Friday, January 29, 2010

Spot the subtle change and win a prize

You might have to look hard, but it's right here in the blog.

What's the prize?

I will honor the winner(s) in March when I make my monthly donation to Partners in Health. There's a spot in the online form to designate one or more names when the donation is in honor of somebody.

That somebody could be you! ;^)

Hanx to Christian at Pallimed for the whole contest/prize idea...

Thursday, January 28, 2010

For J, her family, and her dad

Yesterday, I attended the funeral held for J's dad. J is of one of my dearest colleagues.

She's the physician's assistant who manages the day to day ICU care of neurosurgical patients, along with a nurse practitioner and first year resident. She's bright, capable, confident, and very caring. I include her among the clinicians who influence the way I think about my practice, who guide it, and who I most like to work with.

That's the way it is, isn't it? We look back on years spent in school, or anywhere, and count the best teachers we've had or friends we've known on the fingers of a single hand.

One of the ways that J and I work together is to extubate patients. In our unit, unless the patient is at very high risk for needing reintubation, or has a prior history of difficult intubation, the actual process of extubating them is pretty straightforward. It's done by a nurse and a respiratory therapist, and is over in a matter of seconds. Of course, those few seconds are the anticlimax to lots of careful assessment and preparation, which is where J comes in. The senior resident on the team, or maybe an attending, may note on rounds, "Let's try to get this person extubated." But the team quickly moves on to their next patient, so exploring that possibility, and making it happen when it's the right thing to do, is one of the ways J and I work together.

I've developed a mantra: "Breathe, or die."

It's not a threat, or a sign that either of us takes anything we do lightly. Far from it.

It's a simple statement of fact, and it keeps us keenly aware of the seriousness of it all. The mantra is a way to be sure that what we're going to do is something that should be done.

J's dad died suddenly and unexpectedly. It was an accident. He had two daughters, a wife, and several sisters. His brother died before him, as did his father and uncle who started the manufacturing business that he ran.

I read his online obituary, and looked at his picture there. J's father stands relaxed in a vested tuxedo. Perhaps the photo was taken at her wedding.

I've accepted the fact that I'm older than many of my colleagues, and that I'm even older than some of my colleagues' parents. Now I'm older than at least one colleague's deceased parent.

The funeral was held at a small catholic church tucked away in a pocket of rural New Hampshire. The place was filled. I was pleased to hear the priest who gave the eulogy. He spoke well, and he spoke well of J's dad. He knew him.

At the end of the service, a pianist and a singer in the choir loft began the tune, 'How Great Thou Art.' The musical arrangement was a simple one, and at first the singer's voice was soft, even a bit hoarse and almost bluesy. He slowly gained force with each line, and by the end he was firm, clear, and direct. It was moving. It fit the time and place. It fit our reason for being there.

Then, just a few short seconds after the last notes of the hymn faded from the piano, a man standing just outside the door began a dirge on his bagpipe, and continued playing as we all filed past.

I didn't go on to the cemetery, and returned home along the same quiet back roads I had taken earlier. I thought about the music I had just heard, and about the power music can have at a time like this.

I love listening to opera, though I often don't know the specifics of a particular story when I first hear it. What really grabs me is the sound of the singing, and its emotion. I've been told that, in Italy, opera goers are as passionately involved during a performance as the most rabid Red Sox fans at Fenway Park.

I was lucky to be in the stands for Clay Bucholtz's no-hitter. I understand how someone sitting up in a music hall balcony can be brought loudly to their feet upon hearing a performer really nail it.

There's an episode of 'Six Feet Under' that features a famous aria from Pucini's last opera, 'Turandot,' as part of a man's memorial service. It's a quieter than usual performance of the well-known piece, 'Nessun Dorma.'

The priest who spoke at the funeral talked about the catholic faith in everlasting life, though he presented it as a certainty, as something that catholics know to be a fact.

I have to admit that I'm not nearly as sure about all of that.

I'm going to send a note to J in one of my daughter's cards. I don't know when I'll next see and work with her, or even if. I think I'm also going to include a CD that my son's band recorded. He's the drummer, and he calls their sound a mix of rock, funk, raggae, and rap. They write most of their own stuff, including a tune called 'Life Goes On.' Maybe it will fit a time and mood for J at some point.

For now, here's a 1980 performance of 'Nessun Dorma' by Luciano Pavarotti, with Zubin Mehta conducting the New York Philharmonic. I'm told that this clip shows Pavarotti in his absolute prime. I found another by him here, in a 2006 performance that's listed as his last one ever. He died the following year. I also enjoy watching this version by Roy Cornelius Smith, which has the added benefit of featuring the song in the context of the staged opera.

