Tag: patients

To Break Your Heart

barnstormingblog2 Comments

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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The Tenacity of Nature

barnstormingblog3 Comments

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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The Fly in the Currant Cake

barnstormingblog46 Comments

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:

Waiting in Wilderness: Heaven and I Wept Together

barnstormingblog3 Comments
fog101926

And so you have a life that you are living only now,
now and now and now,
gone before you can speak of it,
and you must be thankful for living day by day,
moment by moment …
a life in the breath and pulse and living light of the present…
~Wendell Berry from Hannah Coulter

fog1228141

~Lustravit lampade terras~
(He has illumined the world with a lamp)
The weather and my mood have little connection.
I have my foggy and my fine days within me;
my prosperity or misfortune has little to do with the matter.
– Blaise Pascal from “Miscellaneous Writings”

foggyfield
photo by Nate Gibson

I laughed in the morning’s eyes.
I triumphed and I saddened with all weather,
Heaven and I wept together,
and its sweet tears were salt with mortal mine.
Against the red throb of its sunset heart,
I laid my own to beat
And share commingling heat.

Rise, clasp my hand, and come.
Halts by me that Footfall.
Is my gloom, after all,
Shade of His hand, outstretched caressingly?
Ah, Fondest, Blindest, Weakest,
I am He whom thou seekest.
Thou dravest Love from thee who dravest Me.
~Francis Thompson from “The Hound of Heaven”

supermoonbarn

My days are filled with anxious and sad patients,
one after another after another. 
They sit in front of their screen
and I in front of mine,
so close yet so far from each another –
a wilderness of unexpressed emotions.

They struggle to hold back the flood from brimming eyes.  
Each moment, each breath, each heart beat overwhelmed by questions: 
How to take yet another painful breath of this sad life?  must there be another breath?  
Must things go on like this in fear of what the next moment will bring?

The only thing more frightening than the unknown is the knowledge
that the next moment will be just like the last or perhaps worse. 
There is no recognition of a moment just passed
that can never be retrieved and relived.  
There is only fear of the next and the next
so that now and now and now is lost forever.

Worry and sorrow and angst are more contagious than any viral pandemic.
I mask up and wash my hands of it throughout the day.
I wish there was a vaccine to protect us all from our unnamed fears in the wilderness.

I want to say to them and myself:
Stop this moment in time.
Stop and stop and stop.
Stop expecting this feeling must be “fixed.”
Stop wanting to be numb to all discomfort.
Stop resenting the gift of each breath.
Just stop.
Instead, simply be
in the now and now and now.

I want to say:
this moment, foggy or fine, is yours alone,
this moment of weeping and sharing
and breath and pulse and light.
Shout for joy in it.
Celebrate it.
Be thankful for tears that can flow over grateful lips
and stop holding them back.

Stop me before I write,
out of my own anxiety over you,
yet another prescription
you don’t really need.

Just be–
and be blessed–
in the now and now and now.

sunset15183

Why I’m Running Late

barnstormingblog9 Comments

wildbunny3

 

duckchelan2

 

It may not be rabbit season or duck season but it definitely seems to be doctor season.  Physicians are lined up squarely in the gun sights of the media,  government agencies and legislators, our health care industry employers and coworkers, not to mention our own dissatisfied patients, all happily acquiring hunting licenses in order to trade off taking aim.   It’s not enough any more to wear a bullet proof white coat.  It’s driving doctors to hang up their stethoscope just to get out of the line of fire. Depending on who is expressing an opinion, doctors are seen as overcompensated, demanding, whiny, too uncommitted, too overcommitted, uncaring, egotistical, close minded,  inflexible, and especially– perpetually late.

One of the most frequent complaints expressed about doctors is their lack of sensitivity to the demands of their patients’ schedule.  Doctors do run late and patients wait.  And wait.  And wait some more.  Patients get angry while waiting and this is reflected in patient (dis)satisfaction surveys which are becoming one of the tools the industry uses to judge the quality of a physician’s work and character.

I admit I’m one of those late doctors.  Perpetually 20-30 minutes behind.

