It may be that when we no longer know what to do we have come to our real work and that when we no longer know which way to go we have begun our real journey. The mind that is not baffled is not employed. The impeded stream is the one that sings.The world, the truth, is more abounding, more delightful, more demanding than we thought. What appeared for a time perhaps to be mere dutifulness … suddenly breaks open in sweetness — and we are not where we thought we were, nowhere that we could have expected to be. ~Wendell Berry from “Poetry and Marriage: The Use of Old Forms,” in Standing By Words
Who among us knows with certainty each morning what we are meant to do that day or where we are to go?
Or do we make our best guess by putting one foot ahead of the other as we were taught until the day is done and it is time to rest?
For me, over four decades, I woke baffled each day that I was allowed to eavesdrop on heartbeats, touch tender bellies, sew up broken skin, set fractured bones, listen to and through tears.
I woke humbled with commitment and duty to keep going even when too tired, to offer care even when rejected. to keep striving even if impeded.
Doing that work, I learned that obstacles will slow but cannot stop the cascade of love and hope over the rocks of life.
My days overflow with the uncertainty of what comes next: finding my real work is to wade in deep, tumbling over the barriers and still keep singing.
Simply keep singing.
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My great grandfather had some fields in North Carolina and he willed those fields to his sons and his sons willed them to their sons so there is a two-hundred-year-old farm house on that land where several generations of my family fried chicken and laughed and hung
their laundry beneath the trees. There are things you know when your family has lived close to the earth: things that make magic seem likely. Dig a hole on the new of the moon and you will have dirt to throw away but dig one on the old of the moon and you won’t have
enough to fill it back up again: I learned this trick in the backyard of childhood with my hands. If you know the way the moon pulls at everything then you can feel it on the streets of a city where you cannot see the sky.
I may walk the streets of this century and make my living in an office but my blood is old farming blood and my true self is underground like a potato.
I have taken root in my grandfather’s fields: I am hanging my laundry beneath his trees. ~Faith Shearin from “Fields”
It just isn’t possible to completely take me off the farm – I have generations of farmers extending back on both sides of my family, so I have dug myself a hole here, resting easy in the soil like a potato and ventured out only as I needed to in order to actually make a living.
A gathering of all my vaccinated clinic colleagues came to our farm yesterday to help me celebrate my retiring from office life. They brought beautiful flowers, plentiful food, kind and restoring words, thirty year old photos and lovely parting gifts, as well as my singing doctor buddy sharing a sea shanty about bittersweet parting. It is helping ease my sorrow at leaving regular doctoring behind, knowing there are more days to come, more time to grow things in the ground, more blissing out over sunrises and sunsets and more hanging laundry on the clothesline.
My dear friends know where they can find me – on the hill above our farm – we may or might never, meet here again but it was such a fine time together yesterday, thank you!
Kind Friend and Companions, Come join me in rhyme, Come lift up your voices, In chorus with mine, Come lift up your voices, all grief to refrain, For we may or might never, all meet here again Here’s a health to the company and one to my lass, Let us drink and be merry, all out of one glass, Let us drink and be merry, all grief to refrain For we may or might never, all meet here again Here’s a health to the dear lass, that I love so well, For her style and her beauty, sure none can excel, There’s a smile on her countenance, as she sits on my knee, There’s no man in this wide world, as happy as me, Here’s a health to the company, and one to my lass Let us drink and be merry, all out of one glass, Let us drink and be merry, all grief to refrain For we may or might never, all meet here again, Our ship lies at anchor, she’s ready to dock, I wish her safe landing, without any shock, If ever I should meet you, by land or by sea, I will always remember, your kindness to me, Here’s a health to the company and one to my lass, Let us drink and be merry, all out of one glass, Let us drink and be merry, all grief to refrain For we may or might never, all meet here again Here’s a health to the company and one to my lass, Let us drink and be merry, all out of one glass, Let us drink and be merry, all grief to refrain For we may or might never, all meet here again
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It has been a long 18 months of dwelling deeply in all kinds of “supposes” and “what ifs” because people were being crushed by a virus right and left.
