In Memoriam

Dwight and I sat in his small apartment and talked about our memories from Pine Street, the neighborhood we had first become friends and neighbors. He was grinning in a mischievous way and I knew something good was coming. “When I first met you, you were juggling outside, and I thought,” he paused to actually chuckle, “Wow, this guy must know kung fu or something if he’s crazy enough to juggle outside in this neighborhood.” That had been nearly five years ago; we laughed hard which felt really good. He adjusted his nasal cannula, paused to breathe, and ate another spoonful of the butternut squash soup my wife had made. He sighed and set it aside. “Dave, this is really good, but I just can’t eat any more. I can’t eat that much these days.” He could barely stand from the easy chair, limited both by weakness and the extreme shortness of breath he experienced as his new normal. I stared at the stains on the carpet and his pants where he had spilled some of the soup earlier. I remembered wiping it from between his toes and off his swollen legs with the same sense of affection and gentleness I did with my two year old son. It felt strange because I knew it shamed him to feel so helpless, this man the age of my father who prided himself in his ability to work with his hands, but there wouldn’t be anyone else to come by that night to help. It was the only thing left I could think of doing to preserve his dignity, something I thought about a lot those days.

There was a pause in the conversation and I asked him a question that I had been meaning to for some time. “Dwight, I’d like to ask a favor from you.”

“Sure, Dave. Anything for you.”

“I’ve been thinking of writing a book or something about my experiences from Pine Street, and I was thinking about how much I learned from you and still do about the city and your life and everything. I was hoping we could write it together, the story of our friendship, or maybe I could interview you. Would you be interested in something like that?”

He answered quickly. Yes, he would like that. Yes, I could make some recordings if I wanted to; he didn’t think he wrote very well but loved to talk and loved to tell stories and we agreed that that might feel more natural. He had been thinking about writing some things down anyways.

We talked a bit more and then I washed a dish or two and went to leave. “Love you, Dave,” he said. I told him I loved him too. It was an exchange he had taken to ending our conversations with over the past two years; it had taken some time for me to get used to, being naturally hesitant to use the L-word, but it felt both expected and natural by now.

I took the elevator down the high rise and drove home. I walked up the steps to my house and thought again about how we could build a ramp so Dwight could visit more easily and see the new home and remark on how different it was from the row houses of Pine Street we had first met in. I thought about what we might cook for him and how much salt to put in it. I did some looking for a nice voice recorder and ordered it on Amazon exactly two weeks later.

I never got to use it with him. He died a week after that, but I didn’t find out until this weekend and only did so because I found that his number had been discontinued. Two months have already passed and I missed the announcement, the interment, the memorial service. I missed everything. Continue reading “In Memoriam”

In Memoriam

The Resurrection

The nurse, the wife, the niece, and I sat together in the small family room, quietly thinking. I felt insulated from the sounds of the busy hospital even as my pager chirped a warning that our ICU was about to get even busier. I resisted the temptation to sit on the edge of the seat and betray the anxiety I felt and the urgency of the conversation. We were gathered to discuss the critical decision to intubate a patient, a man who lay struggling to breathe in a bed just down the hall. We had been trying for days to stave this moment off with a tight facemask that forced pure oxygen into his lungs, but he had been ripping it off in his confused and deteriorating state. He was tiring out rapidly and an internal clock in the back of my mind was counting down towards that tipping point when even intubation might cause his heart to stop and actually hasten his death.

I looked at the wife and remembered our first meeting a few days earlier, when the patient first crashed into the ICU. At that time, she told me how she had been living in the hospital for two weeks, watching helplessly as his first round of chemotherapy set off a series of nasty complications. She told me that the one day she went home to get some rest was the day she got a frantic phone call telling her to come back in and this time to the ICU. I told her she had permission to not feel guilty about going home and she burst into tears of relief, sorrow, and exhaustion. We talked then about his tenuous condition and how sufficient recovery to tolerate the next round of chemotherapy was difficult but not impossible.

But in the days since he only did worse. In the disorientation brought about by his decline, he was in a constant state of fear, agitation, and anxiety. And now, at the edge of his viability, it became my job as the supervising resident to tell her that we were reaching the point of extremis: that his survival depended on breathing through a tube which we might never be able to remove, that his respiratory failure came at the end of a chain of other failing organs, and that even if he survived the ICU stay it was unlikely at his age and in his condition that he would ever recover enough to tolerate the next round of chemotherapy. So I told her what she already knew and we sat still for a moment in that waiting room, listening to my pager and the muted sounds of hospital chaos outside.