I don’t share the reasons why I’m late with my patients as we sit down together in the exam room but I do apologize for my tardiness.  Taking time to explain why takes time away from the task at hand: taking care of the person sitting or lying in front of me.   At that moment, that is the most important person in the world to me.  More important than the six waiting to see me, more important than the dozens of emails, electronic portal messages and calls waiting to be returned, more important than the fact I missed lunch or need to go to the bathroom, more important even than the text message of concern from my daughter or the worry I have about a ill relative.

I’m a salaried doctor, just like more and more of my primary care colleagues these days, providing more patient care with fewer resources.  I don’t earn more by seeing more patients.  There is a work load that I’m expected to carry and my day doesn’t end until that work is done.  Some days are typically a four patient an hour schedule, but most days my colleagues and I must work in extra patients triaged to us by careful nurse screeners, and there are only so many minutes that can be squeezed out of an hour so patients end up feeling the pinch.  I really want to try to go over the list of concerns some patients bring in so they don’t need to return to clinic for another appointment, and I really do try to deal with the inevitable “oh, by the way” question when my hand is on the door knob. Anytime that happens, I run later in my schedule, but I see it as my mission to provide essential caring for the “most important person in the world” at that moment.

The patient who is angry about waiting for me to arrive in the exam room can’t know that three patients before them I saw a woman who found out that her upset stomach was caused by an unplanned and unwanted pregnancy.   Perhaps they might be more understanding if they knew that an earlier patient came in with severe self injury so deep it required repair.   Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection, but is showing potential signs of a pulmonary embolism caused by oral contraceptives.  Or the man with blood on the toilet paper after a bowel movement finding out he has sexually transmitted anal warts when he’s never disclosed he has sex with other men,  or the woman with bloating whose examination reveals an ominous ovarian mass, or finding incidental needle tracks on arms during an evaluation for itchiness, which leads to suspected undiagnosed chronic hepatitis.

Doctors running late are not being inconsiderate, selfish or insensitive to their patients’ needs.  Quite the opposite.  We strive to make our patients feel respected, listened to and cared for.  Most days it is a challenge to do that well and stay on time.  For those who say we are being greedy, so we need to see fewer patients, I respond that health care reform and salaried employment demands we see more patients in less time, not fewer patients in more time.  The waiting will only get longer as more doctors hang up their stethoscopes rather than become a target of anger and resentment as every day becomes “doctor season.”  Patients need to bring a book, bring knitting, schedule for the first appointment of the day.  They also need to bring along a dose of charitable grace when they see how crowded the waiting room is.  It might help to know you are not alone in your worry and misery.

But your doctor is very alone, scrambling to do the very best healing he or she can in the time available.

I’m not yet hanging my stethoscope up though some days I’m so weary by the end, I’m not sure my brain between the ear buds is still functioning.  I don’t wear a bullet proof white coat since I refuse to be defensive.  If it really is doctor season, I’ll just continue on apologizing as I walk into each exam room, my focus directed for that moment to the needs of the “most important person in the whole world.”

And that human being deserves every minute I can give them.

 

chelanducklings5

 

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The Doctor’s Waiting Room Vladimir Makovsky 1870

Dusted

barnstormingblog2 Comments

dustybee

beeweed

 

“Bees do have a smell, you know,
and if they don’t they should,
for their feet are dusted with spices from a million flowers.”
― Ray Bradbury, Dandelion Wine

 

beeblu

bee

 

I admire the honey bee as pollinator and pollen gatherer simultaneously, facilitating new fruit from the blossom as well as taking away that which will become sweet honey tasting of the spicy essence of the flower touched.

As a physician, I can only hope to be as transformative in the work I do every day.  I carry with me tens of thousands of patients I’ve seen over thirty five years of medical practice.  There is no way I can touch another human being without keeping some small part of them with me – perhaps a memory of an open wound or the residual scar it left behind, a word of sorrow or gratitude, a grimace, a tear or a smile.

Each patient is a flower visited, some still in bud, some in full bloom, some seed pods ready to burst, some spent and wilting and ready to fall away.  Each patient carries a spicy vitality, even in their illness and dying, that is unforgettable and still clings to me. Each patient changes me, the doctor, readying me for the next patient by teaching me a gentler approach, a clearer explanation, a slower leave-taking.  Each patient becomes part of my story, adding to my skill as a healer, and is never to be forgotten.

It has been my privilege to be thoroughly dusted by those I’ve loved and cared for.  I want to carry that on to create something wonderful that reflects the spice of living.

Nothing could smell or taste as sweet.

