View from the top of the fire tower

Her wheels spun next to me as my feet pounded cold pavement, arms pumping at my sides. I could no longer talk. Our conversation had gradually faded into this moment as my lungs sucked air. Rounding the final bend we burst out of the woods and strangers stared as she screamed at me to run faster. I was murdering myself to cauterize an old injury with fresh tissue. I’m lucky to have my mom as a one woman cheering section to spur me on.


Our country needs a rebellion, an open resistance against the established authority. We must rebel against white supremacy, male supremacy, hetero/cis supremacy, and nationalistic bullshit. We must rebel for love, acceptance, tolerance, progress, and the future of our species. Pigment, gender, and sexuality place me in the dead center in the establishment, but I’m okay being problematic and learning to be okay with being checked when not properly woke.


On Thanksgiving morning my brother, parents and I found ourselves scattered around our kitchen drinking coffee and grazing on breakfast food. Discussing. Whether or not. To discuss. Politics. But life is politics. This idea that there’s normal life and then there’s political life is a fantasy concocted by white people, those settled comfortably into the dominant culture. Like myself. Besides, it’s way more fun to experience life in all it’s grime and awkwardness instead of settling for bland, meaningless, and good enough relationships with the people who will be with us from birth to death.


Thanksgiving was good. Grease dripped from a piece of Turkey meat my cousin dangled in front of me as has become our holiday tradition. He cooks and I steal food. Eyes glazed over and stomach distended with pie and stuffing, I leaned back on my parents couch with my newest infant cousin falling asleep on my chest. River honored me with some namesake drool and we might both still be napping on that couch if I didn’t have to drive back north to learn more about doctoring.


Helping me eat birthday cake

Because we’re the Cousins, Thanksgiving got political, it wasn’t all babies. Sometimes it’s good to talk to a likeminded friend under the northern stars. And sometimes it’s even better to have a bellyful of whiskey and a cigarette between your lips as you talk with your conservative cousin in his 4-door pickup. Listening was my first step. I was told by one relative that my intensity was overwhelming, so I listened as much as my mouth would allow. What I heard was fascinating.


Perpetuating the fear and racism driving our descent towards authoritarianism is an assault on information. We don’t get the same information. We don’t talk the same discourse. Our facts are not the other’s facts. Too many of us believe that institutions of learning and science are inherently biased and therefor untrustworthy. We have no common source of facts and information to depend on. The first step towards destroying a democracy is to undermine the institutions that pursue knowledge and speak truth to power. The white nationalists/Trump campaign did an excellent job of this during the election.


Creating accepted and trustworthy sources of information is a tremendous task in our age of exploding information. More importantly however, we need to be honest with ourselves about the role that fear, racism, and complacency have all contributed to our current political climate. Trump won all white demographics: young, old, female, male, rich, and poor. Forget the fact that we need to push back on the racist implication that only white people are working class, we’re kidding ourselves if we think that this election was about economics as much as about white nationalist fear.


Sunset at the firetower

Today I’m back up in the northcountry, leaning against exam tables with my head in my hands as I try to figure out how to best serve the men and women who come into our clinic. The sky is grey and the ground is wet, which is unusual for this time of year. Today in the Babbitt clinic I sat back while an elderly white couple in their late eighties railed against the racism, sexism, and economic insanity of Trump and what he stands for. It seems like it’s my fate now to let the wisdom of the elderly wash my soul clean when I find myself losing hope.

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I couldn’t smell the piss that I was told might be soaking the soft clinic chairs. The sun blazed in through the glass windows and I could see rows of single story houses marching down the street. I was working at the Babbitt community center and clinic, a retirement community for the rugged. A bead of sweat was beginning to form on the top of my nose when the old man roused himself.

Those things he said about women. Awful. Not sure what’s going on anymore here. D’ya watch it last night?

It was Wednesday morning and I was hunched over a clinic computer scanning through labs and hoping that the numbers would help me forget. The room was hot and my stomach hadn’t yet uncoiled from the night before.

For the first time since Ohio fell, a little pressure lifted from my shoulders.I looked up at the old man and nodded. Then I stood up, walked across the carpet and pulled on the metal latches to feel the cool air move into the room.

The next day I was back in Ely and I screamed at a patient that I was better looking than Dr. Montana. He was mostly deaf and mostly blind. During the physical I asked him to exhale as I pressed my fingers into the soft tissue of his abdomen to feel for his liver. He looked at me with sightless eyes.

