Civilians is Silly

The other day I got to help my younger brother move furniture. He and his fiancee' are preparing to merge apartments as their wedding approaches, and moving several pickup truck loads of furniture was the next step. It was great to help out with that, because, both of us being busy adults, we had not gotten time to hang out in a few weeks. I was in Georgia, studying for my National Registry Paramedic exam (which I passed, thanks be to God) and he was, is, and still will be for some time, preparing for a wedding.

It is great to have a brother. Friends are great, a wife is awesome, but no one is ever going to understand you like a brother. We can talk about things with that, "You know what I'm saying?" "Yeah, I'm right there with you," "People just don't get it," "No, they don't," kind of agreement. We have different opinions and interests, but we get similar things because we start from the same principles.

Civilians, for instance. Both of us share a similar attitude toward civilians and city folks. We grew up on a farm and were, if not exactly dirt poor, at least soil rich. We liked to build things, break things, learn things, discuss things, argue about things, think about things, and question things. Every thing had a million functions, only a handful of which were included in the instructions. "Ready made" was not in our vocabulary.

Then both of us joined the military and spent years being shuffled like a bad card trick from one side of the globe to the other on various missions. We had no control, we had to be ready to pick up and go at a moments notice and so we learned to discern what was needed and what could be deleted or returned or simply done without. If it doesn't fit in a C-bag or rucksack, it obviously is not required or can be acquired, jury-rigged or hot-wired on-sight, overnight, in flight, on the go.

We have a casual disdain of plans, because they never work. When you make a plan, you have only succeeded in describing one of the million possible ways in which it definitely will not go down. More often than not you have blinded yourself to the one or two ways in which it probably will go down. Best to keep it loose, and just make it up as you go. Screw it, we'll do it live.

One of the biggest discoveries we have both made, which we sometimes commiserate about, is that civilians freak out over the silliest things. Whether it is running late for work, or the color or layout of party decorations, or whether or not they might get a black eye from sparring with friends, or how hard it is to walk up a mountain at 2 mph for a couple of hours, they freak out about it. I once saw a patient in the hospital who was a veteran. He was working in retail as a manager, and when one of his subordinates started freaking out about some boxes that got knocked off the shelf, he told him, "Shut the f--- up and quit crying. No one's got their arms or legs blown off by a suicide bomber have they? No one is dead. No one is getting shot at. So what's the big deal?" This resulted in a complaint, a trip to his superior's office and subsequent trips to a psychiatrist's office. He was unable to wrap his head around the concept that you can't talk to people like that in the civilian work force.

I get where he is coming from. Sometimes I get frustrated and just want to shake people and say, "Wake up! Are you seriously complaining because the server made you wait five minutes before he took your order? Are you starving to death? Are you that important? Do you realize that right now, in a hundred countries around the world (including this one) there are millions of people who are not eating at all? Broaden your horizons and stop being so small and pathetic." People who complain about office politics especially unnerve me, because A: I just want to tell them they haven't gotten shot, lost a patient, or blown themselves up so quit crying; and B: I am going to have to make it in that civilian workplace eventually.

I can talk about this with my brother. He gets it. I can talk about this with my wife. She gets me. Most people start to nod and nervously back away, so I learn to let it go. You see, while our background gives us advantages, it also comes with some drawbacks. Neither of us is good at relaxing. Or rather, what is relaxing to us is incredibly strenuous to others. We want to be engaged, mind, body, heart and soul. The glory of God is man fully alive, and we don't want to be even the least bit dead until we are all the way dead. So a relaxing Sunday afternoon might involve hiking up a mountain, or discussing astrophysics, human genomics, and the moral ramifications of both. As a matter of fact, if we are hiking up a mountain, we are probably discussing some heavy topic at the same time. So we are great at relaxing in our own way, but we have been living at such a high level of intensity for such a long time, that our idea of relaxing is skewed, and neither of us does well with boredom. He goes to school full time and works nights full time. I feel like a day that doesn't start at 4:30 AM and run non-stop until 10:30 PM is wasted. 

We sometimes have a hard time being patient with people who aren't patient with the vicissitudes of life. As my brother says, "We had no control over our lives for so long, we learned to just go with the flow and not stress out about it." (He split that infinitive, not I. I merely left it in, in the interests of historical accuracy.) It isn't life's ups and downs that frustrate us. It is the people who get frustrated at life's ups and downs.

All in all, we are well on our way to being either incredibly active and useful citizens or grumpy old men.

Whichever we end up becoming, we will probably be whole hearted about it. As my brother likes to say, "I never half-ass anything. I always whole-ass it." (Which I believe is a Ron Swanson quote.)

