understanding backward

amazing.  cold and snow covered atlanta.  feels like i'm back in boston.  the kids were out of school all week- it was crazy-but fun.  yesterday i worked, and again, it was a welcome break.  when i got in early yesterday morning i found out two of my patients had died the day before.  i took comfort in knowing they died peacefully and pain free because they were up on our palliative care unit- with some amazing nurses who are so good at the caring part of their job. but there is always a little sting- even when expected- seasons of life.

last night i finished my book, 'the dirty life' by kristen kimball.  it was the book mike gave me for christmas- about farming, food and love. about a girl from NYC who meets a very different boy- on his farm- and how she leaves her life to join him.  she falls in love with him.  she falls in love with farming. with the dirt of it, the work of it.  and it seems for her- he and the earth and the produce of the earth are all one- they can't be separated. i'd complained about the book because i was hearing too much about farm logistics and not enough about love.  but the last couple of chapters pulled it all together for me. i began to understand that for her- they are all related.  she found her self- her identity- her place of peace- somewhere she never expected- somewhere she would never have purposely looked.  she stumbled into it and then she took a risk.
in the manure and the cold farm house and the 4 am waking and the calloused hands- she found purpose and meaning.  it wasn't pretty- but it was beautiful.  it was dirty- but glorious.  it was hard- but sustaining.  it took time, and work- but it gave back in abundance. she describes the constancy of it- the fight against nature trying to reclaim it's wildness.  the importance of vigilance- and the consequences of inattention. she began to value these things.  she saw both the reliability and unpredictability of nature. and to understand the importance of the heat in summer, the frosts and freezing winter, and the rains in between.  each needed, each with merit- even in their extremes.

it reminded me of many parts of my life.  of finding myself where i never dreamed i'd be.  of finding beauty in the difficult.  of process and work and the pain of it- and the glimpses of joy.  that joy often comes covered in dirty- like birthing.  it reminded me of the value of ritual- of the importance of routine- that those things (which we often complain about) ground us firmly- and we'd miss them desperately if they were gone. and of seasons.  the hard ones alternate with the gentle ones-and in the toughness, when our eyes are most wide open- we can see more.

she writes the book about her first year of farming, her first year with her fiancee, 6 years later. this is important. she has the advantage of perspective. of time settling things. of memory sculpting reality, shaving the sharp edges, smoothing the wrinkles. cultivating the lessons and mining the gems from the quarry of that first year.  time heals, but time also gives. that is why i love looking backwards, because that's when the understanding comes.  "you live it forward, but understand it backward." (cutting for stone). and reflection  helps me be more present-or more alive in the present. because my eyes are open and i see more.  there is a saying in medicine, "you see what you look for, and you look for what you know."  time and reflection-remembering- understanding- helps me to know- with out all the raw emotion that swells in the present. so i can look, so i can see.

finding the joy

quiet and icy and cold. today bryn turns 4.  my beautiful little boy.  my beautiful little un-timed but desperately wanted surprise- an answer to prayer as they all were.  i've been thinking about lots of things.  about people being born and people dying.   i've been thinking about being overwhelmed and how i respond to that. about how i treat people when i'm stressed.  and about how when you become a 'missionary' it's like having that fish symbol on your car- or walking around wearing a WWJD tee-shirt.  you'd better not cut someone off while driving, or not give the guy on the street a dollar.  there is something about its external nature, that holds you to be more accountable- that helps you be mindful of the way one should behave.  yesterday was a day of lessons learned. lessons that i really needed.