I understand this kind of thinking, particularly when “in the moment” tragedies, (like a Florida condo building collapsing in the middle of the night) play out real-time in the palm of our hand in front of our eyes and we feel helpless to do anything but watch it unfold.
Those who know me well know I can fret and worry better than most. Medical training only makes this worse. I’m taught to think catastrophically. That is what I have done for a living – to always be ready for the worse case scenario and simply assume it will happen.
Sometimes it does happen and no amount of wishing it away will work.
When I rise, too often sleepless, to face a day of uncertainty as we all do ~ after careful thought, I reach for the certainty I am promised over the uncertainty I can only imagine:
What is my only comfort in life and in death? That I am not my own, but belong —body and soul, in life and in death— to my faithful Savior, Jesus Christ.
“Supposing it didn’t” — says our Lord (and we are comforted by this) but even if it did … even if it did – as awful things sometimes do – we are never abandoned.
He is with us always.
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To see clearly, not needing a drink or pill or puff of any pipe to know I’m alive. To come home, peel off sandals and step onto the cool tile floor needing only the rush of water over strawberries I picked myself and then a knife to trim the dusty green heads from each one, to watch them gleam cleanly in a colander in a patch of sun near the sink. ~James Crews “Clearly” from Healing the Divide: Poems of Kindness and Connection
As a child, I could see some people I loved struggling with daily life like a never-ending wrestling match.
Can’t relax? Have a drink. Feeling irritable? Have a smoke. Can’t wake up? Strong coffee. Can’t lose weight? Amphetamines. Can’t sleep? Valium.
I watched as one after another after another lost the wrestling match with the life’s sharp edges, sometimes dying too young from their self-medication.
As a result, I never could reconcile experimenting with my brain, staying stone cold sober throughout 21 years of school, bored to tears at parties watching others get hammered and stoned. As a physician, I spent half my career trying to help people stop wrestling with life and find their sober selves again.
Like berries picked into a colander, we all need gentle handling, rinsing and hulling, to wash away the dust of the field, the spiders and slug slime.
No more wrestling. Restored to sweetness and sparkling beauty.
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He thought of all the time he wasted being good. Clutched by the guilt of excellence. Polite. Well-trained. But when the long summer afternoons came, too hot to move from the window fan, scent of vapor rising from water jackets, he found pleasure in doing the nothing that had no regrets– wasted afternoons under the Wisteria vine when no one was watching. Aroma thick as a breeze on his shoulder. Thinking of women constantly, forgetting to water the chickens in the barn. He was beginning to feel the release of duty, to feel what it’s like to feel. Demands waiting like barking dogs at the periphery. His good intention to visit the sick woman falling aside as he listened to the rattle of starlings in the rafters––discovering that strange lightness of the body. And the new importance of oak branches where they separate from the trunk. How far out the leaves begin to spread. The startling arrangement of moss like whiskers without discipline. The long plains of earth reaching to the clouds behind the back yard fence. How the ground pushes back when you walk. ~David Watts, M.D. – “Another Side of Transgression” from Having and Keeping
Decades of demands and responsibilities become a falling-down fence line with no end in sight. Having been raised an obedient person with a heightened sense of obligation about constantly fixing what needs repair, I’ve done what I could, where I could, when I could, how I could, though too often ineffective in my efforts.
I’ve always moved from task to task to task – life’s string of fence posts held wires that always needed stretching and patching and straightening. By continually working, I hoped I too would remain standing and functional.
It’s clear the fence isn’t perfect, nor will it ever be. It has served a purpose, as have I. Now I wander along the fencerow, focusing on the walk and the view rather than searching out every little thing which is leaning or loose or gaping.
This walk feels good, lighter, almost cushiony, almost like rolling with joy in the freedom of it. I’m ambling along for no particular reason at all, which is almost intoxicating.
I think I’ll get used to the importance of doing nothing whatsoever.
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The wind, one brilliant day, called to my soul with an odor of jasmine.
“In return for the odor of my jasmine, I’d like all the odor of your roses.”
“I have no roses; all the flowers in my garden are dead.”
“Well then, I’ll take the withered petals and the yellowed leaves and the waters of the fountain.”
