In the Summer of My 14th Year

{Note: I write my posts using Word then copy and paste into the blog.  I wrote this back on January 2nd, saved it and forgot about it.}

In the summer of my 14^th year (I’ve always wanted to use that style opening but have never had the chance)…anyway, as I was saying, it was sometime early in June when I was 14.  I was out of school for the summer (cue Alice Cooper), having somehow survived my freshman year of high school.  One day, Dad said he’d like to go to see a movie over the weekend.  Mom and I said that sounded like a good idea and we suggested we should go to the earliest showing on Sunday, knowing already which movie we were going to take in: A Bridge Too Far.

A Bridge Too Far had been getting a lot of good reviews and the previews I had seen before other movies looked like it was fairly realistic.  The movie was based on the book of the same name by Cornelius Ryan, who had another great WWII book-movie combo in The Longest Day.  Indeed, A Bridge Too Far was probably one of the most realistic depictions of combat until 1998 when Tom Hanks saved Private Ryan and set a new standard in realism.

But when we arrived at the now-defunct Showcase Cinemas on Secor Ave. Dad said, no, he didn’t want to see A Bridge Too Far.  He wanted to see another one, one that neither Mom nor I had heard of and didn’t even sound interesting.  I got insistent – whiny, really – that I wanted to see A Bridge Too Far.  The previews were cool and it wasn’t going to be in the theaters much longer… this was when home VCRs were still a few years in the future and if you missed it in the theaters, too bad.  Dad said no, and he used his definitive, end-of-discussion tone.

For those of you who never had the opportunity to meet James Thomas Erskine, he was a bit larger than life, or at least, as large as life.  He had a certain presence about him.  It wasn’t commanding, but you always knew when he was in the room.  You also have to understand something about his decisiveness.  It was…well…decisive, and pretty much final.  He was a professional firefighter and a Lieutenant on the Toledo Fire Department.  When you’re in that position, you have to be able to rapidly assess and take control of a chaotic situation and start calling the shots.  When you do, you have to give clear, unambiguous orders.  Moreover, you damn well better be right because you are sending or leading your people into harms way, in a way that few people outside public safety services can truly fathom.  Sadly, even when you are clear, unambiguous and right, things sometimes go very, very wrong.  Dad’s decisiveness, while not intransigent, was rarely compromised, and that held true at home, as well.

I was heartbroken that I wasn’t going to see the movie I wanted to see and was going to have to spend 2 hours watching some stoopid movie Dad wanted to see.  As Dad bought the tickets, Mom and I had a quiet sidebar conversation.  She wanted to see A Bridge Too Far, too, and she had also not heard of this movie to which we were about to be subjected.  We both thought it odd that this WWII combat veteran who was fascinated by all things WWII combat was seemingly uninterested in a really good WWII combat flick.

When the movie was over, we emerged from the theater into the familiar warmth of the bright summer sunshine.  Chronologically, it was only about two and a half hours after we entered the cinemas.  Physically, we were still on Secor Ave. in Toledo, Ohio; we were still driving a 1974 AMC Matador to our home at 568 Colima Drive; they were still my parents and I was still their son.  But the universe as I knew it had changed.  An astonishing magnitude of change.  Completely and irrevocably.

In those 121 minutes in the theater I witnessed things that only a few people up to that point had.  Forces of good and evil, battling for supremacy using both swords and spaceships.  Creatures of impossible form – dozens of them – intermingling with humans and each other.  Sentient computers, some able to create holographic messages.  My 14-year old brain was wracked by how real it all was and how much I admired my new heroes and reviled a new set of villains (and let’s not forget one young lady’s really nice figure and jiggly breasts, giving me, or at least lending to, my penchant for brown-eyed brunettes).

The year of my 14th summer was 1977 and the movie that Dad wanted to see and that Mom and I had never heard of was, of course, Star Wars. 

There are bigger Star Wars fans than me.  But there are few who were born after 1970 who will understand how profoundly that movie changed things for those of us who went in to see it with no knowledge of what we were about to see.  Those born later will have had some exposure to light sabers, R2-D2, C3PO, the Millennium Falcon, etc., through extensive merchandising.  Kind of like people born after 1990 are considered ‘digital natives’ and have no idea what life was like before the internet.

These musings of astonishing changes to the universe were brought about by seeing Episode 8: The Force Awakens.  I’m glad that the acting was solid, even if the story was a bit derivative.  After seeing Episode 1: The Phantom Menace, I left the theater thinking that the acting was so utterly horrid that I wouldn’t being shelling out any more cash to subject myself to it.  And I didn’t.  I never went to see the 2^nd and 3^rd episodes, and only caught parts of the 3^rd at home when Brian was watching.

To illustrate my disgust and disdain for the abysmal directing of some very good actors, I had the following conversation on Facebook with one of my friends:

Me: I knew that it wasn't worth a second look when I left the theater thinking that the best actor in the whole movie was Yoda.

KD: R2-D2 carried every scene that he was in.

Me: What?! No way. He was sleep walking through his lines! I have it on good authority that he was hitting the oil bath between every take and his reflexes were almost a microsecond slow through the whole shoot.

KD: He was the only professional on the set! (I heard Liam Neeson asked him for some pointers.) Those ugly rumors about him hitting the oil bath were spread to cover up the fact that he was calling his agent, trying to get out of his contract.