mr. A died yesterday.  i got a message at 6 am from his wonderful daughter.  we'd talked the day before- so i knew it would be soon.  he had started hemorrhaging at home - blood everywhere- from both ends and so she called 911.  he's on home hospice- but it's hard to not call for emergency help when you're dealing with that.  he was pretty much unresponsive- but not on any machines- per his wishes- and in the ICU.  she called to let me know. she called to ask what to do. what if his heart stops she said?  what if there is something we can do to stop the bleeding? "i know he can still hear me- because when i talk his heart rate goes up" she said.  i was so thankful she called.  i explained that at this point he was trying to go- his body was shutting down.  we were chasing failing organs- trying to fill a bucket with an unrepairable hole.  i reminded her of what we both knew- that he wanted us to let him go when his time came- that he didn't want his life prolonged on medicines and machines when he was dying.  i reminded her of the unbelievable care she'd given her dad- of what an example she had been to me and our clinic of love and commitment to family.  i told her her dad can still hear her, and sense her, and that she should go be with him- tell him everything she wants him to hear now- because he is dying- because we need to let him.  he died 14 hours later.

i've been thinking about the importance of honesty and ownership as physicians.  when i say ownership- i really mean leadership.  we do this with the medications we give- and the tests we order- we feel a sense of responsibility to make sure our patients take them, do them, and follow up with us- we are prescriptive with our prescriptions.  we write "orders" in the chart.  but when it comes to people dying- we often begin to cower.  we begin to realize our ultimate powerlessness.  and so we start offering things we know won't work- or won't work for long.  we do things, because we're  doing something. but this is not how we practice medicine with people who aren't dying.  we would never suggest an intervention- or a treatment or a medicine that we know would really not help.  but at the end of life- we begin to grapple at straws- we operate out of our own insecurities.  what if i'm wrong- what if he does pull through- what if he gets another 2 days?  we avoid.  we shuffle.  and in doing this we abandon.  and we push the responsibility onto the family.  i needed to tell her- even on the phone from a hour away- even though i hadn't seen him in 3 weeks, that he is dying.  that we need to let him go.  she needed that permission, she needed it from his doctor.

then the day began with the kids.  a snow day.  everyone home, everyone with energy, and mike and i with a giant todo list.  and after some squabbles and people picking at each other- mike and i went to have our time of regrouping- our time of prayer.  we realized we were stressed and not responding well.  we were feeling overwhelmed and not joyful.  our move to uganda- is actually really hard work.  we're getting ready to sell the house (2 weeks to go), we need to raise our own funds for the next three years, we need to prepare for what we'll be doing over there, we need to help our kids prepare, and we need to do all the same stuff we were doing before- like our jobs, and our laundry, and teach zoe and raise the boys- oh, and have some fun and see our friends once in a while.

and this is where the importance of ritual comes in- the importance of patterns and routines that give stability- when everything else is out of whack.  so following the celtic book of prayer has become our morning routine.  it grounds us- reminds us- puts us back together.  and yesterday, we really needed it- to be realigned.  and we realized that our todo list was rapidly eating our joy.  that the seriousness of it all was stealing our sense of humor.  that we had become the focus of what we're doing- not the missional work- not the call to serve. that we were operating out of fear and not faith, and that if felt bad, and that it was wrong.  we remembered why we love uganda and the ugandan people.  they have joy and laughter and smiles- in way more challenging situations than we're facing.  we remembered that we are only asked to take what we have and give it- not worry about coming up with more. we remembered Gods promise of provision. we remembered how blessed we are, and we smiled, got the kids together and went out and played in the snow with friends.

then came the part about being a missionary.  it was 4:40 in the afternoon, getting colder and about to get dark.  a man called me who i've never met, but who i'd spoken with the day before to ask if he could paint our kitchen (before we sell the house).  he called because he needed money- so he could get his medicine and a pay for a place to sleep.  he was hoping i could give him money today and he'd paint for me later this week. he was several miles away- the roads were all ice- many closed because of the snow stormed we'd had.  i thought about how easy it would be to say no. i've never even met him- and i never have any cash at home - how is he even going to get over here to get the money?
then i imagined him coming over to paint the next week- after someone else had helped him- or maybe after he'd ridden public transit all night to say warm.  i imagined telling him that i'm about to move to uganda as a missionary. and then i heard the words of Jesus- that i've read so many times.