Then she cried. She cried as she told us how just a month ago he had been fishing with his grandson without any cares or illness. She cried as she told us how he had just asked his son to fetch his gun from home so he could shoot himself. She cried as she told us that she didn’t want to see him suffer, that she knew it was time to let him go, but that she still didn’t want to lose him either. I watched the niece cry and even the nurse cry as we felt the force of all her helplessness and fatigue and grief.

I have rarely felt the gravity of a moment as I did then, weighing the value of every word and pause against the ticking of that clock. We decided to let him pass, to stop our modern medical torture and transition him to hospice. And even though I and every other specialist had known from the beginning that this would be the best outcome for the worst and final situation of his life, it still felt like utter and hopeless defeat.

In that moment, I asked if he was a man of faith. His niece offered that he was, and remembered that he always insisted on holding hands and praying together before meals every Thanksgiving and Christmas and Easter. So I offered to pray for them and we did. We gave thanks for the life of love that he lived and the deep affection of family that was the reason why these moments and decisions were so hard. We prayed for the release of his suffering, that in Christ our death is not final but will be overcome. And, in an unusual moment, we even had the audacity to pray for joy.

We left the room and I rushed off to set up the incoming arrival of three sick patients to the ICU. It was so busy that I could not return to the patient’s room for several hours. When I finally sat down at a computer to plug in some orders and take care of paperwork, the nurse came up to me and asked, “Have you been back in the room yet?” I sheepishly said I hadn’t, it had been so busy…

“It’s a completely different room,” she said excitedly. “Before that conversation, it was like a funeral; now they’re talking and laughing and joking and sharing stories about their memories together. I have never seen a doctor pray like that before.” I was stunned; I hadn’t expected such a change either. I stopped by the room and drew back the curtain to see it exactly as she said. I saw the wife’s face transformed, smiling even through her puffy red eyes, the great weight having visibly been lifted from her.

I didn’t cry once throughout the entire encounter but for some reason can feel the tears brim in my own eyes now as I write about it. It has been years but the memory is still clear and bright because, to me, it is the closest thing I have ever seen to a resurrection.

He is risen!

The Resurrection

Counterpoint: Donald Trump got elected and I know exactly what to think

This is written as a public response to Jonathan Imbody, VP of Government Relations for CMDA, who recently wrote an opinion piece for a CMDA blog titled “Donald Trump got elected and now I don’t know what to think.” As he introduces:

If that statement describes how you feel, you are a member of a large group of Americans who neither enthusiastically support nor disgustedly oppose the new administration. You land somewhere between “Not My President” and “Make America Great Again.”

The brief suggestions below aim to help you process what’s happened, what’s happening and what you can do about it all.

While I have great respect for the work of CMDA in legislative advocacy to protect physician freedom of conscience (even if I disagree with certain points), and would consider Mr. Imbody and others as part of the Christ community, there are both specific and coded references written in this piece that I have concerns about. As a former student leader for CMDA and ongoing active member, I am obligated to represent viewpoints of Christian healthcare professionals otherwise excluded in this narrative. Even if my points here constitute a minority perspective, I hope to demonstrate their validity. I also hope these words will not be construed as contention or meaningless dissent, as I do support much of the work and perspective of CMDA, but that it represents a plea to not alienate those who share my concerns from within the body of CMDA constituents.

Mr. Imbody writes this piece as an attempt to placate concerns regarding the Trump administration. He states that detractors are unnecessarily concerned because they have placed disproportionate faith in government to be the “primary vehicle for social change.” He assuages:

Our founders and Constitution, however, designed government with a small “g.” They designed a limited government that reserves maximum power to the people, a deliberately cumbersome system that makes sweeping change difficult.

That realization should help hyperventilating Trump opponents breathe a significant sigh of relief. Ironically, the small government system that Big Government advocates have been trying to dismantle is actually the very system that will protect them from any tyranny they now fear. (emphasis mine)

However, he minimizes or overlooks issues concerning to both physicians and patients related to the new administration and the public. Here are a few:

TRAVEL BAN

Mr. Imbody cites the federal court “kiboshing” of the executive order on immigration as an example of this natural check and balance system. Though the ban has now been limited twice by the federal court, it illustrates both the persistence and the scope with which the Trump Administration is seeking such restrictions. Even with these reversals, the initial implementation of the original ban created sufficient chaos within the legitimate migration of refugees, visa and green card holders, healthcare practitioners, and patients that the response of other medical professional organizations was swift and strong. These concerns focused primarily on the uncertainty it produced among practicing & research physicians planning to travel abroad, International Medical Graduates (IMG) planning to match, and the care & treatment of immigrant children:

Internists: The ACP issued a comprehensive statement with plain opposition to “denying refugee status from persons in designated countries of origin who otherwise would meet refugee status law requirements in the United States,” interference with legal migration, religious discrimination, and forcible deportation. The NEJM published a specific perspective piece on the order’s “detrimental effects on medical training and healthcare,” again related to interference of graduate medical education.