Or, as I would put it, "The generation that carried on the war has been set apart by its experience. Through our great good fortune, in our youth our hearts were touched with fire. It was given to us to learn at the outset that life is a profound and passionate thing. While we are permitted to scorn nothing but indifference, and do not pretend to undervalue the worldly rewards of ambition, we have seen with our own eyes, beyond and above the gold fields, the snowy heights of honor, and it is for us to bear the report to those who come after us. But, above all, we have learned that whether a man accepts from Fortune her spade, and will look downward and dig, or from Aspiration her axe and cord, and will scale the ice, the one and only success which it is his to command is to bring to his work a mighty heart." Oliver Wendel Holmes, 1884 Memorial Day Speech.

Patient Interactions

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My favorite part of medicine is interacting with patients. My second favorite part is fitting the puzzle together, piecing all of the various bits of data from history, exam, labs and the literature to form a coherent image. For some providers, I suppose, that is the most exciting part. Dr. House comes to mind as an example of that disease oriented provider. Others are all about the procedures. They just enjoy getting hands on the patients, physically manipulating the diseased part, and providing healing that way. I suppose that category would include most surgeons. I find, however, that most patient encounters do not require much puzzling. Most are actually quite straightforward. Hardly of my patient encounters require procedures, although they are fun when they happen. However, every patient encounter includes an encounter with another human being. Sometimes these encounters are memorable, sometimes not. Sometimes they are fun, and sometimes they are not. Sometimes there is good rapport, and sometimes it seems that you are speaking totally different languages. Regardless, the encounter is always an encounter with the ineffable other of a human being who is not myself.

Tacoma is known for having a very high percentage of Asian populations. In fact, South Tacoma Way, one of my favorite strips for Asian cuisine, is informally called “South Korea Way.” Street signs are even labeled in Korean. Being a Special Forces soldier, my training includes a foreign language, which, in my case, is Korean. I would not say that I am fluent. I can order food, exchange pleasantries, and maybe chat a little bit about C. S. Lewis’ book “The Four Loves,” (I memorized a good deal of vocabulary for that book when I was preparing for my Korean speaking and listening test). It is not, however, to allow me to hold a conversation with ease with a native Korean speaker.

Several of my patients over the last two weeks were older Korean ladies, wives of Korean war veterans. I usually enjoy chatting with them a little, enough to say “Hello, how are you doing, where does it hurt?” One patient, in particular, was a very sad looking Korean lady who complained of fatigue, tiredness, pain, and heartburn. We talked with her for quite some time trying to come up with a list of her complaints and prioritize them, but she was a very listless and haphazard historian and she complained of confusion. Finally I asked, in Korean, “Sunsengnim (term of respect), do you get confused talking in Korean?” Her eyes widened and she repeated my question back to me in more correct vocabulary. I asked about her Korean friends, and she shook her head sadly.

“I not trusting Hanguk (Korean) peoples, they not sharing feeling. They nod yes, yes, when talk but later they like this behind you back,” she made a blabbing gesture with her hand. I asked if she had any American friends and she said, “I no likey Miguk (Americans) either. They just talking talking saying whatever come in they head. I not like that.”

While the doctor typed his note we chatted about this and that, and she slowly became more and more at ease. It was more “konglish” than either Korean or English. I learned that she was very lonely, and almost always sad. Her house had been broken into (she lived alone) and she just felt nervous and unsafe. She gave me an impromptu lesson in Korean language, history and folklore, and explained why the Korean number 4 “sa” is considered unlucky. I very much doubt we were able to provide any lasting relief for her symptoms, as I strongly suspect most of them had a behavioral or social health basis. She was a sad, lonely old lady, and she needed a friend and a hug more than she needed pain medications, but her fears and isolation kept her from those, so pain medication was all she could understand. However, she seemed to be put at ease by my broken attempts to speak and listen to her in her own language, and there was even something like a half ghost of a smile on her face when we shook hands goodbye.

Was that a good interaction? A positive one? I would not classify it as such, objectively. We learned very little to point our way to a treatment plan, and I do not have much hope that her symptoms will ever be resolved strictly by medicine. However, the attempt to reach out to her was just a little less negative than it otherwise would have been, and I think therefore it was more than worth it.

Another Korean lady the same day came in for coughing and post nasal drip, but she refused to believe that she had allergies. She was very upset at not being able to see her regular doctor (who was on maternity leave) and she denied ever having taken allergy medicine that her doctor had prescribed her. “I throw that medicine away, because I not like takey the pills!” It was hard not to laugh. She was about four feet tall and about two inches in diameter and bound and determined that something was wrong with her, because she could not stop coughing or sneezing, but it was NOT allergies! Bless her heart!

No amount of cajoling in English or Korean could convince her that, yes, in fact she very likely did have allergies, and it was perfectly normal and treatable. We tried to get her to promise at least to try the allergy medicine. When she would not we tried to sneak it into her medicine list without telling her what it was for! We said, “Oh, that’s to make you sniffles stop,” which was true, but she would have none of it. “I not takey the pills.”