My stomach don’t hurt nothing. Least I don’t think so. Might’ve shot myself in it votin for Trump. I dunno. Beard makes you look old ya know. Thought you were older than Montana. Beard makes em handsome.

He grinned as I sat him up. The history was taken, exam completed, and note written. We were shooting the shit waiting for labs to come back. I forgot that I was screaming into his left ear. Greg the triage nurse looked at me funny when I left the room. My beard was shaggy, I hadn’t slept well since Monday night, and I was pretty sure I was wearing the exact same clothes as the day before. I didn’t have it in me to deny my claim and explain myself.

I needed time to think in the woods. I don’t have the money for a good camp stove right now so I stopped by Shopko after work to pick up a hatchet and tarp. On my way home I dropped by the bar to grab a quick beer with some of my coworkers. It was cheap, but not knowing their politics allowed me a moment of respite.

The next day I sewed up a boy’s hand in between impromptu cardiology lectures by the visiting heart doctor. The hand owner wasn’t much younger than me and regaled me with wild stories after I put the local in and the pain went away. I felt competent cleaning, numbing, and sewing the hand, and frustrated when I realized how much I forgot about cardiology. I headed up to the woods on Sat night.


It was the day before the super moon, but it was still impressive as it floated higher and higher in the sky illuminating my camp with ghostly light. The night was cold and good for sleeping. The next morning I held black and boiling coffee in my hands as I sat on the rocks and watched the sun crawl over the treeline. This morning was good for thinking.
The election had no winners. Trump and those who stood by him lost because they fell prey to our basest, saddest, and most pathetic selves. History never smiles on those who act out of fear and hate. However, human civilization is but the blink of an eye in the cosmos, so this is about something bigger than history. America lost this election because love lost, decency lost, equality lost, and justice lost.

We aren’t lost because we lost the election. The struggle for love, decency, equality, and justice plays out from the micro to the macro level every single day in every single human interaction. I have hope that this election will teach us by opening up our eyes to our flaws and bringing people together to fight for love.

But words are nothing, especially these words which are only echos in the deafening chorus of pain and sadness. There are real people who are in fear and pain because of the results on Tuesday night. There is a generation of women, girls, immigrants, people of color, LGBTQ citizens, and muslims who all may feel unwelcome and less than. There are women, children, and men who will suffer because of the actions Trump has threatened and behaviors that he has legitimized. There are people suffering already today because of fear and hate that existed long before Trump entered the stage.

Therefore it is up to every one of us to make use of our own blink in time to fight for love and make the world a better place. I don’t need to lay out an argument for this philosophy because I know that it is embedded in our DNA. From the pro Trump diabetic overjoyed by the success of his CABG, to the six foot tall and devilishly flirtatious 87 year old Lady in Blue, each patient I meet has a goodness in them.



So sitting in the sun and drinking coffee on a cold morning in the BWCA, I thought about how I needed to buy better cookware as well as how I personally will move forward without losing faith in the humanity of those around me. I guess it’s my own weaknesses that comfort me, because I know if I can be better then we all can be better. Although I voted for Hillary Clinton and not Donald Trump, I know that there are days in which I lose my own battles to fear and anger, as do we all.

I can count on one hand the moments and people which/who make me want to be a better man. It’s why I keep feeling drawn to them no matter how destructive they might be. I vow to keep coming back to this election to remind myself to use my time on this earth to stand up and fight for the wellbeing of all people no matter what their gender, color, culture, sexuality, or religious creed. I will work towards being brave enough to make the inevitable sacrifices that come with fighting injustice. And I won’t lose hope.



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Our better angels


Yesterday afternoon I dove off the end of a dock into a glass lake. November water closed over my toes and squeezed the air out of my lungs. I came up sputtering and breathless. The smell of fear didn’t wash off me until I made three trips between the hot cedar sauna and the freezing lake.


Every room I walk into in the clinic has a smell. Soap, sweat, flowers, teen, woods, stress, urine, feces are bold strokes overlying individual smells that aren’t good or bad. I walked into the room last week and the smell was stress, sweat and tobacco. I haven’t been working in Ely long, but we had already met. Underneath the tattoos and anger, there was a sweet woman managing mental and physical health with polypharmacy. She was terrified and stuck between a mountain of medications and a fetus in her womb. HowdidIgethere whataremyoptions Iwishitweredifferent Whyme I’msoscared.


