The Butterfly

What a beautiful morning! Surfboard in hand. Cool sand slid between my toes. The breeze kissed my face. The soft, warm glow of the sun crept up. The water invited me in. The board knifed through the water. The only sound was of my hands exiting the water as I paddled. As I renewed my friendship to the ocean, the east coast of Florida came to life. The waves were perfect. It was in effect that morning. In the lull between swells, I thought of the butterfly.

Long day at work. No news from Georgetown med, but maybe I will hear from them today. I kicked myself for applying so late, although I knew circumstances had not allowed me to really apply much earlier. Heck as it was I lucky enough to take the MCAT and get my application out period. Life has a way of happening while you are making other plans. Lennon was definitely right about that one. Let's see here. Bill, junk mail, have no idea what this is, a letter for Georgetown. Oh shit, a letter from Georgetown. Oh shit, it is not a packet...just a regular letter. Is this a Dear John? Crap. Should I even bother opening it? Who am I kidding? Of course I am going to open it! "We are pleased to..." I didn't need to read another word. I collapsed into the couch and thought of the butterfly.

The port was its usual, commercial fisherman, leisure fisherman, the local assortment of alcoholic fishes, sunny day. I figured the bench was a nice spot to wait. Near the entrance, maybe I could catch a glimpse as she was walking in. If it were not for the gum I had chewed for the last few hours, then my jaw would have been on the floor. Stunning, not enough. Gorgeous, nope, still not enough. Matter of fact, I'm still looking for the right descriptive term. Did I just become the luckiest man on the planet or what? She made me nervous. I never get nervous any more. Suddenly, I felt alive. I sat there completely lost in her. Naturally pretty, eyes that could make a blind man cry, an inviting smile. Pearl necklace with a nice blouse. Legs that didn't stop. Sandals. We had barely said two words to each other, and I was already in the hurt locker. By the end of lunch, I couldn't get enough, beautiful, passionate, funny, loving, caring. I completely melted in my state of paralysis. She was real and right there in front of me. On my drive home, I thought of the butterfly.

I often wonder about the butterfly. At the heart of a very complex system that intertwines us all with the environment around us lies the butterfly. In a wonderful kind of way, every event no matter how small or how great is dependent on those events that came before it. The butterfly batting its wings halfway across the world plays a roll in the wind patterns that affect the surf on the coast of Florida. And, what if those wind patterns set in motion a chain of reactions that allowed me to surf on that beautiful day, get into medical school, let alone meet a woman I completely and utterly adore. I smile when I think of all the possible ways a butterfly may have affected my life. Secretly, I see butterflies as God's angels. It is entirely possible that his work is passed along through butterflies. Entirely possible.

I took it.

Today, I turned around, sped up, and ran right at the damn thing. I caught myself sliding into being okay with okay. I might as well as put up the white flag, high and bright. In the middle of a long run today, I finally broke out. I grabbed that damn 500lb demon off my back and told it to go straight to hell. Except that, it landed on its feet and took off after me. Snarling and energized by fear, the beast accelerated. I felt it gaining on me. I ran faster and faster. It continued to close the gap. It saw me as prey. The beating of its claws grew louder and louder against the concrete. I had had enough. I turned around, sped up, and ran right at the damn thing. I stared right into its eyes. They glowed deep red. Its teeth were exposed, ready to pierce and tear flesh from my body. I have seen this beast many times before in my dreams lately, and every time the dream ended before battle but not tonight. Tonight, this beast was going down. It launched itself at me with a ferocious silence, claws engaged, teeth ready. I in turn braced to dismember it, sword in hand. There was no impact, no collision, no two unstoppable forces colliding in the night. There was only sound of its body slamming into the ground with its head landing a few seconds behind and at a distance of several feet from its body. Tonight, I took it.

Mist

Just out of reach
Like the mist
There she is
No longer a dream

I see her smile
Her lips curl gently
Warm
Inviting

I fall into her eyes
Deep as the sea
I'm lost
Completely captivated

I hear her voice
Relaxed and pleasing
I'm paralyzed
Lulled, not wanting to move

Don't leave
Stay a bit longer
As long as you like
Forever works for me

I Saw Poop Move And So Can You.

It was a first for me. There I was just minding my own business taking Lela for a walk. I've never seen poop move. "Why is it moving?" "I hope answering the question of why doesn't require me to pick up the poop." "Oh man, I don't even want to think about what would happen if Lela sees this poop moving. She might actually try to eat it thinking it was some kind of small animal." "Would I have to brush her teeth if she actually ate the poop?" "Would it make her throw up?" "Would I throw up?" "What if we both throw up?" "Would it be worse if it was her old poop or some other dogs poop?" Lucky for me, Lela wasn't as interested in the moving poop as the sentient being next to her. I wonder if this degree of wonderment will ever leave me. I vividly remember the moving leaves of Panama. A highway full of small leaves, marching to the beat of their own drummer, dribbling along the ground from bush to underground fortress. The leaves were at the mercy of what I considered Super Ants and later Army Ants (really called Leaf Cutter Ants).


http://animals.nationalgeographic.com/staticfiles/NGS/Shared/StaticFiles/animals/images/800/leaf-cutter-ant.jpg

I imagined the bunker was the size of our house with the walls constructed completely of green leafy paper. Their city probably had all of the facets of any city: government, stores, homes, and even that horrible thing called school. I wondered about their holidays and if they had weekends or a beach to go to. But, as I later learned in life, the most important question I asked that afternoon during my childhood was, "Why?"