 

beechestnut

cornbee

beebye

wwubusybees

A Furry, Finned or Feathered Treatment Plan

barnstormingblog4 Comments

leafanclub

Due to changes in Fair Housing Act laws, clinicians are experiencing a significant increase in requests from patients for medical documentation to keep emotional support animals with them in “no-pets policy” rental housing. On a college campus, this leads to far more than just two-legged mammals inhabiting dorm rooms.  There has been an animal explosion on our University campus with over seventy animals of various types approved as an “ESA” in the residence halls and unknown dozens more who live with their owners off campus yet still frequent campus.  Only a small minority of these animals are actually trained and certified as service animals with the right to accompany their owner on public transportation to any public place, including classrooms and eating establishments.  The rest are approved only for housing purposes, yet they are regularly showing up in airplane cabins and grocery stores, dressed in little jackets that are easily purchased along with “certification letters” for big prices on the internet.  ESAs have become part of the campus and community landscape.

As a relatively outdoorsy, green and tolerant northwest University campus, the presence of animals on our campus has yet to seem like a big deal, but as the animal numbers inevitably increase due to 25% of the college student population nationwide currently eligible for an animal due to a mental health diagnosis, it is becoming a big deal as individuals insist on exercising their civil rights along with their dogs.

And it isn’t always dogs.  There are cats, along with the occasional pocketed rat, hamster, guinea pig, flying squirrel, and ferret not to mention emotional support pot bellied pigs, tarantulas, and various types of birds.  And at least one snake.

Yes, a snake.

As a physician farmer concerned with stewardship of the patients I treat and the land and animals I care for, I’m emotionally caught and ethically bound in this treatment trend.  The law compels clinicians to provide the requested documentation to avoid  potential law suits alleging discrimination, yet I’m also concerned for the rights of the animals themselves.   I’ve loved, owned and cared for animals most of my sixty two years and certainly missed my pets during the thirteen years I was in college, medical school, residency and doing inner city work (my tropical fish and goldfish notwithstanding).  I neither had the time, the money, the space nor the inclination to keep an animal on a schedule and in an environment that I myself could barely tolerate, as stressed as I was.   That is not stopping the distressed college student of today from demanding they be able to keep their animals with them in their stress-mess.

As a clinician, I’d much prefer writing fewer pharmaceutical prescriptions and help individuals find non-medicinal ways to address their distress.   I’d like to see my patients develop coping skills to deal with the trouble that comes their way without falling apart, and the resilience to pick themselves up when they have been knocked down and feel broken.   I’d like to see them develop the inner strength that comes with maturity and experience and knowing that “this too will pass.”  I’d like individuals to see themselves as part of a diverse community and not a lone ranger of one, understanding that their actions have a ripple effect on those living, working, eating, riding and studying around them. Perhaps corporate work places, schools and universities should host a collaborative animal center with rotating dogs and cats from the local animal shelter, so those who wish to may have time with animals on their breaks without impacting others who aren’t animal fans, or with potentially life threatening animal dander allergies.

So I find myself reluctantly writing a prescription for a living breathing creature perceived by the law as a “treatment” rather than a profound responsibility that owners must take on for the lifetime of the animal.   With great gravity, I always let my patients know an animal is not disposable like a bottle of pills (or a human therapist) when no longer needed and must have a lifelong commitment from its owner beyond a particular time of high personal stress.

Pardon me now while I go take care of my dogs, my cats, by birds, and my horses and yes, my goldfish.  They are my joy to support for decades and for as long as they need me.

josekelsy

Be Open for Business

barnstormingblog4 Comments

treehousejanuary

rapelje

 

Astonishing material and revelation appear in our lives all the time. Let it be. Unto us, so much is given. We just have to be open for business.
~Anne Lamott from Help Thanks Wow: Three Essential Prayers

 

1233407_683997988296184_779175851_n
same abandoned Montana schoolhouse as above a few years later (this photo by Joel DeWaard)

windowview

 

I have the privilege to work in a profession where astonishment and revelation awaits me behind each exam room door.

In a typical busy clinic day, I open that door 36 times, close it behind me and settle in for the ten or fifteen minutes I’m allocated per patient.  I need to peel through the layers of a person quickly to find the core of truth about who they are and why they’ve come to me.

