Somatic Battlefield

The day before yesterday, that would be Thursday, I woke with a minor, one-sided sore throat.  As I got ready for work it subsided and became barely noticeable after I had my usual coffee from UDF.  I get their Jack’dUp Java, for maximum effect.  I figure that if I’m going to drink something unpleasant for its stimulant effects, best to get the most of it.

As my workday progressed the symptoms of a cold also progressed. My sinuses began to ever so slowly swell. Not enough to need mouth breathing but enough to notice.  The sore throat didn’t come back but my voice started to change, getting huskier, deeper.  I was at a committee meeting at the Hospital Association and over the course of four hours I went from sounding like me to sounding like Morgan Freeman.  Not a bad thing, really, if you feel good while it’s happening, which I most definitely didn’t.

When I got home and dinnertime rolled around, I wasn’t hungry – you’ve seen me and know this isn’t a good sign.  The Missus and I were going to meet Brian at the Rusty Bucket for dinner.  Shelagh went on her own as I wanted to avoid being a latter day Typhoid Mary.  I had probably done enough damage.  I took some cold medicine and went to bed.

At 0 dark-thirty my alarm went off.  My throat was on fire, my sinuses were closed my muscles were sluggish and my head ached.  I had also developed a mildly productive cough.  I got up, took the dogs out and then fed them, hoping the symptoms would subside again.  They didn’t.  I called off work for the day.

Between naps – there were three – I sat around, all bump-on-a-log like, trying to muster the energy to at least read something.  I failed miserably.  Some people will question why I called off work because as far as they can tell that’s what I do in my office every day.  Perhaps.  But at home I got to stay in my pajamas, something that Governors, both Republican and Democrat, frown upon in their employee’s attire. 

I ached all over, felt toxic and couldn’t string two thoughts together.  But as evening approached, I began to feel a bit better and managed to fix myself a bologna sandwich for dinner.  I watched a RedWings hockey game and then went to bed.

I woke up this morning in significantly better shape.  I’m still not well but at least I’m functional.  As I fixed a bowl of oatmeal for breakfast I thought, “Yay, white cells!”  This got me thinking about the body’s immune system.  It’s an incredibly complex thing.  The more you learn about it the more amazing it gets.

The immune system is actually a large, complex set of systems, arranged in a layered defense.  It starts with physical barriers.  Your skin prevents bacteria, viruses and fungi – germs – from entering your body.  The shell of an egg does the same thing for the developing embryo.  Other physical barriers include coughing, sneezing and watering eyes to physically expel invaders.  Enzymes in saliva and tears, and stomach acid (which also contains enzymes) break down germs before they can enter the body.  Mucous snares germs, preventing them from getting to any cells.

If the germs make it past the physical defenses there are many layers of response from your body.  One of the most important is the production of white blood cells called leukocytes.  There are many types of leukocytes, including B cells and T cells, with T cells coming in ‘Killer’ and ‘Helper’ varieties.  Killer T cells do just what the name says – they kill infected cells.  Helper T cells sort of orchestrate the body’s immune response.  They’re kind of like a forward observer directing artillery fire.

A war was being waged inside my body.  Something, probably a virus, had evaded the physical barriers and set up shop, taking control of some of my cells for the nefarious purpose of propagating itself.  My body’s immune system responded, saying, “Not on my watch!” and opened fire.  My ability to perform normal activities of daily living was diminished because energy was being diverted to the immune response, just like wartime rationing (which is why rest is crucial when you’re ill).

When I woke this morning I knew the tide had turned and that I was going to win.  Skirmishes and mop up operations will continue for a couple of days, but my immune system will prevail over the somatic battlefield.

The Most Powerful Words

Unlike what you see on TV, people who deal with emergencies or the critically ill don’t stop to emote about what they just saw or did.  We can’t.  We wouldn't last if we stopped to think about it.  We have to take the incident, strip it of the lessons learned to store them, and then stick the rest of the memory in a box.  The box gets locked and shoved to the back of our minds.  Then we move on to the next patient, quickly, because they likely don’t have spare time for us to “get it together.”