Pediatricians: The AAP statement reads: “Children do not decide where they or their parents were born. They do not choose whether or how to travel to the United States. We owe it to these children to protect them. Far from doing so, this Executive Order temporarily bans refugees—including children and families who are fleeing persecution, war, or violence—from entering the United States and appears to open the door for individual states to refuse to resettle them.
The Order also impacts our colleagues in medicine, as international medical school graduates and pediatric researchers will continue to be among the foreign nationals and refugees impacted by the travel ban. Leaving it to the discretion of Customs and Border Protection to decide whether to grant entry on a case-by-case basis will prevent these professionals from traveling or training here. This means that vulnerable children, particularly in rural and underserved areas of the United States, will be unable to access care provided by some of the brightest minds in medicine.”

Family Physicians: The President of the AAFP issued a public letter to the president plainly stating: “We are deeply concerned that steps your Administration has taken will have a chilling effect on our nation’s physician workforce, biomedical research, and global health. It is often America’s physicians who answer the call to assist people around the world when a public health crisis occurs. Imagine a world where physicians fail to answer the call of the needy because they fear they may not be able to return to their home and families in the United States. Many family physicians are international medical graduates, who have completed all or part of their education and training in the United States. They are professionals who dedicate their careers to the service of their patients in communities large and small, urban and rural. In fact, 20 percent of our membership and over 25 percent of family medicine residents are comprised of international medical graduates. The AAFP applauds and supports wholly the contributions of these individual family physicians to their patients and communities and we celebrate their diversity.”

These are neither hypothetical nor minor concerns. While the multiple publicized examples of physicians temporarily denied entry or re-entry have been reversed, the case of a Houston OB/GYN physician who cancelled his medical team’s trip to perform fetal surgeries, likely resulting in those pregnancy losses, should be distressing to any pro-life advocate. Additionally, the areas that IMGs from these countries serve are disproportionately in medically underserved areas, and though the second iteration of the travel ban would exempt visa holders, it is entirely plausible that it would continue to have a chilling effect on applicants from those countries as well as an implicit bias by program directors against ranking applicants from those countries if there is any degree of uncertainty of their immigration eligibility in the future. In fact, even the NRMP issued a statement on the Executive Order:

The consequences of the Executive Order are far reaching for Match applicants, and the upheaval it is causing is extensive. The affected applicants have worked hard for many years to achieve their goal of becoming physicians, and they should not be denied that opportunity because of a blanket policy that does not consider the individual. Similarly, U.S. training programs should be able to select applicants based on their excellent character and qualifications, without regard to nationality. Both applicants and programs benefit from an orderly process for entry into graduate medical education. The Executive Order disrupts that process very considerably.

This does not even begin to address the impact on refugee migration, which represents a particularly vulnerable population of patients. The revised ban continues to seek a complete and arbitrary suspension of the refugee program for 120 days which threatens the supportive infrastructure of refugee resettlement programs. In fact World Relief, a Christian non-profit agency that works with refugee resettlement, has closed 5 of 27 offices and laid off over a hundred employees in response. Robert George, eminent Constitutional scholar and avid Catholic pro-life advocate who has favored the nomination of Neil Gorsuch to the Supreme Court, soundly denounced (in conjunction with Angela Wu Howard) the travel ban in this joint article from First Things:

I myself only learned about the stringency of our refugee vetting procedures as a result of extensive briefing when I was chairing the U.S. Commission on International Religious Freedom (USCIRF). There are many things in our government that are “broken,” but our refugee vetting system isn’t one of them. We needn’t, and therefore we shouldn’t, shut out refugees who are fleeing terrorism in places such as Syria and Iraq, even temporarily. Because it isn’t necessary to do it, it is, in my opinion, necessary not to do it.