Maybe the priest is right, and everlasting life is a lead pipe cinch. If that's the case, I hope it unfolds like Pavarotti's singing.

Nessun dorma! Nessun dorma!
Tu pure, o, Principessa,
nella tua fredda stanza,
guardi le stelle
che tremano d'amore
e di speranza.
Ma il mio mistero è chiuso in me,
il nome mio nessun saprà!
No, no, sulla tua bocca lo dirò
quando la luce splenderà!
Ed il mio bacio scioglierà il silenzio
che ti fa mia!
(Il nome suo nessun saprà!...
e noi dovrem, ahime, morir!)
Dilegua, o notte!
Tramontate, stelle!
Tramontate, stelle!
All'alba vincerò!
vincerò, vincerò!

Nobody shall sleep!...
Nobody shall sleep!
Even you, o Princess,
in your cold room,
watch the stars,
that tremble with love and with hope.
But my secret is hidden within me,
my name no one shall know...
On your mouth I will tell it when the light shines.
And my kiss will dissolve the silence that makes you mine!...
(No one will know his name and we must, alas, die.)
Vanish, o night!
Set, stars! Set, stars!
At dawn, I will win! I will win! I will win!

Saturday, January 23, 2010

Quick tech update

I've just completed a complicated and mysterious task, namely: I've snagged the domain name, and have set a stealth pointer from it to my blogspot address.

So, from now on anybody can access this blog without having to enter the slightly more awkward text -

Wow. Amazing. Be sure to tell your friends.

Since that's now taken care of, perhaps I can turn my attention to developing some actual content consistent with my goal of exploring end of life care issues for nurses, laypeople, and other health professionals.

Friday, January 22, 2010

Makes sense to me

This post has little to do with end of life, but much to do with blogging.

One of the sources I'm drawing on in developing my paper, tentatively titled "Bloggers Blogging Blogs: An examination of what it is, what it means, and why I think it's pretty freaking cool," is Scott Rosenberg's most excellent book, Say Everything: How Blogging Began, What It's Becoming, and Why It Matters

(Yes, I've added this link as a new Amazon Associate. Buy the book, and baby gets a new pair of shoes.)

Rosenberg's work is both rigorous and readable, just like the best blogs. Here's a small piece (pp 87-88) I want to share:
(Jesse James) Garrett describes the transition as one from a static to a dynamic form. "At first, if you were doing any kind of personal website, I think people approached it as a hobby like woodworking: you were going to craft this beautiful little object...When you crossed the threshold to (blogs), that represents our realization that this is a dynamic medium. It's not about pushing an object into the world, it's about opening a channel between yourself and the world."
On second thought, maybe there is something about end of life in there.

Wednesday, January 20, 2010

Carrying on

I've really had my hands full these last couple of weeks.

Among other things, I'm slogging through the last remaining assignment for the online course I started in September, and which I've blogged about here. I jumped over this particular assignment, a formal research paper using the APA format, and completed the final project. But now I've got to get the paper done. I first got an administrative extension, but that expired on Saturday. Now I'm working with a new deadline of February 8th.

I can do it. I know I can do it.

The paper's actually been kind of fun. My subject is blogging, and there's some really good material on the topic to draw on. I've just never done such formal writing before. We'll see how it goes.

Meanwhile, I've been keeping up a combination of emails and visits with Amy's family. Her death has been very much on my mind, in many ways.

I've lately been thinking about the stark contrast between the unfulfilled promise of Amy's youth on the one hand, and the certain grace with which her two siblings, Phil and Evelyn, not so much older, rose to face the reality of her death. So, too, did Kaitlin, the girlfriend of Amy's brother.

Adults are supposed to stand strong at a time like this. It's what we expect, even from the parents of a child who's died. But to see such young adults, and by that I mean adults who are still young themselves, and who've had no previous opportunities to prepare, carry themselves with dignity...well, let's just say it gives me hope.

I recently wrote to Kaitlin:
...when I said that I was moved and proud to see Phil and Ev, I also meant you, and how you stood with them. As someone who's sort of standing on the threshold of being an old fart (and I emphasize the qualifier "sort of"), it's comforting to see the next generation moving into place.

I feel that way about my own two kids.

I'm also reminded of my mother in law's funeral, just over 5 years ago. She was in her 80's, and had lived a very active life right up until her final week. She died at home, surrounded by her children and grandchildren, which is about as good as it gets.