The wind left. And I wept. And I said to myself: “What have you done with the garden that was entrusted to you?” ~Antonio Machado “The Wind, One Brilliant Day” translated by Robert Bly
This garden bloomed with potential, entrusted to me for 32 years: the health and well-being of 16,000 students, most thriving and flourishing, some withering, their petals falling, a few have been lost altogether.
As the winds of time sweep away another group of graduates from my care, to be blown to places unknown, their beauty and fragrance gone from here.
I marvel at their growth, but also weary weep for those who left too soon, wondering if I failed to water them enough – or is it I who am parched in this garden with a thirst unceasing, my roots reaching deep into drought-stricken soil, ever so slowly drying out?
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Nothing seems to please a fly so much as to be taken for a currant; and if it can be baked in a cake and palmed off on the unwary, it dies happy. ~Mark Twain
Today I will wrap up 45 years of uninterrupted training and doctoring. Most of that time, I have worried I’m like a fly hiding among the black currants hoping to eventually become part of the currant cake.
Maybe no one has noticed. These days we call it the “impostor” syndrome. Mark Twain knew all about currant cake and how easy it was for a fly to blend into its batter.
Even while bearing three children and going through a few surgeries myself, I’ve not been away from patients for more than twenty consecutive days at any one time. This is primarily out of my concern that, even after a few weeks, I would forget all that I’ve ever known. In fact, half of what I learned in medical school and residency over forty years ago has evolved, thanks to new discoveries and clarifying research. I worried if I were to actually to step away from doctoring for an extended time, then return to see patients again, I would be masquerading as a physician rather than be the real thing. A mere fly among the currants palmed off on the unwary.
If being truly honest, those who spend their professional lives providing medical care to others always share this concern: if a patient only knew how much we don’t know and will never know, despite everything we DO know, there would really be no trust left for us at all.
Of course, some say, didn’t the COVID pandemic prove our ignorance? Physicians started at Ground Zero with a novel virus with unclear transmissibility and immense potential to wreak havoc on the human body … or cause no symptoms whatsoever. We had no collected data to base prevention or treatment decisions: would masks just protect others or would they only protect ourselves, or maybe they protect both? Could a common inexpensive anti-inflammatory/antimalarial drug be beneficial or would a parasitic wormer medication be somehow effective to fight the devastation of the virus?
Effective treatments are still being sought all these months later; others have been debated, studied and discarded as worthless.
Or would this pandemic finally resolve thanks to effective yet controversial public health mandates while rapidly distributing highly effective vaccines developed from many prior years of carefully performed research?
During the past 16 months, your next door neighbor, or the loudest tweet on Twitter proclaimed more expertise than the average medical professional and definitely had a stronger opinion. At least we doctors knew how much we didn’t know and how much was simply guess work based on experience, good intentions and hopeful prayer. Gradually, while lives were lost, including too many of our own, real data began to trickle in so decisions could be made with some evidence backing them. But even that data continues to evolve, day by day, as authentic medical evidence always does.
That doesn’t stop all the “quack” flies out there from climbing into the batter pretending to be currants. With so much rapidly changing medical information at everyone’s fingertips, who needs a trained physician when there are so many other resources – sketchy and opportunistic though they may be – for seeking health care advice?
Even so, I am convinced most patients really do care that doctors share the best information they have available at any point in time. None of us who are doctoring wants to be the “fly” in the batter of health care.
As I meet with my last patient today, I know over forty years of clinical experience has given me an eye and an ear for the subtle signs and symptoms that no googled website or internet doc-in-the-box can discern. The avoidance of eye contact, the tremble of the lip as they speak, the barely palpable rash, the hardly discernible extra heart sound, the fullness over an ovary, the slight squeak in a lung base. These are things I am privileged to see and hear and about which I make decisions together with my patients. What I’ve done over four decades has been no masquerade; out of my natural caution, I am not appearing to be someone I am not. This is what I was trained to do and have done for thousands of days and many more thousands of patients during my professional life, while passing a comprehensive certification examination every few years to prove my continued study and changing fund of knowledge.