When I was chairing USCIRF, I called for an increase in the refugee quota. I continue to favor that. Many of my conservative friends disagree, but I believe that justice as well as compassion requires it. The U.S. is not without responsibility for creating the refugee crisis (or the conditions for it)—though we can debate just which presidents and others bear just what portion of that responsibility. I also favor maintaining the stringency of the vetting system, even if that means we do not reach the quota. That’s because I do believe that national security is preeminently important, and I want to make sure that what has happened in some places in Europe does not happen here. The other thing I advocated, and continue to advocate, is prioritization of refugee acceptance based on vulnerability to the worst forms of abuse: murder, rape, torture, enslavement. This is not because I want to bias the system in favor of Christians, as some of my more ridiculous critics on the Left have claimed. It is because decency requires it. Yes, Christians will benefit, but so will Yazidis, Shabak, Turkmen, minority Muslims, and even majority Muslims who are targeted by terrorists (such as ISIS) for helping U.S. forces or opposing terrorist entities. These are the people targeted by ISIS and other evildoers for the worst forms of abuse.

While a check-and-balance system may limit the long term consequences of an administrative agenda, to overlook the short term consequences of the uncertainty introduced does not provide reassurance because it intentionally understates the power of the President to cause real, actualized harm and therefore further alienates the very group meant to be comforted. If the physician creed is to “first do no harm”, how can we as healthcare practitioners — especially Christian ones committed to political advocacy — not object to the irresponsible use of force and poor policy?

I know exactly what to think about that.

HARMS TO PATIENT CARE AND LIVELIHOOD

Even more puzzling is the assurance that we should trust the administration because “thousands of good people will run the new government.”

The Chief Executive determines broad policies, but these people scattered throughout federal agencies make the government run. They flesh out laws through detailed regulations. They write the aims and guidelines for grants that fund the work of non-profit charities and organizations across the country. And they develop the pragmatic policies and programs that help our children learn, ensure that patients receive good healthcare and assist in feeding the poor and housing the homeless.

But Mr. Imbody’s statement remains problematic for many reasons. I draw direct attention to the gross omission, in his benevolent description of the “thousands of good people”, of Steve Bannon, the Chief Strategist of the White House. Bannon, who occupies a position not subject to the scrutiny of Congress for approval (one of the checks-and-balances cited earlier), has raised significant controversy for his leadership of Breitbart News and the alt-right movement. This alone was enough to draw criticism by the Anti-Defamation League for implicit support of white supremacists (though it acknowledges Bannon himself has not explicitly done this). But Bannon’s agenda, which as Chief Strategist is a reasonable proxy for that of the administration itself, has moreover explicitly been to “deconstruct the administrative state.”

While I appreciate Mr. Imbody’s point that government is not necessarily meant to be the “primary vehicle of social change,” the new administrative agenda stands in direct contradiction to his appeal that we trust in its intent to “develop the pragmatic policies and programs that help our children learn, ensure that patients receive good healthcare and assist in feeding the poor and housing the homeless” in that it has both implicitly and explicitly pledged itself to dismantling those things. Not restructuring, dismantling.

Though the American Health Care Act (AHCA) eventually failed to pass the House, it is indicative of the agenda of the administration (and the GOP). On a patient care level, the impact of the AHCA according to CBO estimates would result in worsening coverage loss, premium increases, and Medicaid contraction. Though multiple other professional organizations have taken stances criticizing the current form of the AHCA (including the AAFP, AAP, AMA, ANA, AHA, and even the AARP and Medicaid CMO), I understand that CMDA may not necessarily agree with these shared perspectives of healthcare policy as its constituents are diverse and not all agree that health insurance is necessary for quality healthcare; as an example, the AHCA pledges to increase funding to Federally Qualified Health Centers (FQHC) which are primarily designed to care for uninsured patients, many of which are operated by explicitly Christian organizations (though doubtful that the proposed augmentation will be proportional to the needs of the newly uninsured). I also recognize that other elements of the AHCA also directly align with CMDA interests, such as reducing abortion subsidy by decreasing funding for Planned Parenthood.

But, as the Annals of Internal Medicine has cautioned regarding proposed ACA repeal: first, do no harm:

The 2010 health reform law is far from perfect, in either its structure or its execution; in a less dysfunctional political era, the flaws would have been addressed through subsequent changes. Now, amid the drive not to amend the law, but to repeal it—and absent a definitive replacement plan—physicians, as stewards of the nation’s health care, should be up at arms about the potentially dangerous impact.