I could still feel the tension that the room left in my body hours later as I listened to ‘Start Anew’ by Chook Race and made my way to the sauna by the lake. That feeling of wanting to start over again and remake the past is universal at one point or another. I wanted so badly to tell her that it was all going to be ok. That kind of fear is terrible, but at least there some answers and steps we can help people take to address it. However, there is another subtle kind of fear up here. It’s creeping across America but finding its way most profoundly into poor white rural towns like Ely.

The people of Colombia just voted against peace. Great Britain voted against unity because of fear towards a mirage. The United States is on the precipice of electing a demagogue who rose by stoking fear and hatred against that same mirage. These are not aberrations and our flawed systems can only shoulder so much blame. What happens when the ‘will of the people’ is morally bankrupt? The Crusades, the Renaissance, the Inquisition, the Truth and Reconciliation Commision, the World Wars, and the Christmas Truce, human history is littered with greatness and horror. I believe that we need to begin to lay bear most shameful weaknesses along with our greatest achievements if we hope to discover a better way.


I ran in the woods today, weakly shielded from bullets in my blaze orange t-shirt. I felt no fear as my footsteps padded down pine needle carpets. I felt no fear when I scrambled up rocks wet with rotting leaves. I felt no fear when I was lost at dusk, scrambling through foot trails as darkness made the woods around me black and unknowable.


I still feel have fear, but that fear has changed. When I was little I was deeply afraid of death and what lies beyond my consciousness. When I was little I was afraid of what and whom I didn’t know. The depths of infinity can still rip the ground from underneath me and I’m sure there are things that jump in the night that could still make me pucker. However, the twin gifts of education and exposure have taught me that I have much more to fear from my own follies than the deep woods and dark unknown.


What frightens me today is the possibility of time misspent, people maltreated, and opportunities wasted. I fear that my own weaknesses could prevent me from becoming the man I want to be. I’m afraid that I’m not smart enough, not good enough, and not hardworking enough. I’m afraid that the signposts of time will tick by faster than I can see them and I won’t be able find my way.


The average ‘white working class’ American man is not fighting to put food on the table or a roof over his head. We live in a country where jobs are on the rise and the economy is rebounding, but we are terrified and massively discontented. By no means am I saying there isn’t crushing poverty and that we don’t have an obligation to do better by one another. However, this white male rural fear is deeper than economic and social mobility. One might argue that old and potent racism underlies the current rage. I believe however, that ‘fear of the other’ forms the foundation of racism, and therefore it’s essential for us to try to understand it. Without education and exposure, grappling with existential questions about your place in society has historically led to bigotry and violence.


Now watch these ‘fears of the other’ become kindling. The first seasoned log is our segregated society. The second log is an explosion in technology which numbs our thoughts and perpetuates our biases. In a landscape dry of quality education and cultural awareness, all we needed was the demagogue spark to ignite a raging wildfire of ignorance and hate.


My dad always told me that the post WWI Germans who allowed Hitler’s rise weren’t bad people, they were just afraid. I hear the same language now from people whose friends and family support Donald Trump. However, no one ever argues that what followed WWI wasn’t horrific and that everything that could have been done shouldn’t have been done to stop his rise and prevent that from ever happening again.


We must be better. We must engage our better angels and make a better world. Stopping Trump will only put out the current fire, (Of which I am not minimizing the importance of, fuck Trump), but I believe it is contingent on those who are fortunate to try to understand the real fear in America and meet it head on. We have an obligation and opportunity to build a better world.


My mom is my own yardstick in this regard. I’ve never watched her spend one day without thinking about how to better our world. She is the bravest person I know. She stood up to a faux-liberal South Minneapolis to fight for what she believes in. She put her career and reputation on the line in order to take a stand for just and equitable education. Her peers and colleagues used to disgust me for their cowardice, but now I’m trying to understand their fear. They were some of the people who raised my own friends and peers, so again, good people. Beyond her career, she walked the walk in the way that she educated her own boys. She taught us to be good instead of great and never pressured us to be anything more than kind. I watched her stand tall.


As I pulled myself onto the dock yesterday, I rolled onto my back and felt the unseasonably hot sun steam lakewater off my skin. My heartbeat radiated up into my skull and the whistling pines were the wind instruments in my symphony. Life can be grand sometimes.