Sometimes what I’m looking for is right on the surface: in their tears, in their pain, in their fear.  Most of the time, it is buried deep and I need to wade through the rashes and sore throats and coughs and headaches to find it.

Once in awhile, I can actually do something tangible to help right then and there — sew up a cut, lance an abscess, splint a fracture, restore hearing by removing a plug of wax from an ear canal.

Often I find myself giving permission to a patient to be sick — to take time to renew, rest and trust their bodies to know what is best for a time.

Sometimes, I am the coach pushing them to stop living sick — to stop hiding from life’s challenges, to stretch even when it hurts, to get out of bed even when not rested, to quit giving in to symptoms that can be overcome rather than overwhelming.

Always I’m looking for an opening to say something a patient may think about after they leave my clinic — how they can make better choices, how they can be bolder and braver in their self care, how they can intervene in their own lives to prevent illness, how every day is a thread in the larger tapestry of their lifespan.

Each morning I rise early to get work done before I actually arrive at work,  trying to avoid feeling unprepared and inadequate to the volume of tasks heaped upon the day.   I know I may be stretched beyond my capacity, challenged by the unfamiliar and stressed by obstacles thrown in my way.  It is always tempting to go back to bed and hide.

Instead, I go to work as those doors need to be opened and the layers peeled away.  I understand the worry, the fear and the pain because I have lived it too.   I am learning how to let it be, even if it feels miserable.  It is a gift perhaps I can share.

No matter what waits behind the exam room door,  it will be astonishing to me.

I’m grateful to be open for business.  The Doctor is In.

 

brokenbarn

cabincentra

Good to Melt

barnstormingblog4 Comments

darkhedgesantique

 

How exactly good it is
to know myself
in the solitude of winter,

my body containing its own
warmth, divided from all
by the cold; and to go

separate and sure
among the trees cleanly
divided, thinking of you

perfect too in your solitude,
your life withdrawn into
your own keeping

–to be clear, poised
in perfect self-suspension
toward you, as though frozen.

And having known fully the
goodness of that, it will be
good also to melt.
~Wendell Berry “The Cold”

frost1411

Man has places in his heart which do not yet exist,
and into them enters suffering,
in order that they may have existence.
~Leon Bloy

ice321419

I watch new heart chambers form every day
too frozen solid, too overwhelmed
with hurt
and loss
and despair
to continue to pulse warm.
So I try
to help patients let go of
their suffering,
let it thaw to liquid, let the ice melt down,
allow it to pass through freely
forgiving, forgiven~
a heart changed
by winter transformed to spring,
flowing warm from new found grace.

frozenpineneedles

A Calling Out

barnstormingblog3 Comments

geese113162

geesev6

A psalm of geese
labours overland

cajoling each other
near half…

The din grew immense.
No need to look up.

All you had to do
was sit in the sound

and put it down
as best you could…

It’s not a lonesome sound
but a panic,

a calling out to the others
to see if they’re there;
~Dermot Healy from A Fool’s Errand

geese913

geese113165

We are here to witness the creation and abet it. We are here to notice each thing so each thing gets noticed. Together we notice not only each mountain shadow and each stone on the beach but, especially, we notice the beautiful faces and complex natures of each other. We are here to bring to consciousness the beauty and power that are around us and to praise the people who are here with us. We witness our generation and our times. We watch the weather. Otherwise, creation would be playing to an empty house.
~Annie Dillard from The Meaning of Life edited by David Friend

geese1119152

By the time Saturday rolls around, I am overwhelmed by the amount of “noticing” I needed to do in the course of my work that week.  Each patient, and there are so many,  deserves my full attention for the few minutes we are together.  I start my clinical evaluation the minute I walk in the exam room and begin taking in all the complex verbal and non-verbal clues sometimes offered by another human being.

How are they calling out to me?

What someone tells me about what they are feeling may not always match what I notice:  the trembling hands, the pale skin color, the deep sigh, the scars of self injury.  I am their audience and a witness to their struggle; even more, I must understand it in order to best assist them.  My brain must rise to the occasion of taking in another person, offering them the gift of being noticed and being there for them, just them.

This work I do is distinctly a form of praise: the patient is the universe for a few moments and I’m grateful to be watching and listening. When my patient calls out to me, may they never feel they are playing to an empty house.

evening113163

geesesouth

geese11516