I saw a picture online recently (it can be found here).  It was pretty moving and dredged up some old thoughts.  The picture is of an emergency physician who, after a particularly bad death, walked out of the ED, knelt down and cried.  The picture was snapped by a paramedic in his squad and, with permission, he posted it online.  The picture went viral, especially in the emergency community, because we’ve all been there.  We’ve all had experiences with the death of babies or children or little old ladies who remind us of our grandmother or whatever.  Something about that patient flips a switch, prevents our normal coping mechanisms from working and ruthlessly guts us.  We grieve, quietly, privately, then the memory gets stuck in the box, we recompose and get back to work.

These incidents are rare, but they do happen (and if they aren’t rare for a person, that person will be gone from their profession quickly).  But what happens more often than the “gutted-grieve-get back in the saddle” events are moments of sadness.

Most of my moments of sadness came from my time working for private ambulance services in Toledo and Cincinnati, where the bulk of our runs were to nursing homes.  I transported countless people to the hospital when it was apparent this would be their last trip.  Most were so sick that they weren’t aware of what was going on, but more than a few were just as aware of their situation as I was, probably more so.  I learned early on that for these people the most effective therapy in my drug box, airway kit, the cabinets of my one hundred thousand dollar squad and my personal bag of tricks was simply to hold their hand.  For many of them, mine was the last hand they would hold, their last touch of humanity before entering the fast-paced, overworked clinical realm of the emergency department.  It always made me sad.

But something always made me sadder.  The sadness was strong but brief.  It was the sadness of bearing witness to permanent loss.  The permanent loss was always heralded by a physician who would speak what I consider to be the most powerful words: “Stop CPR.  Time of death is…” 

In that instant, that patient, that person, was gone forever.  All their knowledge and their experiences, their loves and losses, memories good and bad, tragedies and triumphs, an older person’s accumulated wisdom, a young person’s future and potential…poof.  Gone.

I know that I did a bad job of concealing my sadness in that moment.  Frequently, a physician or a nurse would see me and try to console me.  “It was her time,” they’d say.  Or “You did everything you could.”  They mistook my sadness as being a result of being defeated by our common arch-nemesis, death. 

That wasn’t the case at all.  I rarely placed any hope in saving these nursing home residents.  They tended to be either chronologically advanced, from their mid-80s to mid-90s, or ravaged by time and disease, with 65-year olds looking like centenarians and being just as fragile.  We were crushing their chests with CPR, inserting artificial airways, plying them with a dozen medications and blasting their hearts with strong doses of electricity.  We worked by the book and everybody got our A-Game, but I harbored no illusion of the outcome. Resuscitation was started on these folks because of a perverse 1980s federal rule regarding the number of deaths allowed in a nursing home, and because the concept of Do Not Resuscitate orders and advanced directives was still taking hold (because of this I have probably done more field resuscitations than most EMS personnel today who weren’t around in the 80s).

Obviously futile effort or not, the sadness overtook me whenever the physician said the most powerful words.  Stop CPR. Time of death is…

One day we transported a little old lady, whose weight and age were approximately the same, to an ED while doing brutal and pointless CPR on her.  As we wheeled into the resuscitation room we began to give verbal report to the assembling ED staff: “87-year old female, down for unknown length of time before nursing home staff found her.  CPR in progress for approximately 20 minutes.”

As we transferred her from our stretcher to their bed the doc asked how far along we were in the resuscitation.  We told him we gave the fourth dose of epinephrine as we pulled in.  That told him everything he needed to know.

“Stop CPR. Time of death is…”

As I pulled my gloves off and headed to the sink to wash my hands, I glanced over my shoulder at the body.  The sadness of permanent loss set in.  As usual, I didn’t hide it well and a nurse noticed.

“There wasn’t anything you could do for her,” she said gently.

“I know. It’s just sad,” I said. I pointed at my head, “Everything she had up here…everything she was is gone.”

She stared at me for a second, looked to the body and back at me.  I could see in her eyes she felt it, too.

