Here is a story to break your heart. Are you willing? This winter the loons came to our harbor and died, one by one, of nothing we could see. A friend told me of one on the shore that lifted its head and opened the elegant beak and cried out in the long, sweet savoring of its life which, if you have heard it, you know is a sacred thing., and for which, if you have not heard it, you had better hurry to where they still sing. And, believe me, tell no one just where that is. The next morning this loon, speckled and iridescent and with a plan to fly home to some hidden lake, was dead on the shore. I tell you this to break your heart, by which I mean only that it break open and never close again to the rest of the world. ~Mary Oliver “Lead” from New and Selected Poems
Why shouldn’t we go through heartbreaks?
…if through a broken heart God can bring His purposes to pass in the world, then thank Him for breaking your heart. ~Oswald Chambers from “Ye are not your own” from My Utmost for the Highest
These last two years have seen an epidemic of heart-break.
Due to hospital visitor restrictions, thousands of loved ones have died of COVID without family by their side, deprived of the solace of hearing familiar voices and being touched by familiar hands. A weary and over-worked health care team can only do so much in their efforts to comfort and console when so many patients are losing their battle with the virus at the same time. Although nurses and doctors have always been witnesses to the cries of the dying and the weeping of the grief-stricken, that is usually together at the bedside.
An iPad screen isn’t the same for those saying good-bye forever.
For all the advances of our modern society – through technology and communication and the development of medical miracles – people still die and others still grieve and weep over their loss. We’re not used to dying happening with such frequency to those who have no business dying in the first place. We assume death rates exceeding birth rates happens only in third world countries beset with drought or plague.
Not any more.
So my heart is tender – for those lost, for those left behind, for those trying their best to save lives when they are weary and ill themselves, for the irony of hundreds of thousands of unnecessary deaths when the preventive measures available to us all are so clear-cut.
If anything, a breaking heart is an open invitation for the solace of a God who himself had no business dying in the first place, but did. He cried out in a long, sweet savoring of his life and ours, saving us in the process.
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By the road to the contagious hospital under the surge of the blue mottled clouds driven from the northeast — a cold wind. Beyond, the waste of broad, muddy fields brown with dried weeds, standing and fallen
patches of standing water the scattering of tall trees
All along the road the reddish purplish, forked, upstanding, twiggy stuff of bushes and small trees with dead, brown leaves under them leafless vines —
Lifeless in appearance, sluggish dazed spring approaches —
They enter the new world naked, cold, uncertain of all save that they enter. All about them the cold, familiar wind —
Now the grass, tomorrow the stiff curl of wildcarrot leaf
One by one objects are defined — It quickens: clarity, outline of leaf
But now the stark dignity of entrance — Still, the profound change has come upon them: rooted they grip down and begin to awaken ~William Carlos Williams “Spring and All”
I ask your doctor of infectious disease if she’s read Williams he cured sick babies I tell her and begin describing spring and all she’s looking at the wall now the floor now your chart now the door never heard of him she says but I can’t stop explaining how important this is I need to know your doctor believes in the tenacity of nature to endure I’m past his heart attack his strokes and now as if etching the tombstone myself I find I can’t remember the date he died or even the year of what now are we the pure products and what does that even mean pure isn’t it obvious we are each our own culture alive with the virus that’s waiting to unmake us ~Brian Russell, “The Year of What Now”
It is the third January of a pandemic of a virus far more tenacious than we have proven to be, it continues to unmake us, able to mutate spike proteins seemingly overnight while too many of us stubbornly remain unchanged by this, clinging to our “faith over fear” and “my body, my choice” and “lions, not sheep” and “never comply” — because self-determination must trump compassion for the unfortunate fate of vulnerable millions.
We defend the freedom to choose to be vectors of a contagion that may not sicken us yet fills clinics, hospitals and morgues.
William Carlos Williams, the early 20th century physician, would be astonished at the clinical tools we have now to fight this scourge. William Carlos Williams, last centuries’ imagist poet, would recognize our deadly erosion of cooperation when faced with a worthy viral opponent.
So what happens now?
Starting with this third pandemic winter, with our souls in another deep freeze, covered in snow and ice and bitter wind chill, a tenuous hope of restoration could awaken – tender buds swelling, bulbs breaking through soil, being called forth from long burial in a dark and cold and heartless earth.
Like a mother who holds the mystery of her quickening belly, knowing we nurture other lives with our own body, we too can be hopeful and marveling at who we are created to be.
She, and we, know soon and very soon there will be spring.
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Under the harvest moon, When the soft silver Drips shimmering over the garden nights, Death, the gray mocker, Comes and whispers to you As a beautiful friend Who remembers.
Under the summer roses When the flagrant crimson Lurks in the dusk Of the wild red leaves, Love, with little hands, Comes and touches you With a thousand memories, And asks you Beautiful, unanswerable questions. ~Carl Sandburg, “Under the Harvest Moon”
As we enter the season of all that is lush and lovely which starts to wither and decay before our eyes, we know the flowers and trees aren’t alone. Death, whispering within its gray night’s cloak, has been stealing the young and old since time began, but never as boldly as during a pandemic. Millions of family members are left with nothing but bittersweet memories of their loved ones now buried deep.
The harvest moon – not nearly bright enough, as a poor reflection of the sun – mocks us who covet light during a rampage of contagious illness and death.
As we endure the searing beauty of yet another dying season, let us treasure those we protect through our care and concern. Let us cherish the memories of those we’ve lost. There can be only one answer to the unanswerable questions: Love itself died to become Salvation, an ever-sufficient Light that leads us home.
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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.
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.
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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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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.
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.
Morning without you is a dwindled dawn. ~Emily Dickinsonin 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.
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?