It Needn’t Have Been So…

You are alive.
It needn’t have been so.
It wasn’t so once, and will not be forever.
But it is so now.

And what is it like:
to be alive in this one place of all places anywhere where life is?
Live a day of it and see.
Take any day and LIVE IT.
Nobody claims that it will be entirely painless, but no matter.

It is your birthday and there are many presents to open. 
The world is to be opened.
It is the first day because it has never been before
and the last day because it will never be again.

BE ALIVE.
~Frederick Buechner from The Alphabet of Grace

When I was very young, I would trace my finger over the long scar that curved along the front of my mother’s neck and ask her what happened. She would tell me her thyroid gland had been overworking so she had to have it removed before I was born. That’s all she had to say about that and I never thought to ask more. Somehow I knew, just as my knowing my father would not talk about his experience as a Marine in WWII, my mother was hiding more than her big scar under high collars or a pearl necklace.

Hers was a deeper scar I couldn’t see or touch.

However, my older sister – about five at the time – remembers my mother’s illness. Mom was a little over thirty when her hands began to tremble, her pulse raced and she was irritable with trouble sleeping. My parents were hoping for a second child, but unable to get pregnant. Once her doctor diagnosed thyrotoxicosis , Mom had the option to try a new medication that had been recently developed – propylthiouracil – meant to suppress the function of overactive thyroid glands.

It didn’t work for her and she felt worse. It caused more side effects and my mother’s symptoms grew so severe, she was unable to leave her bedroom due to severe anxiety and paranoia made worse by insomnia. My paternal grandmother came to help since my father needed to continue to work to support the family but there was little that could be done other than sedation to ease my mother’s symptoms. My sister recalls not seeing Mom for days, unnerved by the wailing she heard from the bedroom. From her description, I now wonder if Mom was experiencing the beginning of thyroid “storm” (extremely high thyroid levels) which is potentially life-threatening with severe physical and emotional side effects.

After Mom was hospitalized and her entire thyroid was removed, she was placed on thyroid hormone supplements to take daily for the rest of her life. It took months for her to recover and feel somewhat normal again. Her eventual hormonal stability resolved her infertility as well as most of her other symptoms. She remained chronically anxious and had heart palpitations and insomnia the rest of her life, like a residual stain on her sense of well-being, although she lived another 55 years. The trauma of how her illness affected my dad and sister was never fully resolved. They all suffered. I can understand why those months remained as hidden as my mom’s surgical scar.

I was born about two years later – the second baby they never expected could happen. My brother was born 20 months after me.

From my family’s suffering came the solace of new life.

So I nearly wasn’t.

I’m reminded on each birthday:
I needn’t have been here yet by the grace of God I am.
I need to BE ALIVE and LIVE THIS DAY because it will never be again.

This is a truth for us all to cling to.

Each day is a gift to be opened and savored.
Each day a first day, a last day, a great day – a birthday of amazing grace.

A new book from Barnstorming is available to order here:

The Fly in the Currant Cake

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.

My ID photo from my first year of medical school 1976
45 years later…

A new book from Barnstorming is available to order here:

A Prescription for Maggots

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 fly maggot photo from a recent Atlantic article on maggot therapy found here

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 [44]. Maggot therapy may also reduce the duration of antibiotic therapy in some patients [16].

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 [52]. 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 [48]. 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 about its 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 [62]. Perceived pain or discomfort with the dressings associated with maggot therapy may limit its use in approximately 20 percent of patients.

Biobag of maggots on a wound from http://www.uptodate.com

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:

image from Starz – Outlander Season 5 Episode 9
image from Starz – Outlander Season 5 Episode 9

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

A new book from Barnstorming is available to order here

(no maggot pictures in this book, I promise!)

The Delicate Sadness of Dusk

The talkative guest has gone,
and we sit in the yard
saying nothing. The slender moon
comes over the peak of the barn.

The air is damp, and dense
with the scent of honeysuckle. . . .
The last clever story has been told
and answered with laughter.