Burntside lake

I’m going to finish this off with a post from my cousin Megan, I couldn’t have said it better myself:


Regardless of what happens on Tuesday, Trump does not nor ever will represent me. I decry his hateful, violent, bigoted, and racist rhetoric. My Muslim neighbors, I stand with you. My Somali neighbors, I stand with you. My Latino neighbors, I stand with you. My immigrant neighbors, I stand with you. My Native neighbors, I stand with you. Women, feminists, LGBTQ individuals, I stand with you. We must do better. Vote for Hillary on November 8th.




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Goodbye to the 612


I’m not sure how I’ll handle the separation, so I figured I’d reflect on the last month of living with dreamboatdrayton. The past few weeks  have thrown both the beauty and brevity of life into sharp contrast. I watched my impossibly stunning friend Grace get married as the pacific surf crashed behind her. On a cold gray day 72 hours later, I opened my phone and found out that another friend had passed away. This past month was split into a two week child psychiatry rotation and two weeks of construction work. After concrete ended, I packed up my Prius and drove far into the north country.


I spent the mornings of child psychiatry talking one on one with patients. Conversation bounced back and forth with footballs and soccer balls. Afternoons filled up with admitting patients and discussing cases with the two doctors I worked with. This was easily the most intuitive and heartbreaking work I’ve done in medical school. Every day I met with traumatized children who didn’t have the opportunity to see the world as the safe, loving place that I did growing up. I wanted to take each and every one of them home with me. On the other hand, it was astounding to see their capacity for introspection and tenderness. A young boy who was nonverbal and violent during admission would end up talking softly to me about his favorite foods the next morning. A high schooler who screamed at his mom and the staff on Monday, hung out with me on Wednesday, smiling shyly and laughing as we talked about school. I struggled through oragami and coloring but excelled in football and legos.


This rotation led to a conversation with a friend of mine about the ethics of medicating mental health conditions. He questioned the long term health effects of medications, symptomatic vs etiological treatment, and the pressure that we put on parents and their children to exist on the range of what “experts” have decided is normal. I agree that medicating children in hopes to achieve “normal” functioning can be dangerous, but I also believe that we need to do the best we can with what we have. I saw talented clinicians work with deeply troubled children who had become a danger to themselves and others. It was powerful to see the child after layers of illness were peeled back. That act of discovery made me want to come back for more.


All children should have a fair opportunity for success. All children should have loving and supportive families. All children should meet our world through thoughtful, educated teachers and police who take the time to see their goodness. That world doesn’t exist right now. I see my role as a doctor as pushing to better the world we live in while simultaneously treating patients in the context of our current and flawed planet. The literature is clear that besides inherently increased morbidity, mental illness is associated with decreased life expectancy. So why are there so few resources dedicated to mental health? How do we decide when to rehabilitate and treat people versus jailing them? How much autonomy should destructive parents (most likely suffering themselves) have over their children’s lives? Etc, etc, etc. Plenty of thoughts for the following weeks.

Five months ago, I staked out the two weeks after child psychiatry for blissful nothingness. It was my first time to relax in many months. But when my dad told me he could use a hand, and I fought against my inherent laziness and came out of retirement to work for Cousins Brick and Stone.


On Wednesday morning construction week two, we poured concrete at 7:00 am. The sky was dark and the air was cold. After ten minutes of wheeling cement, I stripped off my sweatshirt. The cold air hit my hot skin and I felt alive and deeply well.  Concrete work is fast and hard and it’s quickly obvious if you don’t know what you’re doing. Most of all though, it was a pleasure and unique opportunity to be able to spend time as a man working alongside my father. I still have much to learn from this man whom I’ve used as a model to mold my own life. I watched him design complicated structures while thinking about how they might need to evolve in the future. Driving from lunch buffets to steel yards I watched him embody his stated philosophy that “We’re only here for a short time so we might as well have fun.” He has friends scattered all over the city. Someone once told me that I was too hard on my dad. She was right. We can blow up at each other after less than a look. However, the flip side of being so similar is that we both work hard to cherish the time we spend together, comically quick to reconcile and tell each other that we love one another. These past two weeks were a priceless embodiment of that relationship.


Unfortunately, construction was short lived and I left the cold concrete to fly down to Malibu for a friend’s wedding. I watched my beautiful friend get married on a white sand beach. I panted through mountain runs with another friend who’s more like a brother. I found myself a part of a debaucherous dancing trio of men tearing up a gravel dance floor populated by women in their 60s. I passed out on a beach after being body slammed by the cold surf. Sunday morning I was already fantasizing about my future practice in Southern California. Everything about the weekend screamed life, but it’s hard to differentiate the fantasy from reality. I knew someone who hated when I constantly questioned and deconstructed pleasurable luxuries that fall my way, so she would have appreciated the unabashed exuberance of Malibu. However she would have quickly seen my misanthropy regain control when I found out my return flight was first class. I tried unsuccessfully to pawn my seat off on a few passengers and then the flight staff.


