strange that people would try and deal so ineffectively with these issues at 2 in the morning. I lie back down only to get another page within 10 minutes from the same patient:

"Hi again. What can I do for you?"

"Hi Dr. McLaughlin. I've got 3 cigarettes left, and I'd like to quit smoking. Can you call in a prescription for me for a nicotine patch?"

"Um... no."

He called back again tonight, asking for prescriptions for his albuterol and nicotine patches. I'm not sure why he didn't call during the regular office hours. I called them in again, though the pharmacy closed 20 minutes before he called. The thing is, I'm quite confident nothing medically dangerous is going on. I suppose I can relate to someone with an atypical sleep-wake cycle, being on nights myself right now. And I suppose it's good that he feels he has someone that he can go to with his concerns, though I'm not sure how much I helped. My guess is that it's hard for him to establish those kind of connections. And then, there's the issue that, at some point, you have to stop and inform him of the boundaries for appropriate usage of this phone service. Or maybe it's just one of those quirky, humorous life stories.

...Start Putting Them In The Water

Just like any other field, in medicine we joke that some day soon they'll start putting some of the more popular pharmaceuticals in the drinking water. Well, it appears that we already have, more or less passively, albeit in amounts so small it's trivial. But, don't worry, any of you men out there who feel bad knowing that female hormones may be in your drinking water can just rely on the anti-anxiety and anti-depression meds also there to provide the necessary balance.

(In truth, I'm just posting this to move those restaurant logos out of the top blog spot. Why did I do that?)

Lobster Tail at Market Price

This is part of a story my wife would be unlikely to blog/brag about, so I'm telling it. There is a (in my opinion) very fine tradition at Rachel's residency program, where any resident who scores above a certain percentile on their annual inservice exam is treated (significantly, with their significant other) to a dinner on the house at the Chop House, Ann Arbor. The most-improved resident also gets a spot at the table. The remainder of the residents are taken out to White Castle by another boss physician, a tradition aptly termed "Chomp House". This is the third of four of Rachel's years, and we just got the news that she scored high enough for the third consecutive year, and was also the most improved. (I wonder if that means we can take a meal to go?)

Oh, Chop House, how I love thee! And how I would never shell out the cash to go there if it wasn't free. Fine service, excellent presentations, superb wine. The lobster bisque is a must to start off with, but the entree is always an interesting choice. Our first year, we were more cautious, ordering a middle-of-the-road steak (price-wise). Last year, I plucked up and splurged on the $54 Kobe beef steak, which was the finest steak I have ever tasted. The last great hurdle is the South African Jumbo Lobster Tail (roughly the size of a football), which goes for a mere "market price". Market price? You don't even want to know.

My wife is good to me. And by the way, she gets excited about this, too.

Ships Passing In The Night

Not quite as idyllic as this photo, we have ventured into the month of February, and we are very thankful that it's the shortest month of the year, for the following reason: Rachel is on nights, and Eric on days. Rachel is off weekends, and Eric is on.

Here's the weekly run (with minor variations): Sunday night through Friday morning, Rachel works 14 hours every night. She gets off at 7am, when Eric goes into work, and goes back in at 5pm, and Eric arrives home shortly thereafter. Most of the weekend, she is free, but Eric works at least half of each weekend, including overnight. Thus the challenge.

After we spent 4 out of the 12 months before our wedding in different hemispheres, the first words out of Rachel's mouth were "Let's never do that again." And we still hold to that, and currently we wish our schedules seemed less reminiscent of that time. But there's a few things we cling to.

First, that time does pass. This is an amazing fact, but not quite as amazing as our hearts' unwillingness to recognize it. Heart knowledge of this kind seems to come with age, and we're still pretty young, as that goes. But we've learned it some, and we hold to this truth. Second, we have had difficult months before, and when entrusted to our heavenly Father, we are amazed that time together can materialize in the strangest places. Will this trend continue this month? We don't know, but God's behavior in the past gives us reason to think he might act similarly in the future.

So pray for us. Send Rachel nice emails and visit Eric in the evenings. =)