Additionally, to imply that the new administration will be proactive about developing new programs to “help our children learn… assist in feeding the poor, and housing the homeless” is also directly contradicted by President Trump’s initial budget proposal, which:

- Eliminates US Interagency Council on Homelessness
— Eliminates Community Development Block Grant and Community Services Block Grant
— Eliminates funding for Habitat for Humanity and YouthBuild
— Eliminates the Home Investment Partnership Program
— Eliminates assistance to Community Development Financial Institutions
— Eliminates weatherization assistance program and Low Income Home Energy Assistance Program
— Reduces Legal Services Corp
— Reduces SNAP and WIC assistance
— Reduces Job Corps
— Eliminates the Senior Community Service Employment Program

In summary, this is a reduction of the:

- Department of Health and Human Services by 16.2%
— National Institutes of Health by 20%
— Department of Education by 13.5%
— Department of Housing and Urban Development by 13.2%

While one may make an argument in favor of these cuts in terms of a lack of efficacy by these programs, any claim that these are meant to improve the deficit is offset by the fact that these savings only make up 6% of the simultaneously proposed increase to defense spending by $54 billion. The proposed increase in defense spending also sends the signal that there is no intent to replace the cut programs but to rather displace their responsibility to states.

To therefore claim that this administration will make these issues a priority is financially, intellectually, and politically disingenuous.

I know exactly what to think about that.

THREAT OF INTERPERSONAL VIOLENCE

While not all instances of violence should be attributable to the new administration or its constituents, it cannot be ignored as a primary cause of concern and anxiety among the many who oppose it. Mr. Imbody’s logic that the opposition’s primary concerns stem from “trust in government” and therefore the protections of the checks-and-balances system above should let “hyperventilating Trump opponents breathe a significant sigh of relief” is incomplete. Quite frankly, people are afraid of getting hurt. A Muslim colleague at my institution had a brick thrown through his daughter’s window after the election because she had a Clinton sign in it. Two Indian men were shot and killed by a white man telling them “get out of my country.” A Sikh man was shot in his driveway after being told “go back to your country.” There has been an increase in reported hate crime incidents in the past year (though this number is hopefully declining). Though President Trump has denounced some of these and the administration has suggested that they are statistically unlikely events, so are terrorist attacks. Yet the President and administration have used one set of threats against the safety of Americans to justify the Executive Orders for a travel ban while responding to the other set by excluding “white supremacists” from categorization as violent extremists.

This does not even begin to address issues of structural violence such as the mass forcible deportation and incarceration of illegal immigrants or that of mass incarceration in general. Whatever our political position regarding immigration or social policies may be, as Christian healthcare providers our primary concern should be the health of our patients, whomever they may be and however we come to encounter them. From this perspective, the administration’s early actions paint an aggressive stance that cannot be brushed aside as mistakes or indelicate handling.

I know exactly what to think.

CONSTITUTIONAL DISDAIN

Mr. Imbody also highlights President Trump’s appointment of Gorsuch as an example of comforting change to the composition of the Supreme Court:

From this list, President Trump has nominated Judge Neil Gorsuch, an originalist in the mold of the late Justice Antonin Scalia, whom Gorsuch would replace. This nomination provides significant reassurance that the Supreme Court will be guided more by the rule of law, which protects everyone equally, than by ideology, which favors only those who support the ideology.

But the President himself, as indicated by his tweets and rhetoric and unprecedented leverage of Executive Orders, expresses disdain or ignorance for Constitutional principles themselves. He recently hinted, in reference to prior suggestions made during his campaign, that he would like to change libel laws to influence the media. He has openly challenged the legitimacy of Judge Curiel’s rulings against Trump University solely on the basis of Curiel’s Mexican ethnicity and heritage, a remark that Speaker Paul Ryan openly admitted at the time as being “the textbook definition of a racist comment.” This does not even begin to probe the concerns regarding conflicts of interest with the Emolument clause.

What does President Trump really think about the Constitution? Does he intend to govern in a way that respects the rule of law and the courts or does he intend to push their limits in favor of his maximal benefit? I know exactly what to think about that.

ANTI-BIBLICAL CHARACTER

This is the most egregious omission in a blog post representing an explicitly Christian organization. That there would not be a single word of criticism or even expression of concern by Mr. Imbody regarding this President — who would be disqualified to become even an overseer in a church much less a self-proclaimed Christian President — is both disturbing and disheartening.