It wasn’t until I was sitting in my marginally wider seat back to Minneapolis that I fell to questioning the reality behind the white sand beaches and million dollar homes. On whose back is that kind of luxury built on? How can that kind of wealth justify itself?


Time unravels in front of me as I turn over these questions in Ely. The space heater rumbles next to my chair, warming my legs, sore after a long run alone in the woods. I’m happy up here in the cold, and the occasional pang of yearning I feel isn’t for beaches and bikinis. I feel content in these quiet moments with a glass of whiskey while reading or listening to NPR. Without the constant distraction of the internet or the pleasures of the city, I’m left with peace and a pleasantly melancholic pang for family, friends, and good moments of time since passed. This life here is another kind of luxury, one however that I hope is training and rejuvenation for a life of continued service.


For Ari, we will always love and remember you.


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I’m with her

It should have taken no more than 30 seconds of watching the debate to understand that there is not an option in this election. That being said, it shouldn’t have been a question in the first place.


Whether it’s fear of having a woman in office, fear of immigrant men, women, and children, or fear of people who look different from us, I hope Trump supporters can take just one moment to look inside themselves and reflect.  Are they modeling the kind of people that they hope their children will someday become? On which side of history do they fall?


I’m struggling with this question: At what point do “good people” who have different political beliefs than ourselves become “dangerous people” because their beliefs endanger the lives of others? How far does a candidate need to go before we reevaluate how we approach the relationships with people we love, but hold disturbing political beliefs.


I think back often on Nelson Mandela. He fought violently (literally) against a society and system of beliefs that were based on ignorance and oppression. However, he continued to strive for understanding and forgiveness for those same people.


I want to continue to understand and forgive people their humanity, but I will not accept these beliefs and attitudes in any form. It is my responsibility as a privileged and non-maligned member of society to fight as hard as I can against this fearful, hateful, and oppressive mentality. Over the next month I’m gonna make shit weird and uncomfortable  when talking politics. This will be going against my non-confrontational Minnesota values.
This election is different from others not just because of what might happen if a racist, sexist, demagogue gets elected. It’s different because supporting that demagogue means aligning with fear and hate. We must be better than this.

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Wake up call (revised)

“Sometimes there’s nothing more we can do,” my attending physician warned me as I sat in her office after rounds. We were talking about to her about the seemingly insurmountable battle my patient “Jane” was fighting in regards to her health. Jane was homeless and living out of a hotel with her children and grandchildren. She was wheelchair-bound from multiple amputations due to a rare illness caused by an allergy-like reaction to nicotine. Her health was further complicated by heart failure, high blood pressure, depression, narcotic abuse, and nicotine addiction. Over the past year Jane had been in and out of the hospital and non-adherent with her medication and follow up. She was recently fired by her home health service for lack of communication and refusal of services. Her survival easily be measured in months, and she wasn’t even 50 years old. It didn’t take a medical education to see that stable housing and strong social support were necessary for her health care, and she needed more than just pain control and medical stabilization.

So back to “Sometimes there’s nothing more we can do,” a comment from a physician for whom I cannot overstate my respect, but with whom I completely disagree. I selfishly chose medical school over other healthcare work because of the power and social capital that an MD can wield in terms of social activism. Jane’s story further reminded me of need to use that voice to speak truth to power. Nine days out of ten she was joined in the hospital by her daughter and two grandsons. The small hospital room had become their most stable home. On hospital day three, I took her grandson up to the seventh floor of the hospital to play cards and because he wanted a view of the new Vikings stadium. So I took this homeless 9 year-old Minnesota boy up to look at the stadium, which he’ll most likely never afford to enter, that Minnesota state and local taxpayers paid approximately 498 million dollars to build. So again I disagree, I believe that there is something we can do for the roughly 10,000 homeless people in Minnesota, over 3,500 of whom are children. For starters, we can house our neighbors with our taxpayer dollars instead of spending it on football. These numbers should make you sick to your stomach. The cost of this one stadium, let alone the tax breaks, equals to almost 50,000$ per homeless Minnesotan.