Finally when the visit was over she stood up and said, “Thisa better working. You not makey me better I go to Korean doctor!” I felt like saying, “Fine! Go to a Korean doctor! What sense does it make to come to a western doctor and then refuse to take western medicines?” She never got angry, she just laughed at us like we were too ridiculous for believing that she was so weak that things like allergies and pills could apply to her. She did, however, tell us most emphatically that kimchi was going to keep us young and healthy and that I was going to live longer than the doctor because I loved kimchi and he “only likey the pizza!” He had never said that he didn’t like kimchi, he simply had never tried it, but in her mind that lumped him in with all the other pizza eating Miguks!

I cannot get angry at patients like that. I love their eccentricity, and I respect their autonomy. God bless them, if they want to grow old and cantankerous and get their kicks out of making fun of western medicine, more power to them. I hope I have enough spark left in me when I am old to be grumpy and funny like that.

The patients I feel sorry for are like the 60 year old man who came in for a regular checkup. In the course of the interview he mentioned having a new feeling of shortness of breath whenever he walked up hill. This prompted a deeper interview, a physical exam, an EKG, and the end result was that he was going home with a bottle of nitro, a bottle of baby aspirin, and a follow up appointment for an exercise stress test. As the appointment progressed and the diagnosis took shape, I could see the growing possibility reflected in his face and posture. His shoulders sank, more and more, his face became more and more bewildered, distant, afraid. It was a relief when the doctor finally said the word: “Heart disease.”

“We need to make sure you don’t have heart disease.” Amazing how we all knew that was what we were talking about, but we were reluctant to say it.

“Are you doing okay?” I asked.

He looked up at me. “I guess. It’s just I have a lot going on at home. I have family troubles, and my dad is not doing too well, and now this.”

“A hell of a thing,” I said.

“A hell of a thing” He agreed. His dad’s brothers had died in their early sixties of heart attacks. His face fell even further when he found that he could not work out until after the stress test, because of the risk of having another incident. “I can’t go to the gym?” His build spoke for itself. Despite his slight beer gut, his shoulders and arms were thick and powerful. He had been lifting his entire life. Now he would have to give it up, perhaps for a very long time, perhaps forever. Not only that, but because Viagra reacts synergistically with nitroglycerin, and can cause a catastrophic drop in blood pressure, he could not take Viagra until after the stress test, when we would have a better plan.

He looked at the doctor. He looked at me. “No weight lifting? And now you tell me no sex? Doc, what’s the point?”

At times like this you feel guilty about the clock, ticking away, reminding us that his appointment was only supposed to last twenty minutes, and that is long since up. How do you kick him out the door so the next patient can come in and tell us all about his acne and how it is affecting his social life?

I might be getting old, or maybe my parents were just poor and backwards (poor they certainly were) but it never would have occurred to them to take us to the doctor for acne, especially not acne so mild as to be invisible under long, thick black hair. There were a dozen or so cystic comadones around the hairline on his forehead, and another dozen along his hairline in the back. This rates a trip to the doctor?

And yet, it is a big deal to him. It never was to me, (I could have cared less for popularity at that age) and that may make it difficult to relate. One hopes that he grows to be a little less concerned about such things as he gets older and gains perspective, but he is not older. He is a teenager. This is where he is, this is important, and in its own way it is as devastating to him as a tumor would be to me. Why should I allow my age and experience to deprive me of empathy for his lack of age and experience? Would not that be shallow mindedness without even the excuse of youth and ignorance? And how difficult is it to prescribe some erythromycin face wash and an exfoliant? We sympathize with many, many older patients who are just as silly, and with less excuse. Certainly in my life many, many older and wiser people have put up with my ignorance and silliness. Shall I refuse to do the same for him?

So I resisted the urge to write him a script for “soap and water” or “a nice cup of man the heck up!” and provided one for face wash instead. I wish him well at his next high school social function. He was a nice kid, after all.

In reviewing these patient encounters I find it very difficult to classify them as “positive” or “negative.” That is more or less to be expected. Any encounter with another human being is essentially an encounter with the unknown. We do not hear the other perfectly, we do not communicate perfectly. The best I think we may expect of ourselves is the continual effort to be present; beyond all filters, preconceptions, contexts and languages, present for the other to be the other. Is it possible? Probably not. It is a worthy effort, I think, for only thus is any real meeting possible between humans. So, in any encounter, there is always more that could have been achieved, or less that could have been said badly, or some aspect that could have been improved. It is never perfect. The mistake, I think, is to try to reduce it to a technique. Technique is a tool, body language, active listening, participatory conversation techniques, or what have you. The essence, however, is goodwill towards the other. It is goodwill that will overcome all barriers, and hopefully shine through our clumsy, inept attempts at using our various languages, to communicate with something essential in the other person. On that level, perhaps we may even hope that some kind of real healing might occur.