When Jeanne (my wife) and her siblings were working out the details of their mother's funeral, the question of pallbearers arose. I suggested her grandchildren, and the siblings promptly agreed.

We had gotten into the limo, and were waiting outside the funeral home to get underway to the church. Eight of my mother in law's grandchildren between the ages of 18 and 28, six of them young women, two of whom were pregnant, stepped out with her casket, then loaded it into the hearse.

These were the same grandchildren whose young faces appeared in endless holiday photos and pictures of poolside parties going back to the late 1970's. And now here they were.

My sister in law, Mary, the mother of 3 of the pallbearers just said, "Well, look at them." We all knew exactly what she meant.

Just look at you.

Sunday, January 17, 2010

The kindness of others

Kindness is a hard concept to pin down. The word's innocuous, like the word 'nice.'

One the one hand, everybody knows what both words mean. We hear them every day, we're admonished and encouraged to act towards others in these ways, to do things that are nice or kind, and we each try so hard so often to do just that.

But I think it's precisely because the words are used so often, and so readily, that they've lost their meaning. We don't really know what somebody's saying when they say that something we do is 'nice,' or observed that we've been 'kind.'

Well, speaking for myself, I'll say that I don't always know what somebody's saying when they tell me that a thing I've done or made or said is nice or kind.

I've had that experience - once, at the end of a laundry list of alleged transgressions, it was observed that something I did was 'nice.' It sounded like an insincere acknowledgment, a back-handed compliment with the emphasis on back-handed.

I also had another recent experience, two of them, actually, and both came as affirmations of what kindness and thoughtfulness and being nice can really mean. They were each delivered directly to my door by a uniformed employee of the federal government, which is also a nice thing. Who doesn't look forward to the mailman?

The first was from an old acquaintance who still publishes a highly-regarded paper newsletter about food. John Thorne is the equivalent of an online or blogging buddy from the days when the world wide web had been conceived, but not adopted or even known by anybody who wasn't a diehard geek or computer researcher at CERN. I was struggling back then with my own publication 'Tips From the Pit,' so-called because I was determined to make my name as the foremost authority on all things barbecue, and after I first reached out to John he never stopped commenting, encouraging, advising, and cheering me on, in pretty much the same way that those thousands of people line the route of the Boston Marathon each April, holding out paper cups of Gatorade for the runners to snatch along the way, yelling at them "You can do it! You can do it!"

I reconnected with John last month when I ordered a copy of his latest book directly through his web site, as a gift for my son's girlfriend. Among the many other benefits of eliminating the middleman, I got an inscribed and autographed copy, which made for an impressive gift. I followed his package to me by sending him and Matt one of my daughter's holiday cards. John, in turn, sent me a copy of his very fine limited edition essay on milk toast, including the inscription, "When the world is too much with you."

The second came from a nice young man named Shin, who lives in Korea and is pursuing my daughter with what I believe are the best intentions. They met online, each helping the other learn their respective languages, and at some point not too long ago Shin decided to fly halfway around the world for a face to face visit. He joined us for dinner one night. I barbecued a chicken.

Shin's 'thank you' package arrived at the same time as John's hand-crafted pamphlet, and included a fine note for Jeanne and me, along with two bookmarks. I got the one with a picture of a woodpecker, and Jeanne selected the one illustrating an old Korean folk tale that involves beautiful young girls on a swing by the river, and timid monks watching from behind the bushes.

I'm also grateful for the comments and emails from the small, but big-hearted, audience that keeps an eye on this blog.

All of these gifts aren't just kind of nice. They're true kindnesses, and they're very welcomed.

Wednesday, January 13, 2010

That which doesn't kill me makes me stronger

I never really paid much attention to that apocryphal phrase, or when I did I quickly dismissed it as some kind of slogan that's not only of no personal interest, but which I associate with a kind of appalling hyper-macho sentiment.

I feel differently right now. The saying makes sense, and is directly applicable to where I find myself at this particular moment. It's even a source of comfort.

As the old year's faded and the new one's blossomed, I've faced three distinct and serious challenges. They've collectively forced me to confront death, the meaning of family, and my professional identity. The three challenges are different and distinct, but they've also reinforced and played off each other in my mind.

I've been writing here about the death. I mostly knew Amy when she was a shy but sparkle-eyed pre-schooler and kindergartener with the kind of captivating smile that only a child of that age can genuinely display. She was the youngest, smallest, and quietest of the five children I drove each day to school, two of whom were her older siblings, and the other two of whom were my own son and daughter.