By the time I finished washing my hands the sadness had passed. I had pushed it into the box and headed out to clean and restock the squad, making it ready for our next adventure.

For decades I thought that other than that one nurse, I was the only one who was so deeply affected by the most powerful words.  It turns out I was wrong.  It turns out that most, if not all of us, have that feeling.

In February 2014, a nurse from Charlottesville, VA, named Jonathan Bartels published an article in the journal Critical Care Nurse.  In it he describes “The Pause,” a sort of brief and quiet ceremony that begins right after the most powerful words are said.  In Bartels’ words:

After a death in the emergency department, I would stand, ask that no one leave, and invite my peers to bear witness with me, to be together and present in a singular moment of grief and loss. I would ask each to, in their own way, offer silent recognition of the lost human life—someone’s mother, father, sibling, or child—to remember that the person who had died loved and was loved, to understand that the person’s passing deserved recognition, and to acknowledge that our own efforts, too, were worthy of honor.

Even though it started out that way, The Pause isn’t just a little local ritual.  It caught on at his hospital and is now part of the curriculum of the nursing program at the University of Virginia and others.  Word of The Pause is spreading: I heard about it through a story on NPR.

While I may have practiced my own personal mini-version of The Pause, I’m glad that Bartels had the courage to speak up and do the first one openly.  I’m sure that for many people it will help blunt the power of the most powerful words.

Tamed

The Missus and I were grocery shopping today and one of the items we were looking for, Kleenex, sparked a memory.

In the late 1980s, I was a 20-something action-adventure paramedic living in Cincinnati.  I was working a lot of jobs, mostly related to EMS, but still didn’t have much money, mainly because I worked in EMS.  But I was happy.  I had my own apartment, a small circle of intensely close friends, did an exciting and important job, and had no serious cares.  I am also the type who doesn’t equate being alone with being lonely and was comfortable with spells of solitude.  Most people who knew me at the time (except those intensely close friends) assumed that I was going to be a lifelong bachelor.  It may well have turned out that way because there wasn’t a need to change anything.

And then I met Shelagh.

The particularly pretty one and I met while running here.
This squad is where we first kissed...
BEST. VEHICLE. INVENTORY. EVER.

I was introduced to a group of new recruits who had just joined the squad, noting one particularly pretty one with a British accent to die for.  To make a long story short, I found myself one day asking the particularly pretty one if she’d marry me.  {SPOILER ALERT: She said yes.}

As a result, in early 1992 I moved out of my apartment and into suburbia.  The house I was moving into was instant and unadulterated “American Dream”…it came complete with a wife, two kids and two dogs.

It was a bit of an adjustment for me.  As in, the Titanic took on a bit of water.  While Shelagh and the boys had been living as a family unit since Alan was born, I had been flying solo for the better part of a decade, including the formative years of my early and mid-20s.  There were any number of bachelor ways that failed to conform to the standards of the landed gentry and, more importantly, family man.

Gradually, I caught on.  Besides becoming fluent in British English, I became a better team player, thinking in terms of ‘we’ and ‘us’ instead of ‘me’ and ‘I’.  I became used to and adopted the various folkways and traditions of the family I had married into.  I was introduced to the concept of laundry hampers, a truly radical idea for a guy whose apartment had been right across the hall from the laundry room.  We decorated the house together, including a brief bit of madness where the particularly pretty one and I tried hanging wallpaper together.  Throughout the process of catching on, however, I never had to give up the core of my identity: action-adventure paramedic.

So I continued my paramedic ways, doing the things paramedics do, and thinking in the twisted-but-self-preservational way that paramedics have to think to survive the horrible things we encounter.  I thought that little had changed in me, except my behaviors at home.  Then it happened.

I was given a shopping list.  It included Kleenex.  As I hit the tissues aisle I started examining my choices.  The type with lotion was out since they are the exact opposite of helpful when trying to clean your glasses.  I found the type I wanted and started to figure out which box colors would be appropriate for the rooms where we keep Kleenex.