The saying is trustworthy: If anyone aspires to the office of overseer, he desires a noble task. Therefore an overseer must be above reproach, the husband of one wife, sober-minded, self-controlled, respectable, hospitable, able to teach, not a drunkard, not violent but gentle, not quarrelsome, not a lover of money. He must manage his own household well, with all dignity keeping his children submissive, for if someone does not know how to manage his own household, how will he care for God’s church? He must not be a recent convert, or he may become puffed up with conceit and fall into the condemnation of the devil. Moreover, he must be well thought of by outsiders, so that he may not fall into disgrace, into a snare of the devil. — 1 Timothy 3:1–7

CONCLUSION

Mr. Imbody concludes his piece by stating:

As of this writing, the Trump administration is just a month into governing and already has made some strides and some mistakes. The normal course of any administration is a rocky start followed by greater calm and competence. It’s too early to call.

The extent to which the administration advances policies and achieves results that better our own lives and the lives of others around the world does not just depend on one man. It depends upon all of us, advocating for good policies, demanding accountability and supporting our elected leaders with respect for their offices and with prayer.

I agree that it depends on all of us to advocate for good policies, accountability, and respect. However I strongly disagree that it’s too early to call.

I know exactly what call to make.
I know exactly what to think.

Counterpoint: Donald Trump got elected and I know exactly what to think

Ashes to Ashes

This Monday our family went to the funeral of Uncle Ron, whom I barely knew. An uncle twice removed, we had met perhaps four times in life: his daughter’s wedding, my wedding, and two family reunions. Our conversations were brief but good. The first one was him telling me how much he was looking forward to retirement from his work and how hard it was to find good workers these days (they told the young guys all they had to do was show up for work, pass a urine drug screen test, and they would have a job; a third of them failed anyways). The second was how he was relieved but trying to ease into the retired life. That was the last time we’d meet because the cancer came fast.

Metastatic B-cell lymphoma. The ferocity of the disease and the futility of interventions was difficult for my new and beloved extended family. As my wife noted, it was the first death of our parents’ generation and all the more disquieting. I missed the service itself to be on babysitting duty for our active toddler, instead watching him play on a bare playground near the funeral home, listening to the quietness of the country hills of Pennsylvania. I listened to the muted and off-hand reflections from those who knew him and they were as he was: straightforward, tinged with humor, faithful, loyal, and dedicated to family.

I also heard about his journey to faith through weekly Sunday dinners with his mother-in-law. I heard about his transition to hospice and, in the final days of his life, an acceptance of the inevitable outcome and a literally fearless trust in the Lord.

In a time of grandstanding, trolling, noise, and uncertainty, it has been both sobering and refreshing to be reminded of certain things. I was recently reminded of an article describing the five most common things regretted by the dying as studied by a palliative nurse:

1. I wish I’d had the courage to live a life true to myself, not the life others expected of me.

“This was the most common regret of all. When people realise that their life is almost over and look back clearly on it, it is easy to see how many dreams have gone unfulfilled. Most people had not honoured even a half of their dreams and had to die knowing that it was due to choices they had made, or not made. Health brings a freedom very few realise, until they no longer have it.”

2. I wish I hadn’t worked so hard.

“This came from every male patient that I nursed. They missed their children’s youth and their partner’s companionship. Women also spoke of this regret, but as most were from an older generation, many of the female patients had not been breadwinners. All of the men I nursed deeply regretted spending so much of their lives on the treadmill of a work existence.”

3. I wish I’d had the courage to express my feelings.

“Many people suppressed their feelings in order to keep peace with others. As a result, they settled for a mediocre existence and never became who they were truly capable of becoming. Many developed illnesses relating to the bitterness and resentment they carried as a result.”

4. I wish I had stayed in touch with my friends.

“Often they would not truly realise the full benefits of old friends until their dying weeks and it was not always possible to track them down. Many had become so caught up in their own lives that they had let golden friendships slip by over the years. There were many deep regrets about not giving friendships the time and effort that they deserved. Everyone misses their friends when they are dying.”

5. I wish that I had let myself be happier.

“This is a surprisingly common one. Many did not realise until the end that happiness is a choice. They had stayed stuck in old patterns and habits. The so-called ‘comfort’ of familiarity overflowed into their emotions, as well as their physical lives. Fear of change had them pretending to others, and to their selves, that they were content, when deep within, they longed to laugh properly and have silliness in their life again.”