With my sleeping self I met
my obligations, but now I am aware
of the silence, and your affection,
and the delicate sadness of dusk.
~Jane Kenyon, “The Visit” from Collected Poems

As we slowly adapt to evenings spent with family and friends again, taking off our masks to actually witness the emotion on a familiar, now unveiled, face:

There are smiles and laughter again. We are trying to remember how to be ourselves outside the fearfulness that contagion wrought. More important: there are tears again. And wistfulness. And regret. And longing.

This delicate sadness happened – even to those of us who were never directly touched by sickness. We will never be the same, never so light of heart again, remembering what this past year has cost.

It is a slow transition to dusk. We sit together now and watch it come.

Cure for Every Hurt

hankerchief tree (Ireland)
Baby Barn Owlet hiding in the rocks and grass
River carp (2-3 feet long) in Higashi-Kurume, Tokyo

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

photo by Tomomi Gibson

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.

Soli Deo Gloria

A new book available to order https://barnstorming.blog/new-book-available-almanac-of-quiet-days/from Barnstorming and poet Lois Edstrom!

Diagnosing a Case of the Dwindles

Morning without you is a dwindled dawn.
~Emily Dickinson in a letter to a friend April 1885

For the past year, the most common search term bringing new readers to my Barnstorming blog is “dwindled dawn.” I have written about Emily Dickinson’s “dwindles” on occasions, but had not really been diagnosed with a serious case myself until recently.

I am not the only one. It has spread across the globe and I regularly recognize the symptomatology of the dwindles in my clinical work with patients.

There really isn’t a pill or other therapy that works well for this. One of the most effective treatments I might prescribe is breaking bread with friends and family all in the same room at the same table while the sun rises around us, lingering in conversation because there could not be anything more important for us to do.

Just being together would be the ultimate cure.

Maybe experiencing friend and family deficiency helps us understand how vital they are to our well-being. You don’t know what you have ’till they’re gone, sadly some now forever.

Point well-taken; it is high time to replenish the reservoir before dwindling away to nothing.

So if you are visiting these words for the first time because you too searched for “dwindled dawn,” welcome to Barnstorming. We can dwindle together in our shared isolation.

Because mornings without you all diminishes me.
I just wanted you to know.

Hold Life Like a Face

The thing is
to love life, to love it even
when you have no stomach for it
and everything you’ve held dear
crumbles like burnt paper in your hands,
your throat filled with the silt of it.
When grief sits with you, its tropical heat
thickening the air, heavy as water
more fit for gills than lungs;
when grief weights you like your own flesh
only more of it, an obesity of grief,
you think, How can a body withstand this?
Then you hold life like a face
between your palms, a plain face,
no charming smile, no violet eyes,
and you say, yes, I will take you
I will love you, again.
~Ellen Bass, “The Thing Is” from Mules of Love

There is so much grief these days
so much loss of life
so much weeping.

How can we withstand this?
How can we know, now,
when we are barely able to breathe
that we might know – at some point –
we might love life again?

Take Her Hand

She wakes to gray.
No words to guide the way
toward son. His unfamiliar face seems kind
enough. She nods hello. Just yesterday
she knew his eyes, but now?

This morning’s mind
welcomes the past but not the day. She was
someone: woman who woke at 3:00 to sing
her restless son to sleep, his calm her cause
for celebration. Today the dawn brings

no clarity, yet still the stranger comes
and draws her curtains wide. She thinks outside
is where she left her life: daughters, a son
who meet sunrise without her. Look, the light

is brighter now. The kind man helps her stand.
To see the morning sun, she takes his hand.
~Marjorie Maddox “Alzheimer Aubade”

Lying still, your mouth gapes open as
I wonder if you breathe your last.
Your hair a white cloud
Your skin baby soft
No washing, digging, planting gardens
Or raising children
Anymore.

Where do your dreams take you?
At times you wake in your childhood home of
Rolling wheat fields, boundless days of freedom.
Other naps take you to your student and teaching days
Grammar and drama, speech and essays.
Yesterday you were a young mother again
Juggling babies, farm and your wistful dreams.