Stability

It's a testament to the state of my life right now that, although I originally thought of this post two, almost three, weeks ago, I haven't had a chance to write it down until now. That, in itself, is not that unusual. I often take a long time to finish a thought, even in face to face conversations. It is not unusal for me to think about a blog for weeks before I actually write it out, and I wish I could say that was the case with this one. However that is not what happened. What happened was I got the idea, sketched out a brief idea in my head, and then forgot about it for two weeks because I simply didn't have the time to think. Or rather, I had time for thinking, but other things took priority.

But tonight I am back at the house before eight, my e-mails are caught up, tomorrow's lunch is packed, and my stomach is full so let's see if I can't write something.

About two and a half weeks ago I went out with some friends to a lecture on Benedictine Spirituality (it was a lot more fun than that makes it sound.) The Benedictine order has a tri-fold vow that they make, which is slightly different from the typical religious vow of poverty, chastity and obedience. Benedictines vow obedience, conversion of life, and stability and it was the vow of stability that made up a good portion of the talk. Considering that the audience was primarily young adults there is a certain irony in that.

Stability in the Benedictine order means that the monk makes a choice to remain with his monastery for the rest of his life. He cannot even go to visit another monastery without permission from his abbot, and he can never move out without breaking his vow. Even to work outside the monastery requires special permission. Perhaps the reason why this concept stuck so strongly with me is because it is the complete antithesis of our modern culture, especially among my generation. In America things are made to wear out. When it does wear out you throw it away and buy a new one. We try different jobs or college majors looking for the perfect fit, by which we usually mean something that will never get old or be boring or require us to get up early on a monday morning. If something doesn't stay as fun and fresh as it looked in the brochure we discard it and try something else. We take up one relationship after another, looking for one that will stay interesting and spontaneous. When our own humanity interferes with that fantasy we fight, break up, and go out looking again. We live in an unstable and disposable culture, and against that background the stability of the Benedictines stands in sharp, formidable contrast, like a mountain.

A few days after this talk a close friend of mine pointed out that my life is almost exactly the opposite of the Benedictine vow. Since I left home at 17 I have lived in Texas, New York, Korea, Kansas, Iraq, Afghanistan, North Carolina and Washington State. The longest I have stayed in one place was two and a half years in North Carolina. The second longest was fifteen months in Afghanistan. Interspersed with that has been a string of short stops at various places for schools and a short trip to Thailand. Truthfully, there has been very little stability in my adult life. It's odd, however, that it took someone else looking at me from the outside and pointing it out before I saw that. It puts into context my growing desire to put down roots somewhere and stop moving every couple of years. My books are getting harder and harder to lug around.

That lack of stability, however, was not apparent to me because in reality it is somewhat superficial. I don't really define myself in terms of place, but in terms of character and relationship. My priority for most of that time was not my job or the unit or my career. Instead I was focused on developing my character. I had a very clear idea of the sort of person I wanted to become and that provided a context for everything that happened outside me. Every change, or move, or event was simply one more thing shaping me, but it was the shaping that I was interested in, not the things themselves.

As I got older I did not become any less focused on that interior life, but it took on a new dimension. It became a relationship, rather than a solitary pursuit of an ideal. I began to see how God was the one shaping me, or to put it another way, calling me, and began to recognize His immediacy and His stability. At the same time I was also recapturing, or maybe developing for the first time, a real, solid appreciation for my family. I realized that, no matter how long I was in the Army it was not a permanent thing. It is designed not to be permanent. It is the kind of job that you can do only for a certain portion of your life. Even within that time you change units and duty stations every few years. But God and Family, they do not change. God is the constant upon which all true constancy rests. He has been with me, leading and guiding, calling and shaping, every moment since I was formed in the womb. And the tool that He used to form and shape me was my family. My parents will always be my parents, in this world and in the next. My siblings likewise, and my cousins and aunts and uncles and grandparents, etc. The relationships exist outside of the narrow confines of time. That is what is important, that is what is real and stable. That is what has provided the constancy in my crazy life, even when I was too dumb to see it.

The Benedictine vow of stability is not a norm but a witness. In voluntarily tying themselves to a single geographic location for their entire lives they bear witness to the rest of us that we are meant to do the same, spiritually. We are meant to choose freely to belong to something (say rather Someone) that will last. Love, then, is our bedrock. Goodness, truth and beauty are footprints of that love, but more than the footprint is offered us. We are told that we may learn to possess that very Love Himself, for He longs to give Himself too us. That is our permanence, our stabilty, our constant endurance. All else is but a ripple.