Lawmakers argue that they’re investing in the future, which will in turn bring more money back to the state. However the numbers don’t back this up. A 2007 (Culhane et al) study found that the cost savings of housing homeless patients in Hennepin County was over 100,000$ per patient per year just in healthcare costs. Not to mention savings due to reductions in HIV incidence, jail bookings, and school costs. It should enrage you that instead of spending money on entertainment and leisure after taking care of our vulnerable people, we spent half a billion dollars building a stadium that statistically (when looking at other comparable stadiums and cities) will not recuperate its costs. A paper from the International Association of Sports Economists showed a strong consensus among economists that stadiums are not worth their price and that the benefits they bring don’t match their costs. Furthermore, a new Taxpayer Alliance report showed correlation between public subsidization of new stadiums and lower medium incomes and higher poverty rates in those same cities.

The responsibility of this ridiculous situation is on every one of us. It’s on us every time we talk about, support, or glorify football in its current iteration. We can’t stand by anymore and blithely support through our words, dollars, views, and actions a sport that destroys the brains of the men who play it and bullies weak politicians out of taxpayer dollars. Because it’s a fucking sport that doesn’t matter and the costs are too high. Every once in awhile, the veil needs to be pulled back so we can glimpse our collective insanity. Grown men in fancy suits sit next to each other on TV and talk seriously about other grown men playing ball games. There’s nothing inherently wrong with this, and it would be nothing more than kind of pathetic if we lived in a society that didn’t have homeless and hungry children, poor public education, rampant gun violence, and pervasive discrimination regarding race, gender, sexuality, and religion. But all of these things do exist, so we need to re-examine where what we stand for as a society.

Before finishing my rotation in Medicine, I spent 3 weeks caring for Jane who, like I mentioned, was living with Thromboangitis obliterans (Buergers Disease). Buergers is a devastating illness in which your body has a more or less allergic reaction to nicotine that causes your small blood vessels to fibrose, leading to rapid loss of extremities to gangrene and amputation. The first time I met Jane she was sitting up on her bed when I walked into the room, crying and asking for pain medication. Her right leg was amputated below the knee, all five of her toes were amputated on her left foot, and she had open draining ulcers on both legs and where her toes used to be. The sour smell coming from her ulcers was something I would get used to over the next three weeks. We started her on IV antibiotics and began to treat her pain with opiates. Her pain was a complicated soup of Buerger’s disease (the nicotine causes pain crisis), open wounds, edema and inflammation due to heart failure, and opioid tolerance and addiction.

I began to quickly learn more about healthcare than I’d learned in months of medical school classes. Medically we were managing congestive heart failure, Buergers Disease, pain, hypertension, and COPD. Emotionally we were managing depression, narcotic and nicotine addiction, and anxiety. Socially we were managing homelessness, dependent children and grandchildren, poor follow up, and medication non-adherence. And personally she taught me about interprofessional collaboration, managing my own expectations, and the absurdity in the idea that physical, emotional, mental, and social medicine can be separated.

On the morning of hospital day two I ran into Jane being wheeled out of the hospital by her 9 year-old grandson at 7:30 am. This was ten minutes after having a half hour conversation with her about her illness and the dangers of having even one more cigarette. Nothing I could do in that moment would stop her from going outside to smoke, not even a promise of tea and a backrub. Later on that night, I realized that I was angry with her. I was angry because she woke up a nine year-old to take her outside to smoke, angry that she couldn’t do what seemed obvious, angry that children had to suffer for the mistakes and illnesses of adults, angry that she didn’t do what I wanted her to do. This was a manifestation of my own weakness.

I need to let go of my own need for control and just be the best doctor I can be. I need to redirect my rage toward a system that methodically discriminates against against poor, immigrant, female, and patients of color. I need to sublimate that rage into care and love for the patient in front of me. The relationship that Jane and I developed over her three week stay was complicated but rich. I began to understand that beneath the pain, amputations, and medications, she was just like any mother trying to do the best for her little clan. To the embarrassment of both myself and her daughter, she mischievously tried to marry us off, and I was reminded that I’m still a young man working for a grown woman who has a lifetime of knowledge and experience.

Her hospital course was rocky. Some days I came home inspired after seeing over a dozen brilliant people from different specialties (hospitalists, care coordinators, social workers, nurses, cardiologists…) all working hard towards a shared goal of getting Jane and her family back on solid ground. Other days I’d stop by her floor only to hear someone bitching cattily about her, find out she’d taken her whole family outside to smoke at 3:00 am, and see her sitting in bed sobbing, snowed with opiates, and begging for more pain meds while her two grandsons fought over a cell phone in the corner of the room.