Today you looked about your empty nest
Disguised as hospital bed,
Wondering aloud about
Children grown, flown.
You still control through worry
and tell me:
Travel safely
Get a good night’s sleep
Take time to eat
Call me when you get there

I dress you as you dressed me
I clean you as you cleaned me
I love you as you loved me
You try my patience as I tried yours.
I wonder if I have the strength to
Mother my mother
For as long as she needs.

When I tell you the truth
Your brow furrows as it used to do
When I disappointed you~
This cannot be
A bed in a room in a sterile place
Waiting for death
Waiting for heaven
Waiting

And I tell you:
Travel safely
Eat, please eat
Sleep well
Call me when you get there.

Turning Darkness Into Light: Shadows Flee Away

There is nothing I can give you that you do not already have,
but there is much, very much, that, while I cannot give it, you can take.

No heaven can come to us
Unless our hearts find rest in it today.
Take heaven.

No peace lies in the future
Which is not hidden in this present instant.
Take peace.

The gloom of the world is but a shadow;
Behind it, yet within reach, is joy.
Take joy.

And so, at this Christmastime,
I greet you with the prayer that for you,
Now and forever,
The day breaks and the shadows flee away.
– Fra Giovanni Giocondo letter to Countess Allagia Aldobrandeschi, Christmas Eve 1513

We are reminded in hundreds of self-help books, both secular and faith-based, to count our blessings in order to find happiness in our daily existence. The point is to peer out from under the shadow of gloom and grumbles to where light and hope is unimpeded.

It’s good advice as old as the Psalms, even if some folks don’t want to associate gratitude and blessings with Someone who actually bestows them.

There are some days when the shadows overpower all feelings of thanksgiving: seeing the tent and box cities of the homeless expanding, watching the numbers of sick and dying rise exponentially, witnessing the suffering of the lonely and isolated among us. How is it possible for us to grasp heaven or feel peace when all seems so bleak?

That is exactly why the Babe was born so many years ago, bringing with Him the Light and Hope so sorely needed by the world then and the world now. With His dawning, shadows flee away; we only need to take the joy and peace He offers.

Alleluia!

Oh little child it’s Christmas night
And the sky is filled with glorious light
Lay your soft head so gently down
It’s Christmas night in Bethlehem town.

Chorus: Alleluia the angels sing
Alleluia to the king
Alleluia the angels sing
Alleluia to the king.

Sleep while the shepherds find their way
As they kneel before you in the golden hay
For they have brought you a woolly lamb
On Christmas night in Bethlehem.
Chorus

Sleep till you wake at the break of day
With the sun’s first dawning ray
You are the babe, who’ll wear the crown
On Christmas morn in Bethlehem town.
Chorus

Alleluia, Alleluia, Alleluia, Alleluia, Alleluia. Alleluia

Turning Darkness into Light: Dust Made Manifest

Nobody in the hospital
Could tell the age 
Of the old woman who
Was called Susanna

Because she had no visitors
I would stop by to see her
But she was always sleeping

One day I was beside her
When she woke up
Opening small dark eyes
Of a surprising clearness

She looked at me and said
You want to know the truth?
I answered Yes

She said it’s something that 
My mother told me

There’s not a single inch
Of our whole body
That the Lord does not love

She then went back to sleep.
~Anne Porter  from “Susanna”

photo by Andrea Nipges

So many people lie in a hospital bed these days, all alone
and fearful, wondering what could happen next,
waiting for the tide to turn and move them back to the shore
or sweep them out into the arms of their Creator forever.

We tend to forget the love of the One who made us,
including our funny looking feet, our anxieties,
the crooked teeth, the wrinkles, the scars, the split ends —

We see only our imperfections and frailty
when our Creator sees dust made manifest
in His image.

He loves us even when we do not love ourselves,
as we hide our flaws and cover up our vulnerable nakedness.

He loves every inch
because we are His opus,
a masterpiece,
so He became one of us.

He knew exactly what He was doing
and even now,
in the midst of our loneliness,
He knows exactly what He is doing
with the dust that still swirls around us.