The hidden fly in the currant bush of health care may be disguised enough that an unwary patient might gobble it down to their ultimate detriment. I know I’ve not been that doctor. I’ve been the real thing all these years for my patients, even if I’ve seemed a bit on the tart side at times, yet offering up just enough tang to be exactly what was needed in the moment and in the long term.
And someday, hopefully not too soon, I will die happy having done this with my life.
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You can’t say you haven’t been warned: there are creepy crawlies in this post
Things I will never like: 1. Drying off with a cold, damp towel. 2. The feeling of seaweed wrapping around my legs. 3. Anything that was popular in the 70’s. 4. Licorice, yam, or raisins. 5. That high-pitched screech that babies make. 6. Writhing maggots. ~Bill Watterson from It’s A Magical World: A Calvin and Hobbes Collection
A few weeks ago, I had a bit of home-made potato corn chowder left over that I added to our compost bin in our barnyard. It isn’t often that much animal protein makes its way into the bin so when I checked on the compost a few days later, I was amazed to see it teeming with fly maggots in the midst of their Thanksgiving feast. Ordinarily pictures and videos of maggots would not find their way to this blog. People might be looking at this blog while eating their breakfast or lunch and writhing maggots are not something you are expecting to see. My apologies in advance and now is the time to delete delete delete.
Therefore: a trigger warning. Don’t scroll down further if you would rather avoid seeing (and hearing) creepy crawly things.
My first medical exposure to maggots came while examining the leg and foot wounds of the homeless folks I helped care for when training in an inner city emergency room. Peeling off old ragged stockings and socks would often reveal more than dirty feet – in fact, the maggots may have been somewhat beneficial in those cases yet we were quick to dispose of them.
Maggots are, in fact, fascinating creatures with potential therapeutic value, notwithstanding their gross-out factor. This week in a brief Atlantic article found here, there is a summary of a recent study in France comparing typical surgical debridement of venous ulcers of the skin with maggot therapy. Maggots were faster in cleaning the wounds but didn’t enhance eventual healing any more than traditional surgical care. There wasn’t a difference in the discomfort level as long as the patient didn’t know which therapy was being used. For those who had been randomly assigned to maggot therapy in one study, an astounding 89% said they would opt for the insects over surgeons if faced with needing wound care in the future.
I’m not sure what that says about surgeons, but it is a great compliment to maggot larvae!
Here is a formal cross-referenced evidence-based summary from UptoDate.com about wound treatment with biologic methods:
Biologic — An additional method of wound debridement uses the larvae of the Australian sheep blow fly (Lucilia [Phaenicia] cuprina) or green bottle fly (Lucilia [Phaenicia] sericata, Medical Maggots) [42,43]. Maggot therapy can be used as a bridge between debridement procedures, or for debridement of chronic wounds when surgical debridement is not available or cannot be performed . Maggot therapy may also reduce the duration of antibiotic therapy in some patients .
Maggot therapy has been used in the treatment of pressure ulcers [45,46], chronic venous ulceration [47-50], diabetic ulcers [42,51], and other acute and chronic wounds . The larvae secrete proteolytic enzymes that liquefy necrotic tissue, which is subsequently ingested while leaving healthy tissue intact. Basic and clinical research suggests that maggot therapy has additional benefits, including antimicrobial action and stimulation of wound healing [43,47,53,54]. However, randomized trials have not found consistent reductions in the time to wound healing compared with standard wound therapy (eg, debridement, hydrogel, moist dressings) [55,56]. Maggot therapy appears to be at least equivalent to hydrogel in terms of cost [56,57].
Dressing changes include the application of a perimeter dressing and a cover dressing of mesh (chiffon) that helps direct the larvae into the wound and limits their migration (movie 1). Larvae are generally changed every 48 to 72 hours. One study that evaluated maggot therapy in chronic venous wounds found no advantage to continuing maggot therapy beyond one week . Patients were randomly assigned to maggot therapy (n = 58) or conventional treatment (n = 61). The difference in the slough percentage was significantly increased in the maggot therapy group compared with the control groups at day 8 (67 versus 55 percent), but not at 15 or 30 days.
The larvae can also be applied within a prefabricated “biobag”, commercially available outside the United States, that facilitates application and dressing change [58-61]. Randomized trials comparing “free range” with “biobag”-contained larvae in the debridement of wounds have not been performed.