feed my sheep.
i was hungry and you gave me food.
i was cold and you gave me shelter.
i was naked and you clothed me.

and i thought about how blessed we are- how warm we are- how we'd gone to the market and had food. i thought about injustice and homelessness as a reality, not a research topic.  i thought about the value of one human life.  i thought about WWJD (what would Jesus do).  and that answer was easy- it became a matter of how much should i do, not what should i do.

and i remembered the $100 dollar bill that was still in the purse i'd used in ethiopia- the $100 dollar bill that a man had given to me on the airplane- when i told him i was becoming a missionary in uganda.  that gift had had a huge impact on me.  a big gift from a man i'd never met- a man i'd never see again.  a man who'd felt a need to give- and responded.  that $100 dollar bill was a symbol- a promise of God's provision.

now, here before me was a man i'd never met- a man with a huge need- a man who needed to feel God's provision- and i was the one being asked to provide that.  so i responded.  i warmed some chicken and got some fruit and drinks together and packed him a dinner.  i got the $100 dollar bill  and asked mike to drive out and get him, to give him the food, the money, and take him to get his medicine and take him to a hotel- or a friends house. and mike did.  the man got what he needed and slept at a friends house.

when mike came home we sat down to dinner and talked about our day.  about what we'd learned about joy and peace and poverty and injustice and following Jesus.  we talked about provision. about how this man had actually given us a gift.  he'd helped us to step back and remember our mission, to look up, to get the focus off ourselves- to live as we should, as we are called to live, to live that now.  and in this day of lessons, we found our joy.

joy

i had a patient today in clinic who i really like. i've seen her about 4 times now. she is my age. she is dying. she comes in about every month- always calm- always together- always kind- peaceful.
a year ago, she was fine. now, her body is not- but she is- she really seems fine.
so today i asked her why.
she told me -her faith.
"in what?" i asked.
in Jesus, she said. we know so little, and the real picture is so big, we just see a small piece of it, she said. none of us know when our time is up- so live well, she said. be present- enjoy it- savor it.
so wise.
she's mastered what i keep trying to grasp- to just be- no matter what. to not let the stresses get to me so befuddled. to not be so easily enchanted by the sunshine and in despair over a bad zoe day. here is a woman who is dying when she shouldn't be. who has every right to be sad and angry and bitter, resentful, and unhappy. but she doesn't let her new reality change her person- she doesn't let her cancer, steal her joy. wow.

this week was spring break for everyone. we were home for our "stay-cation". zoe went for a sleepover one night and was gone the entire next day. so i had time with just the boys. it was so fun. i actually played with them- and enjoyed it. i know that sounds crazy, but i spend a lot of time organizing things and driving them and feeding them- but not nearly enough time - just playing. that next day when zoe was home- it was really hard. suddenly i was back in the world of sticky thoughts and hypersensitivity- and immediately i became grumpy and sad. mostly i was sad at myself for being so lame. for being so easily swayed. for allowing her mood- her challenges- her differences to dominate my mood and my person. for knowing that my response is key- i can make it better or worse, for everyone.

i remember when mike and i were going through the prenatal diagnosis with jude- we decided that no matter what the outcome, no matter how disabled he might be- we wouldn't let it destroy our joy. it was a really important decision- a commitment that we would hold each other accountable to. i'm seeing now, with zoe, that we need to make that commitment again. i see how often, i let our circumstances - our tough moments - spiral me down- eat at my joy- poke holes in it. deflate me. i leave today and zoom in to the future, terrified. i chew on all the decisions that i need to make about her and question the ones we've already made. i spend so much time in worry or dread that i miss the living it.


so i left clinic today feeling so blessed by this woman's presence. blessed by our connection and so thankful for her willingness to share her wisdom. to show me that it's possible. to remind me that joy is not happiness- it's bigger and deeper. that life can be so hard- but we are not swallowed by the badness. there is and can always be- our joy.
find it, hold on to it.