“Wait,” I thought to myself. “Colors?  Where the hell did that come from?”

I stopped thinking about Kleenex and started thinking about my own thought processes.  At no point did Shelagh ever tell me I picked the wrong color of tissue box, nor would she.  If brought home a red box for placement in a room that was predominantly green in its décor, there would have been no problem.  No scoffing or sighing.  No rolled eyes or frowns.  It would simply be put where it was needed.  It was just a box of Kleenex.  I was the one with the aesthetic tissue issue.  It came from me.

My arms dropped to my side, my jaw went slack, and I lost focus on what was in front of me when I realized what had happened.

“Dear God,” I thought.  “I’ve been domesticated.”

Erskine’s Home for Wayward Pets

At my Mom’s funeral last week, there were many lengthy descriptions of what a nice, sweet person she was, of her love of family, of her love of parties (she would celebrate pretty much anything as long as it got the family together) and of her strength.  Mentioned only once or twice was her love of animals.

It wasn’t until everything was over that I realized this was a bit of an oversight and a lost opportunity.  I’m taking this opportunity to correct that lost one.

Yes, Mom loved animals.  All of them.  She fed squirrels on her porch and that food also attracted birds.  And there was also ‘Mama Dove’ - a mourning dove who decided to nest in a hanging plant on the back porch.  It would have taken no effort to shoo her away and save the plant.  After all, the bird could find someplace else to lay her eggs.  But that was simply not the way things were done at the home of an animal lover.  Mama Dove laid her eggs undisturbed, hatched her clutch, they fledged and Mama and Papa Dove moved on, leaving the dead plant behind.  But they came back for the next couple of years, taking advantage of the safety of the hanging basket and enjoying the Erskine hospitality.  This hospitality extended to Mom buying a plant in a hanging basket each year, for the sole purpose of giving Mama Dove a safe and comfortable nesting place.  And this wasn't just any cheap hanging plant.  It was carefully and thoughtfully acquired, including criteria such as Mama's comfort.  She was that kind of animal lover.

In my 21 years there, our house was without a pet only for a couple of years when I was a boy, between the time our German Shepherd Fritz died and when we took in Daisy because Diane’s apartment complex changed its rules and wouldn’t allow dogs anymore.  It wasn’t long after that before it became a long-term, multi-critter abode with the arrival of Jane’s cat, Christy (which is its own long story involving the sickly little runt-of-the-litter kitten who melted the heart of the crusty old, cat-hating firefighter to win a new forever home).

Fritz, in need of a good brushing.

Christy

Mom imparted that love in her kids and that was clearly manifested at its strongest in Diane and Jane.  There’s never been a lack of a menagerie in Jane’s residences, nor was there ever at Diane’s.  I guess I also got a big dose of it.  I mean, my first word was not "Mama" or "Dada," it was "Fritz," the aforementioned German Shepherd.  Shelagh and I have always had two dogs, and for a while we also had two cats (Shelagh’s allergies meant that when Phydeaux and Spike died, we wouldn’t have cats again).  I don't have a bird feeder, I have a bird feeding station, dubbed ‘Tim’s Diner’, that serves up four different types of feed to ensure no birdie in our neighborhood goes hungry.  This includes the hawks that dine on the slower patrons of Tim’s Diner (hey, when you get close to nature, you’re going to see it uncensored).  I also put corn on the ground for our non-avian customers, including, but not limited to, squirrels, white-tail deer, raccoons, possums, bunnies, and skunks, who in turn, are fodder for the coyotes that live in farm field behind our house (see previous parenthetical comment).

But Mom was different.  She loved animals as much as anyone.  But what was different was that animals were attracted to her.  Not just ‘they all wagged their tails when they met her’ kind of attracted.  We’re talking iron-to-metal, moth-to-flame, swallows-to-San Juan Capistrano kind of attracted.  Reincarnation of St. Francis of Assisi kind of attracted.  Seriously, there wasn’t a stray animal in the south end of Toledo unable to find its way, somehow, to 568 Colima Drive.