Amy had grown up considerably when I last saw her, when Jeanne and I enjoyed a late summer dinner with her parents. She was tall and beautiful, with an outgoing presence and unmistakable sense of confidence. She was looking forward to her transfer from the nursing program at St Louis University after her sophomore year, to the program at Boston College, and Jeanne was making arrangements to provide her with some of the required texts.

Now, she's gone, and the whole nursing profession has lost a promising colleague who would have made such a tremendous difference in countless peoples' lives.

I haven't spoken of my family, but it's a pretty simple matter: I have an older brother who's been relentlessly abusive my entire life. The reasons are his, as is the sickness they stem from. His daughter, who was born within five days of my son, and whose early birthdays we celebrated with joint parties, is getting married at the end of this month. My three other siblings and their spouses are going to the wedding, but Jeanne and I did not even receive the engagement announcement last summer. We only learned about it while visiting my oldest brother, when we saw the photo card lying on his coffee table.

It pains me to be so coldly excluded from a rare family celebration, but the actions of my brother and sister-in-law are even more despicable. They've drawn our respective children into the emotional cesspool of his unresolved anger and their shared petty grievances.

I wonder what their conversation with my niece was like, as they drew up the guest list? I wonder what her brother, my nephew, is thinking, knowing that his "coolest," though infrequently-seen, uncle won't be there? And since there are few secrets in the age of Facebook, I've had to answer my own kids' questions, "Hey, Natalie's engaged. What's up with the wedding?"

I tracked down the lucky bridegroom - one of my sisters read his name to me over the phone from her copy of the invitation, though she never commented on why I didn't have my own. I located his parents and spoke with his mother, who assured me that she'd forward my gift as soon as she received it. I checked the online bank balance today, and learned that Natalie and Louis have cashed our gift.

One small victory, and a sign that good faith can still prevail.

Peace out.

Thursday, January 7, 2010

A year begun

I had resolved, sort of, to start posting here more frequently this year.

We're already one week into it for this first post, only my fifth since last month's magnum opus.

Work has been very busy, with much to do and even more to reflect upont.

And holiday time profoundly intereferes with most matters not directly associated with trees, turkeys, and generally, though not exclusively, crappy music.

Mostly, though, my thoughts and feelings have been for our friends Jeff and Melissa, and their two grown children, Phil and Evelyn, with the sudden death of their daughter and sister, Amy.

While talking with Melisaa recently, I noted that Amy's death had challenged me with feelings that I hadn't anticipated, and that I generally don't encounter with patients and families around end of life.

I guess one reason is that right now I don't have the benefit of my professional armor, the role and boundary that protect me while enabling me to be most helpful to others. The pain of Amy's family is too stark, and we're too close as longtime neighbors and friends. I've become, or made myself, a part of this story, with a role I don't normally fill.

It's a role that I accept, even treasure. It's always a priviledge to be part of a death, and I don't have to further explain that sentiment to readers and colleagues who've chosen this work.

After drawing upon James Joyce's The Dead in my most recent post, I turned to John Huston's extraordinary film adaptation.

The story weaves together many important themes, among them loss and remembrance. Huston faithfully turns Joyce's carefully crafted words into thoughtful action. Among the many key scenes is one in which Gabriel watches as his wife, Gretta, is drawn into her own memories and grief.

Here's how Joyce introduces the scene:
Gabriel had not gone to the door with the others. He was in a dark part of the hall gazing up the staircase. A woman was standing near the top of the first flight, in the shadow also. He could not see her face but he could see the terracotta and salmonpink panels of her skirt which the shadow made appear black and white. It was his wife. She was leaning on the banisters, listening to something. Gabriel was surprised at her stillness and strained his ear to listen also.
Here's how Huston conveys it:

I think what Gabriel demonstrates, perhaps contrary to Joyce's intent, is the importance of bearing witness. I can identify with him here as I consider Amy's death.

Neither of us can know the pain experienced by the ones we stand with. It isn't ours to have, or heal, or even comment on.

But I think we can bear witness to that pain, and thereby do something very important, even essential.
If you'll be the lass of Aughrim
As I am taking you mean to be
Tell me the first token
That passed between you and me

O don't you remember
That night on yon lean hill
When we both met together
Which I am sorry now to tell

The rain falls on my heavy locks
And the dew it wets my skin;
My babe lies cold within my arms;
But none will let me in