So anyway, the series seems to be back on track and all is well in the post-1977 universe.

May the Force be with you.

Simultaneous Responsibilities

The person who occupies the Oval Office has a lot on his or her plate (or should I just use the now-acceptable genderless singular pronoun ‘their’?).  We all know that this person is “The Most Powerful Man Person in the World” but what does that entail?

We know what the big, overall issues are.  The economy, foreign affairs, defense, taxes, etc.  But these are complex, interwoven issues that are made up of a near infinite number of smaller issues that range in size from personal issues to ones of global scope.

To deal with these things, the federal Executive Branch is headed by the President and aided by his Cabinet Secretaries.  Established in Article II, Section 2 of the Constitution, the Cabinet's role is to advise the President on any subject he may require relating to the duties of each member's respective office. The Cabinet is divided into the following Departments:

• State
• Treasury
• Defense
• Justice
• Interior
• Agriculture
• Commerce
• Labor
• Health and Human Services
• Housing and Urban Development
• Transportation
• Energy
• Education
• Veterans Affairs
• Homeland Security

The President also directly oversees, among others, the Environmental Protection Agency, Office of Management and Budget, US Trade Representative, US Mission to the United Nations, Council of Economic Advisors and the Small Business Administration.

Having a Cabinet means the President, thankfully, doesn’t have to be an expert in all of these things, which is good because nobody can be.  But the duties of the Chief Executive requires them to be at least conversant in all of these areas because the direction in which those Departments head is set by the President.

Despite being “The Most Powerful Person in the World” the direction in which the President takes the country is constrained by the Legislative Branch.  Congress writes the laws that govern the country and it’s the Executive Branch’s job to administer those laws – to execute them, hence, the name.

There is frequent dialog between the Legislative and Executive branches.  The lawmakers sometimes need the executive’s overall perspective when writing laws, and sometimes the executive sees a need for a new law or a revision to an existing law.  There can be a lot of give-and-take and deal-making, but sometimes this works out well for both sides and as a result, the American people benefit.  This never makes the news because why should good governing be covered by the media?  It’s when the legislative and executive viewpoints are at odds with each other that we hear about it.  The media seem to love the political and bureaucratic catfights and pissing matches.  The process takes time and the more rancorous it is, the more time consuming it is.  The President may not be directly involved in those negotiations but still has to direct them.

With all of these areas of oversight, here a very small sample of the specific issues that the President must deal with:

• The federal budget
• Money laundering by organized crime
• Bank regulation
• Fish hatcheries
• Highway safety
• Outer space
• Children’s television
• Phone service for the disabled
• Internet service for the disabled
• Phone and internet service for the rest of us
• National forests
• Puerto Rico: Nation? State? Leave it where it is somewhere in between?
• Indoor air quality
• Outdoor air quality
• Oil spills
• Fracking
• Groundwater
• Coastal water
• Water resource development
• Tariffs
• Tax-free retirement plans
• Civil service pay reform
• Major crime
• Minor crime
• Moderate crime
• Price fixing
• Immigration
• Science, technology, engineering and math education
• Vocational education
• All other education
• Job training (which is not part of education)
• Public health
• Personal health
• Family planning
• Head Start for when the family planning doesn’t work out
• Nutritional labeling
• Aging baby boomers
• Social Security
• Aging baby boomers bankrupting a Social Security system that didn’t foresee a Baby Boom
• Rural development
• Urban development
• Suburban development
• Energy
• Utilities
• Interstate commerce*

Notice that I only listed domestic issues above.  The President is also given the duty of conducting foreign affairs by the Constitution.  There are 267 “world entities” according to the CIA World Factbook.  How the United States of America deals with all of them, friend and foe alike, and how it reacts to how they deal with each other, rests on the shoulders of one person.

To imagine how complicated this task is, let’s use just one example: North Korea.  Global intelligence think tank Stratfor describes North Korea’s global strategy as being three-pronged: ferocious, weak and crazy.  There are no right answers to North Korea, only less bad ones, but the three prongs guarantee that it’s impossible to really tell which ones those are.  Whichever wrong answer is selected – and it will always be wrong – the President of the United States selects it.

And then what do you do when two friends have a significant problem with each other?  We like Turkey and we like Greece, but they do not like each other and have some serious issues over Cyprus.  India and Pakistan constantly tussle over Kashmir, occasionally getting into skirmishes and even small wars over it.  But they now both have nukes.  In 1982, two allies went into an all-out declared war when Argentina invaded the Falkland Islands and Great Britain said, “Oh, I don’t fucking think so.”

So all of this, all of these decisions, and much, much more rests in the hands of the President of the United States of America.  Sometimes the responsibility to make a history-altering decision occurs at the exact same time as all the ones I’ve listed above.  And here’s the hell of it: ALL of these decisions MUST be made.  The President must provide an answer to each and every question.  Some answers are easier, and some decisions are less important, but the President can’t walk away from any of these questions.  Ever.  Even if you don’t like the questioner.

Are you reading this Mr. Trump?

*List adapted from fellow native Toledoan P.J. O'Rourke's brilliant attempt to explain government, "Parliament of Whores"

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.