So, why was this poop moving? Okay, so I have to be honest. I was really hoping for see the really cool Dung Beetle of Africa.


http://www.south-africa-tours-and-travel.com/images/flightless-dung-beetle-mike-gerhardt-addoelephantnationalpark.jpg

But, I had to settle for some kind of local beetle bench pressing the poop. The beetle was huge, about the size of those damn bluetooth headsets that people run around with sticking out of their ears. On a side note, I have a theory that those people are actually aliens using those damn bluetooth headsets to translate our language into their native tongue. Let it go, it's a working theory. Back to the case at hand, moving poop equals large beetle getting in an afternoon workout...don't fall into the trap of immediately jumping to African Dung Beetle, as you just might be mistaken.

Taxonomy Spoiler: In actuality, the African Dung Beetle and the beetle I found earlier this afternoon belong to the same scientific family and subfamily, Scarab (Scarabaeidea and Scarabaeinea...yes, you can put that many vowels into the same word, thank you Latin). This means the two beetles are related and one might even consider the beetle I found today to be a North American Dung Beetle.

Lub Dub

Lub dub…lub dub…lub dub
Sweat beading on my forehead
Deep breath, fogging my eye shield

Lub dub……lub dub……lub dub
Knife
SLAP as the knife hits my hand

Lub dub…lub dub…lub dub
Second deep breath, fogging my eye shield
Blasted mask

Lub dub……lub dub……lub dub
Stroke of the blade with firm pressure
Skin separation under tension

Lub dub……lub dub……lub dub
Suction
SLAP

Lub dub……lub dub……lub dub
Stroke of the blade.
Fat slides away.

Lub dub……lub dub……lub dub
Stroke of the blade.
Fascia yields.

Lub dub……lub dub……lub dub
Small retractors, no make it large retractors.
2nd set of hands, pristine metal tools under command.

Lub dub......lub dub……lub dub
Monitors scream and flash.
Shit…

Lub dub…lub dub…lub dub
Blood, blood, blood.
Suction the field.

Lub dub…lub dub…lub dub
Start norepi, IV saline wide open.
Where is that damn blood I ordered?

Lub dub…lub dub…lub dub
Blood pressure spirals down.
Under my breath, F&#* me.

Lub dub…lub dub…lub dub
Max the norepi.
Where did this little shit go?

Lub dub…lub dub…lub dub
Under my breath, stupid kid.
Why did he have a gun anyway?

Lub dub…lub dub…lub dub
Lub dub…………………………..
Piercing constant alarm.

Lub dub…lub dub…lub dub
I can’t find the goddamn bleeder.
Damn it. Stupid kid.

Lub dub…lub dub…lub dub
Time of death, zero one thirty-five hours.
Stupid kid.

Great Balls of Fire

It was once stated to me, "...that will be one of those memories that flashes before me as I die." The words were absolutely perfect and absolutely true. The statement presented in the context of a happy moment in life. I like that idea of my memories flashing before me as I pass away. I imagine that all such memories are not just happy memories. I think it would be wrong to imagine it as such. Life is so much more than happy. Some of my most powerful memories root themselves in loss under such terms of death, leaving home, not having a dad around for a few years, and personal sacrifice in family time. For many of these memories, oddly, I fear forgetting them, thus I keep photographs or physical reminders around me. On my wall is a picture of Columbia's last re-entry as seen on the cover of "Times" with the caption, "The Columbia is lost." The crew's faces, mannerisms, and days on orbit remain burned into my thoughts. In my truck, I keep reminders of my dogs who passed away. For a long time, I kept tokens of injuries that ended my chances of advancing into the world of soccer. And yep, somewhere I have memories of past romantic relationships. Some of these memories feel more like scars than memories. I have noted this to be the case especially with the death of some patients. These patients are the ones who in my mind shouldn't have died yet. When this happens I find myself flashing back to the Columbia's balls of fire. As a kid, I pictured doctors to be these people who could strike down death with fierce unwavering intention to pull people back into the living. Back then, I secretly wanted to be that guy. I wanted to pull people back who shouldn't die yet...along with saving the world from something. I now know that guy really doesn't exist most of the time. However, every now and then if you are in the right place at the right, then you get to be that person. You get to be the person who says, "Not now, not today." When those moments occur then just maybe I will get to see them again right before I die.