In Christ, we have redemption of the life that is in such a way that points to the greatness of what is to come. It is not achieved by political power or even by the work of our hands. It is received as a gift from divinity, through which we have access to joy inexpressible:

Blessed be the God and Father of our Lord Jesus Christ! According to his great mercy, he has caused us to be born again to a living hope through the resurrection of Jesus Christ from the dead, to an inheritance that is imperishable, undefiled, and unfading, kept in heaven for you, who by God’s power are being guarded through faith for a salvation ready to be revealed in the last time. In this you rejoice, though now for a little while, if necessary, you have been grieved by various trials, so that the tested genuineness of your faith—more precious than gold that perishes though it is tested by fire—may be found to result in praise and glory and honor at the revelation of Jesus Christ. Though you have not seen him, you love him. Though you do not now see him, you believe in him and rejoice with joy that is inexpressible and filled with glory, obtaining the outcome of your faith, the salvation of your souls. — 1 Peter 1

On this Ash Wednesday, we remember that from ashes we came and to ashes we will return. I look forward to the fifth time I will see Uncle Ron.

Ashes to Ashes

Dead Bodies and Lamentations

What do you do with a dead body in the room?

My first dead patient arrived that way. He was half naked, pupils blown, head bashed in from a car accident in which he was thrown through the windshield. It was my first week on the wards as a medical student and though I had been through enough trauma alerts with the surgical team to know the drill, the brutality of it all still took me by surprise. The trauma bay was chaotic for all of twenty minutes as the team performed what they already knew would be an exercise in futility: chest compressions, central lines, bags of saline, etc. Someone had asked me to get warm blankets so I scurried around retrieving them but primarily tried to stay out of the way. Once the twenty minutes of resuscitation were over, the chief resident called the time of death and everyone simply stopped what they were doing and awkwardly shuffled out of the room. I remember standing there under the bright spotlights alone with the dead body, blankets still warm in my hands, watching as blood suddenly decided to gush out of the man’s skull and onto the tiled floor. I remember staring at the growing puddle and feeling like the most helpless and useless person in the world.

In the years since, I have been in the room with a dead body more times than I can count. I have been the one to warn the family of what was coming, whether they were prepared or willing to hear it or not. I have begged them for permission to stop CPR, to acknowledge the death as final and irreversible. I have had to make the pronouncement of death. I have watched family weep with silent tears and have had them scream at me from down the hall. I have done CPR on babies and adults. I have helped zip up the body bag. Even as I write this, my memory relives the hearing of those noises, faces, voices, lamentations.

Whether I want to or not, whether it is fair or reasonable or not, my job puts me in a position to listen to a wide range of hurt and anger and grief. It has become reflexive to absorb these narratives, in part because it makes me better at my job but also because the plainness of the suffering voice is compelling. That said, some days I come home both thoughtful and irritable, resentful of my role as a dustbin for the sorrows and troubles of others. I grouse and pour myself some seltzer over ice and sort through the emotions of others that have been laid on me.

But in some odd way, I have also come to appreciate such experiences even if I cannot bring myself to be thankful for them. In thinking about that helpless experience of watching blood spill out of a man’s head, of pushing a baby’s chest in perfunctory CPR, of shocking a dead body into convulsions over and over again, I am forced to acknowledge the brutality of death and visualize how easily the sacred becomes desecrated.

I recently heard seminary professor Dr. Soong Chan Rah talk about the Book of Lamentations, how it begins with a funeral dirge for a nation humiliated, raped, and obliterated into exile. He talks about how the book speaks about the dead body in the room, the death of the nation of Israel. It is composed in broken meter, styled to imitate a limp, written from the voices of the beaten and wounded.

How lonely sits the city
that was full of people!
How like a widow has she become,
she who was great among the nations!
She who was a princess among the provinces
has become a slave…

My eyes are spent with weeping;

my stomach churns;
my bile is poured out to the ground
because of the destruction of the daughter of my people,
because infants and babies faint
in the streets of the city.

They cry to their mothers,
“Where is bread and wine?”
as they faint like a wounded man
in the streets of the city,
as their life is poured out
on their mothers’ bosom.

- Lamentations 1:1; 2:11–12

There has been a lot of talk in the post-election season about “understanding one another” and “coming together” and “moving on.” There has been a lot of wondering about “why can’t we all just get along?”, a question that would seem honest and harmless if not for its implicit favoritism towards the dominant culture.