All the cats except Christy were strays who found their own way to Mom.  KC, Boomer, Kitty…each of them was a tiny little kitten that just showed up on the front porch and wouldn’t leave.

Boomer (L) and KC (R)
It should be noted that as long as these two wanted 
to use this basket, nothing was put in the basket by any humans. 
This went on for months.

One day I came home from school and headed into the kitchen where Mom was talking with somebody (Cindy, perhaps).  On my way to the kitchen I noticed a small brown dog crashed out behind one of the chairs in the living room.  I verbally noted the presence of the little dog and inquired if Mom was aware she had attracted yet another one (she was).  Turns out that earlier in the day, this dog was running around the grounds of Burroughs School, the neighborhood elementary school.  A boy took him home - likely using the old 'It followed me home' gambit - but wasn’t allowed to keep him.  He had to find a home for the mutt or it was going to the pound.  The kid was going door-to-door through the neighborhood desperately trying to find a home for the little guy.  When he got to our house, the boy was in tears and Mom, of course, couldn’t tell him no.  That’s how we got Hershey, a really good little boy and my bestest little buddy.

Hershey, who never, ever failed to put on his whipped puppy look 
whenever a camera was pointed his way.

Another time, Mom came home from grocery shopping.  She asked me to help unload the car since there were a lot of groceries.  I went out and leaned in through the open back door to grab a grocery bag, only to find myself face-to-face with a HUGE dog.  It looked like a Doberman, but one on steroids.  Lots of them.  It was the late 70’s and I had never heard of, let alone seen, a Rottweiler.  The dog didn’t seem agitated at me, but I didn’t see a wagging tail either (again, I didn’t know of the breed and docking), so I slowly backed out, hoping not to die a gruesome death in or just outside Mom's car (everybody had the same aspirations as a teenager, right?) and headed to the porch.  My conversation with Mom went something like this:

Me: Mom, what’s with the big dog in the car?

Mom: What dog?

Me: The great big dog in the back seat.

Mom: There’s no dog in the car.

Me: Um, yes. Yes, there is.

It turned out to be a friendly, well-behaved pooch.  It went willingly with us to the backyard, where we put it up until the owners were found, just down the street.

And then there was the dog that invited itself to the party.  Mom was having some type of Tupperware / Mary Kay party and a dog showed up on the front porch.  It wanted in.  It tried to get in.  It was insistent that it get in.  When conventional means of entrance were rebuffed, it chewed its way through the screen door, entered the living room and sat down as if it had an invitation, had made a reservation and was damned if it was going to be denied participation.  This encounter made the newspaper.

There were many more strays that found their way to Mom.  They were less remarkable, with the dog showing up, getting put in the backyard, fed and watered, and the owner located or the dog taken to the shelter (a true last resort).  But it happened enough to not be unusual.

Many years ago, a couple of decades ago, in fact, one of my siblings, thinking about all of these animals finding their way to Mom, declared that 568 Colima Drive should be known henceforth as Erskine’s Home for Wayward Pets.

And so it was.

-----

Post Script

While rummaging through my old photos for the pictures above, I found two that, in my opinion, capture the spirit of Mom better than any others possibly could:

Here we have five animals, all former strays, celebrating the birthday of one of them.  All the pets and all the humans had a great time doing this.  And that, more than anything, was Joe Ann Kathryn Erskine.

A bit late...

So I finally finished posting my Haiti diary.  The trip was in the spring of 2011, so it's only 4 1/2 years late.  School got in the way (I took a quarter off to make the trip).  I guess I could make other excuses:

• The sun was in my eyes;
• There were locusts;
• I had a doctor's appointment;
• I was washing my hair;
• I was dry cleaning my dogs;
• I was washing the squirrels in the backyard;
• I overslept;
• I was trying to find a word that rhymes with 'orange';
• The dogs ate my homework;
• I got stuck on Level 10 of Angry Birds;
• I wasn't allowed to leave the table until I finished eating the broccoli; 
• I've been having flare-ups of my Cotard's Syndrome and think I'm dead.

So choose the one you like, it doesn't matter.