Perspective

After a pretty intense month in the ICU, one's perspective on life and priority decisions shifts. Anyone who as spent any amount of time around death knows that something changes in a human being after you have stared down this beast. It morphs from this far off almost imagery place to a very real and very close demon with blood dripping from its claws and its cold, damp breath sending a chill down your spine. Your body wants nothing more than to run from it, but you demand more of yourself. In lieu of performing instinctive behavior, you go toe-to-toe with a monster who takes the very life out of its victims.

For quite some number of years now, I have been in positions where the decisions I made had very real and very ultimate consequences. A month in the ICU only reaffirms the importance of preparedness, of calm in the face of panic, and of team work. There is also this realization of perspective. For some people, as was the case of the gentleman behind me at the coffee shop earlier today, a 'rough day' means they had to spend a whole hour taking care of a cell phone problem that really wasn't a major problem to begin with. To the team in the ICU, a baseline 'rough' day means death and then talking to the family. I learned an important lesson about perspective. Just because I am privileged in what I do for a living, i.e. taking care of sick people and dealing with really deep issues/problems, does not give me the right to stomp on someone else who's problem is of questionable less severity. Quite simply, one must be charitable in character. In other words, something that isn't a big deal to you may be a very big deal to someone else. This is a very hard lesson for me, and at times I must revisit it.

Cheers.

Damn If You Do...

You never know what you will get in the emergency department. Two a.m., as I walked into the room, I found a near eighty year-old nearly climbing out the emergency room bed as if she was a 1 year-old trying to get out of the crib. “Ma’am, I need you to say in the bed.” I repeated iterations of this line three more times. She never responded to me, and further she never really acknowledged my presence in the room. She had a blank stare that looked off into infinity. Her language was broken beyond all recognition. Something was seriously wrong; at that point I had not a clue beyond knowing something was seriously and critically wrong here. “Nurse, let’s get some ativan on board, one now please.” This situation was becoming unsafe for the patient. Soon thereafter she calmed down, but unfortunately she still could not tell me what about what happen. I turned to her desperate sister who could only seem to focus on the wrong details of what happen, as if she was trying to explain why the Moon orbits the Earth by comparing it to Chinese economics. Quite frankly, I spent more time redirected the interview than anything else. Fortunately, I was able to obtain some crucial facts and then had a chance to exam her along with looking over the few labs the emergency department had obtained. Unfortunately, it seemed the emergency physician dismissed the case as soon as the call was made to the ICU; such a move is very dangerous for the patient. Furthermore, the physician couldn’t muster any kind of handover or briefing for me. She quite simply left me to my own devices in lieu of working with me. Fortunately, I was able to get down to the E.D. quickly from the ICU. In summary, I found the patient had a critically low sodium level, level low enough to kill and kill quickly. I also discovered a mass in her lower abdomen, which I diagnosed as an incarcerated hernia causing a blockage of the intestines. At least I could now explain the history of vomiting, dehydration, and to a certain extent the low sodium. I ordered another liter of saline, wide open. Now the delicate balance between ultra low sodium levels causing death and repleting the sodium too fast causing irreversible brain injury began. I had to replete her volume and her sodium, but I had to do so without killing her. In all honesty, the quick rehydration is what saved her life, but in the process nearly caused me to lose a few liters of sweat. Given my examination of her, I ordered a surgery consult. They dismissed the hernia as of being any concern by countering my claim of intestines being trapped in the hernia. I left the unit shortly thereafter…my 24-hour shift turned 36-hour shift had to end sometime.

A full day of rest.

6 a.m., good morning to the ICU. I went immediately to my patient that I admitted over twenty-four hours prior. What an amazing sight! She was completely different. I sat and talked with her for a good 15 minutes, and then I read the reports and notes. Turns out, the surgeon, that night, was wrong, and she very much needed surgery and did get an operation soon after I left. What was neat really neat about the whole thing was the attending general surgeon on service came over to our team in the middle of morning rounds. He apologized to us and was thankful we were so persistent. Apparently, after I left on that prior day, our team lead went ahead and had the patient scanned despite surgery words. Later in the day, I had the pleasure of writing the transfer note to step the patient down to the regular hospital wards and also to meet with the patient and her sister again. I cannot explain the feeling of knowing that I played an important role in saving someone’s life. It is pretty damn neat.

Code Blue

"70 year old male, witnessed cardiac arrest, CPR in progress, peripheral IV line established, intubated, non-shockable rhythm. We'll see you in five." It is an eerie feeling, the waiting that is. You look the room over, equipment in place, personnel ready, white coat off, gloves on, then silence. It is not the normal quiet of the evening as you wind down before bed. This silence pierces your every thought, only interrupted by controlled breathing. The damn thing happens so quick. Someone says, "they're here." You peek down the hall to see paramedics and a gurney wheeling toward the room with one paramedic compressing a chest. With a blink, things fast forward, and now you are walking away from the room. Some of the team perhaps even you is sweating and physically tired from the compressions. You replay the entire course of events, questioning your decisions. Nevertheless, it is over. You don't forget. You try, but you don't forget.