There are many things to lament, as there are many things that are broken, and this is legitimately true in most shades of American politics. But racism is a particular sort of devastation in our history that merits its own dirge, one that the American church has been too reluctant to sing. Think for a moment about the white nationalist conference in DC and resurgences of the KKK, then think about these words from the book, “The Cross and the Lynching Tree”:

No historical situation was more challenging than the lynching era, when God the liberator seemed nowhere to be found. “De courts er dis land is not for niggers,” a black man from South Carolina reflected cynically. “It seems to me that when it comes to trouble, de law an’ a nigger is de white man’s sport, an’ justice is a stranger in them precincts, an’ mercy is unknown. An’ de Bible say we must pray for we enemy. Drop down on you’ knee, brothers, an’ pray to God for all de crackers, an’ judges, an’ de courts, an’ solicitors, sheriffs, an’ police in de land.” Whether one was lynched on a tree or in court, the results were the same. “Lord, how come me here,” they sang, “I wish I never was born!” (page 27)

The language of lament has helped me understand what has been so bothersome about the “evangelical” Christian voice in the national politic. We talk about how the church is the cure to American culture without acknowledging its complicity in a long history of corruption and tainted ambition. We talk about our entitlements to freedom without mentioning the offal nature of slavery and oppression. We demand forgiveness and reconciliation without recalling our viciousness of speech and deed. We talk about God’s sovereignty as resurrection without mourning the abused and defiled body of Christ. We have skipped ahead to resurrection songs when the bleeding body is still naked on the stretcher.

What do you do with a dead body in the room?

What can I say for you, to what compare you,
O daughter of Jerusalem?
What can I liken to you, that I may comfort you,
O virgin daughter of Zion?
For your ruin is vast as the sea;
who can heal you?

Your prophets have seen for you
false and deceptive visions;
they have not exposed your iniquity
to restore your fortunes,
but have seen for you oracles
that are false and misleading.

All who pass along the way
clap their hands at you;
they hiss and wag their heads
at the daughter of Jerusalem:
“Is this the city that was called
the perfection of beauty,
the joy of all the earth?”

- Lamentations 2:13–15

Dead Bodies and Lamentations

Scum of the World

I could hear the cussing from inside the room and noted the awkward glances of nearby nurses and staff who turned to look and gawk. Even though I only sat a few feet outside the door, I ignored the increasingly loud litany of expletives and deliberately focused on the screen in front of me. He was my patient and I was doing my best to concentrate on his rapidly evolving list of medical problems, the electronic progress note already ballooning in front of me as I tried to prioritize multiple terminal conditions competing for attention. I scrolled through pages of old notes that were littered with repeating instances of phrases such as “lost to follow up,” “did not comply with therapy,” “uncooperative,” and the ever favored, “signed out against medical advice.” I paused and watched as a freshly berated specialist walked out of the room, sat down at a nearby computer, and dictated into his own note the word “belligerent.” The diction snob inside me was pleasantly surprised to hear a new and applicable word and so I inserted it into my note as well.

Last week my pastor asked me, “How do you keep from becoming cynical?” The question caught me off guard; it occurred in the context of a series of conversations on the struggles of caring for people in both spiritual as well as physical matters. My reply was somewhat flippant as I didn’t have a good response. The question was unintentionally pointed; Pastor Tom is a quick-witted man and one of the many reasons why I respect him so much is that even though he appreciates a dry and sardonic sense of humor, he intentionally suppresses it. By contrast, I relish in lengthy conversations about all things dark and cynical. In college I would rant about the evils of systems of poverty, child slave labor, sex trafficking. Nowadays I rant about urban violence, health disparities, child abuse, racism, Donald Trump. I am not shy about these views and justify vocalizing them as a mechanism for challenging injustice, but the genuine and curious nature of Pastor Tom’s question left me unexpectedly exposed to scrutiny. After all, what is justice and how does that apply in medicine? What is the root of cynicism and why are criticism and sarcasm so satisfying?

Continue reading “Scum of the World”

Scum of the World

Trauma: What Freud Learned About Rape

In medical school we glossed over Freud because psychoanalysis had largely become outdated. Popular culture has turned his method into a mockery; we chuckle to think of the bearded psychiatrist listening intently to some dude reclining on a sofa talking at length about the hidden sexual meaning underlying his bedwetting dreams. In the new era of cognitive behavioral therapy and evidence based medicine, the realm of the subconscious seems better studied by functional MRI scans, neurobiological theories, and data-driven analysis & interventions. To see medical professionals chasing fanciful interpretations of dreams or inkblots would now seem quaint at best and like quackery at worst. Do we really esteem Freud’s preoccupation with the psychosexual stages of children with anything but puzzlement? Unsurprisingly, I was taught to have a low opinion of Freud and consequently rarely thought about him or his theories through the rest of my clinical training.

And yet I’ve recently come to a new appreciation for Freud from an unexpected source. Continue reading “Trauma: What Freud Learned About Rape”

Trauma: What Freud Learned About Rape