A main disadvantage of maggot therapy relates to negative perceptions aboutits use by patients and staff. One concern among patients is the possibility that the larvae can escape the dressing, although this rarely occurs. Although one study identified that approximately 50 percent of patients indicated they would prefer conventional wound therapy over maggot therapy, 89 percent of the patients randomly assigned to maggot therapy said they would undergo larval treatment again . Perceived pain or discomfort with the dressings associated with maggot therapy may limit its use in approximately 20 percent of patients.
The STARZ show Outlander (a show and series of books by scientist Diana Gabaldon I thoroughly enjoy) used real maggots in the fifth season of the show when in 18th century America, wife (and surgeon) Claire successfully treats her husband Jamie’s snakebite wound with the larvae. Actress Caitriona Balfe describes her co-starring maggots in this brief video:
So there are still things to learn about medical therapies we used in the past which have been sidelined or forgotten in our push for modern treatment modalities. The days of leeches and maggots may not be over after all.
And now for video, complete with little maggotty sound effects — scroll down
Maggots in our compost bin – enjoying corn and potato chowder leftovers
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Gardens are also good places to sulk. You pass beds of spiky voodoo lilies and trip over the roots of a sweet gum tree, in search of medieval plants whose leaves, when they drop off turn into birds if they fall on land, and colored carp if they plop into water.
Suddenly the archetypal human desire for peace with every other species wells up in you. The lion and the lamb cuddling up. The snake and the snail, kissing. Even the prick of the thistle, queen of the weeds, revives your secret belief in perpetual spring, your faith that for every hurt there is a leaf to cure it. ~Amy Gerstler “Perpetual Spring” from Bitter Angel
We all want to fix what ails us: that was the point of my many years of medical training and over 40 years “practicing” that art. We want to know there is a cure for every hurt, an answer for every question, a resolution to every mystery, or peace for every conflict.
And there is. It just isn’t always on our timeline, nor is it always the answer we expect, nor the conflict magically dissolved. The mystery shall remain mystery until every tear is dried, as we stand before the Face of our Holy God who both loves and judges our hearts.
Sometimes this life hurts – a lot – but I believe in the perpetual Spring and Resurrection that guarantees our complete healing.
To pull the metal splinter from my palm my father recited a story in a low voice. I watched his lovely face and not the blade. Before the story ended, he’d removed the iron sliver I thought I’d die from.
I can’t remember the tale, but hear his voice still, a well of dark water, a prayer. And I recall his hands, two measures of tenderness he laid against my face, the flames of discipline he raised above my head.
Had you entered that afternoon you would have thought you saw a man planting something in a boy’s palm, a silver tear, a tiny flame. Had you followed that boy you would have arrived here, where I bend over my wife’s right hand.
Look how I shave her thumbnail down so carefully she feels no pain. Watch as I lift the splinter out. I was seven when my father took my hand like this, and I did not hold that shard between my fingers and think, Metal that will bury me, christen it Little Assassin, Ore Going Deep for My Heart. And I did not lift up my wound and cry, Death visited here! I did what a child does when he’s given something to keep. I kissed my father. ~Li-Young Lee, “The Gift” from Rose
I did, without ever wanting to, remove my own children’s splinter, lanced a boil, immobilized a broken arm, pulled together sliced skin, cleaned many dirty wounds. It felt like I crossed the line between mommy and doctor. But someone had to do it, and a four hour wait in the emergency room didn’t seem warranted.
My own children learned to cope with hurt made worse by someone they trusted to be comforter.
I dealt with inflicting pain, temporary though it may be, to flesh that arose from my flesh. It hurt as much as if it were my own wound needing cleansing, not theirs.
Our wounds are His – He is constantly feeling our pain as He performs healing surgeries in our lives, not because He wants to but because He must, to save us from our own destruction. Too often we yell and kick and protest in our distress, making it all that much more difficult for both of us.
If only we can come to acknowledge His intervention is our salvage: our tears to flow in relief, not anguish, we cling to His protection rather than pushing Him away, we kiss Him in gratitude as we are restored again and yet again.