By hospital day eighteen however, she started to turn a corner. She had diuresed enough fluid that her legs were less edematous and therefore less painful, and she was requesting less pain medication. She was also nine days cigarette free. Then came the shattering news that a routine ECHO showed that her idiopathic cardiomyopathy had lead to an 11% ejection fraction (normal is 55-70%). This meant that every time her heart squeezed to pump blood to the rest of her body, it was only able to squeeze out 11% of the blood from her left ventricle. Jane was now faced with an entirely new and pressing death sentence that had nothing to do with her lifestyle or choices.

We discharged her from the hospital with improved pain and controlled heart failure. She was given a comprehensive education regarding her illness, and coordination with social services for housing and home health. Furthermore, she had a nicotine cessation plan and was eleven days without a cigarette. As a team we decided to hold off on broaching the subject of palliative care because forward-thinking and medication adherence might be her best palliative option. At the end of the day, Jane isn’t a character that exists to teach me lessons, she is a flesh and blood human being that tragically exemplifies our society’s twisted values, both good and bad. Furthermore her story should serve notice for us to re-examine what we support with our words, dollars, actions, and to remind us that we live in the same city as a homeless woman with multiple amputations and terminal congestive heart failure living in a hotel while supporting her 2 children and 2 grandchildren because she can’t afford stable housing.

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Saturday afternoon


When I left the hospital today, black storm clouds framed the Minneapolis skyline, perfect running weather. Early this week when I went running with similarly threatening skies, the rumbling thunder gave way to sheets of rain and marble sized hail. It made for an exhilarating return trip and a meditation on the  power of nature. Today the weather held, so instead of meditating on life and death I thought back on an incident that happened one week before.

Last Saturday afternoon was gorgeous, I got an early admit so I was walking out of the hospital at 3 pm, 2 hours before I expected to. I snapped the pannier to my bike, rolled up my scrubs, and kicked off downhill towards the hospital entrance. As my bike lazily rolled towards the street, I heard yelling on my left and turned my head to see what was going on. Four security guards were standing around a young black woman who was crying and staggering towards the street, catching herself intermittently on the brick wall of the hospital and the concrete pillars holding up the parking garage. She was wearing shorts, a grey t-shirt, and hospital socks. She had spittle running down her shirt and foam in her mouth. She looked unwell.

I turned my handlebars and pedaled up towards the scene, leaning my bike up against the hospital wall and slipping on on my t-shirt shirt as I walked towards security. The girl was now sitting on the ground with her back to a post, crying and banging her head against the concrete. I could hear one of the guards angrily telling her that she needed to leave the premises as the others stood next to him and watched. As I approached, he turned to me and aggressively told me that I needed to “walk away.”

Now I’m a white man in scrubs and I shamelessly used that social capital, ignoring his command and continuing to walk forward. I said that I was a student doctor who worked at the hospital and asked what was going on. One of the other guards quickly stepped between us and told me that the girl was admitted for a seizure disorder, but that her ED workup was negative. He said she tried to leave the hospital on her own, and was eventually discharged AMA (against medical advice). He then handed me a plastic bag full of her medications, grateful for the chance to be relieved of responsibility. I took the bag and sat down on the sidewalk in front of the girl as the four guards walked away.

The girl didn’t like me. She didn’t like the fact that I was sitting with her. She didn’t like the fact that I put my hand between her skull and the concrete. She didn’t want to be in the hospital. She didn’t want me to call a cab to take her home. She didn’t know why her boyfriend wasn’t there. Every few minutes she stood up and staggered a couple feet only to sink back to the ground, sometimes spilling onto her back, shaking and spitting, her eyes rolling to the back of her head. These spells only lasted a few seconds, during which I tried to keep her from biting her tongue. She would then sit back up and start crying again, unable to articulate much beyond her emotions.

After 20 minutes or so of cyclical conversation and behavior, I was only able to elicit her name, her age, that she was close to her family but that they were on a camping trip, and that she just graduated from high school. When I started to feel like I wanted to pull out my own hair, I knew I had to check myself, so I sat back on my heels as she cried in front of me and ran through what I knew:

The patient was harming herself
She was vulnerable (18 year old girl, alone, no wallet, shoes, ID or phone)
She was either having seizures or some sort of conversation disorder
She was not behaving like a competent adult
She has family she’s close to
I did not have the skills, words, or knowledge base to resolve the situation on my own

She had stopped banging her head, and she didn’t look like she was going to be moving anywhere quickly, so I walked into the ED and asked the admitting nurse what was going on. She told me the same story I heard from the security guard, and when I said that I thought the girl was unsafe and should be readmitted, she asked me if I’d like to talk to the ER Doctor. I said yes, and he came out a few moments later with an irritated look on his face. When he asked me what I wanted, I told him that I was a medical student working at the hospital and that I became concerned when I saw the recently discharged patient outside the ED. As I began to tell him what I saw, he interrupted me.

He told me I had “no idea” about the patient or her history, and that what I was seeing was nothing more than an attention-seeking behavior problem. Stifling my reaction to the heavily race-coded phrase “behavioral problem,” I replied that I agreed with him that I didn’t know anything about the patient’s history and that he likely had a much better idea of the patient than I did. That being said, I followed, there’s a girl outside with no ID, no phone, no shoes, foaming at the mouth and harming herself by banging her head against the wall. “Stay away from her and get out of my face,” he snarled and walked back into the ED.

I might have stood for 10 seconds in disbelief with my hands pressed down against the admission desk. As I turned to leave, another bearded young white man, either a scribe or nursing assistant, I couldn’t tell by his scrubs, turned to me and said “we see these people all the time.” I let my frustration get ahold of me as I angrily asked what he meant by that and whether she would have been treated the same if she were white. His eyes immediately widened as he said “You can’t say that. You shouldn’t be saying that,” but I was already walking toward the door, trying to figure out where to go from there.

The girl was still sitting on the ground with her back against the wall. I squatted down in front of her trying to collect my thoughts when two other nurses, both men, came outside beside me. One of them sat down beside her and restrained her from banging her head against the wall, which she had started doing again as they walked up. The other had a wheelchair and spun it around so that it was in front of the girl. I asked them if they would take her back inside, and the one holding onto her head nodded. He said that was why they came outside, and that he thought she wasn’t safe and needed to be re-admitted. She initially struggled when they tried to get her up, but seemed to collapse into the chair once she was in it. As they wheeled her into the ED, I walked back inside to talk to the senior resident on call. The resident was going over notes with another medical student in the lounge when I walked in. I quickly explained what had happened, including what I thought went wrong.

I understand that dealing with patients who are that difficult must be frustrating, because they are the people who require the most complicated physical, mental, and emotional care.  I am also aware that I knew less about the patient’s story than the ER Doctor did, and I can imagine how frustrating it is to deal with a complicated patient and then have a 3rd year medical student question your decisions.

However, what I saw was a  scared, sick, 18 year old girl who was two months out of graduating from high school. She was harming herself, unable to articulate her needs, and extremely vulnerable. There are always options if we take the time to figure them out, even though this kind of problem-solving isn’t as sexy as diagnosing something rare like Pheochromocytoma. We could contact social work and psychiatry, bringing them in to to lay eyes on the patient and lend a different perspective. We could send an aid or sitter outside with the patient to make sure she doesn’t hurt herself. We could place the patient on a hold in order to do a further workup and contact her family. Or at the very least we could tell security that it is their job to make sure the patient stays safe and has a ride home.

I also know that there’s a good chance that the ED team went over all of those options and maybe more. However, I refuse to believe that with all of the options and brain power available, that there was nothing more that we could have done. Maybe I’m naive but I still think hospitals should strive to be a place of healing and caring for the whole person, not just their lab numbers. And I know I’m still learning, but from what I can tell, the line between mental health and behavioral decision-making is a fine one and probably not a line at all.

I spent a lot of time reflecting on this incident, and am still not sure whether or not writing about it is a good thing, because it’s hard not to make the story about ‘me,’ when the story really should be from the perspective of those who suffer the most. Because I’m so lucky, I biked home, went swimming, got drinks and dinner on a patio, woke up to a feast of a breakfast made for me because I had a long day, just in time to drive over so we could watch my mom win her age group in yet another triathlon.

I knew I wanted to write though, because I spent the following afternoon eating good food by the creek in my family’s backyard, holding my cousins new babies, and playing with their toddlers.  This afternoon reminded me that my generation has an obligation to fight to make their world into a better one.  I want them, as well as my future children, to grow up in a society that does all it can to hold up those in need. And I guess the first step for me is rattling the cage when I have the opportunity to, and taking on the responsibility of my profession by working to contextualize and humanize every person I work with,  striving to serve my community, and staying hungry for change.


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