We are never alone

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Our trailcam is trained on the enclosure in the upper field where we bury our compost. Every night it records the presence of coyotes, sometimes one, sometime a little pack of three sibs, munching away on banana peels and carrot tops and onion skins. Whoever believes that coyotes are strict carnivores apparently forgot to inform our visitors.

In addition to the coyotes there’s the occasional family of racoons, an opossum or two, a bunny, a feral cat, a tiny scurrying mouse and once, spectacularly, a swarm of slithering river otters. There were about eight of them, coursing over and around the frame where the compost is buried. They didn’t linger—there were no fish to be found.

When I walk up the hill to bury the compost I never see any of these critters; their feedings are strictly nocturnal. They have no interest in seeing how their nightly meal is delivered, but the avocado pits and trimmed broccoli ends and rotting head of cauliflower that was hidden in the back of the vegetable bin scattered across the lawn testify to their activity.

The webcam recordings make me think of other unseen things that have occupied the same space I do. For example, our usually mute driveway eloquently speaks to us after it snows. It tells us about the coyotes on the way up to their snack bar, and of the over-wintering geese in search of the sparse supply of grass. And the revealed tire tracks inform us that someone got lost driving down Manual Road and ended up in our driveway, only to turn around and continue the search for their destination. Surely all this activity goes on even when it hasn’t snowed, but we have no inking of our myriad visitors.

I expand my time frame to consider visitations in the more distant past. We live on land that was occupied by Native Americans for thousands of years. Indeed, a small remanent of their long-term presence is the Suquamish Tribe Reservation just across the bridge. Since a creek borders our property and flows into the bay, our back yard must have been a frequent gathering place. When I mow the lawn I’m undoubtedly walking through the exact same space where families sat in a circle and ate roasted salmon and wove cedar baskets, and where kids piled up oyster shells to see who could build the tallest stack. And when I paddle my kayak around the bay I’m almost certainly crossing the paths of innumerable canoes setting out on fishing expeditions or carrying people to the mainland.

Going even further back, I read that Columbia mammoths, American mastodons, and giant ground sloths inhabited western Washington. They may well have trudged up and down Manual Road, munching on leaves, succulent grasses, tree bark, and the sedges lining the shore. It’s amazing to think that when I’m driving my old green truck up the road to drop off a package at UPS I’m traversing the same space that these ancients once occupied. Fortunately it’s quite unlikely that I’ll run into one.

Then there are the things that simultaneously occupy the space that I do. Obviously, the air I breath and the sunshine I bask in. But a frightening proliferation of electromagnetic waves are also pulsing around and through me—Verizon and T-Mobile; 98.1 FM; 444.475 MHz, the frequency of our local ham radio repeater; innumerable microwave communications; cosmic rays arriving after a trip of hundreds of light years; and who knows how many encrypted messages and drone signals and radar waves.

The things I’ve mentioned so far are all subject to documentation through camera, snow prints, some sort of detection device, or an historical or fossil record. But what about presences in the space we occupy that aren’t so easily verified? Our Suquamish neighbors certainly experience the immanence of their ancestors, as well as other beings, both animal and supernatural. Other traditions recognize a wide variety of occult entities, some benign, some not so much. For example, many people are aware of angels, always nearby, who guard and protect and guide them. And there are those who believe that we regularly rub elbows (or whatever appendages they might have) with unseen aliens of various origins and motivations. Who am I to say that none of this is so?

Surely then, even when we think we’re experiencing solitude, we’re fooling ourselves—we are never alone. We’re always sharing the same space with a multitude of entities, past and present, potentially detectable and not. And undoubtedly, in ways we’re unaware of, we’re affected by these presences.

On some mornings I grab the compost bucket and walk up the wooden steps to the upper field to bury the contents. I taste the crisp air and tune in to the big cedar’s gently waving branches and, above the branches to the slowly streaming clouds. Then I look down the hill to the brightening bay. I feel peaceful, and alone. But if I reflect, I realize that I’m not alone at all. I’m with animals, signals, and spirits of all sorts. If I pause my digging and lean on my shovel I can feel them. Then I look up and see the coyotes—noses furiously twitching, eyes scanning the horizon for friend, foe, and food. And I smile in their presence.

We do it anyway

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After my morning shower I grab the squeegee and carefully scrape down all the surfaces. The theory is that this will lead to less water spotting and perhaps prevent mold growth. But as I scraped away the other day (an activity I find quite burdensome) I wondered if I was actually doing anything useful. On rare occasions when I don’t squeegee, say because I’m running late for a ferry, I have to admit I don’t notice any water spots the next day. And since we have a good vent fan, the shower room seems to dry out pretty quickly. Do I really need to worry about either mold or water spots?

And speaking of showers, is it really necessary to take one every day, as I’ve done for many years? I recently read a commentary by a dermatologist who said that daily showering is quite unnecessary, and in fact is probably a bad idea since it tends to dry out the skin. And besides, it wastes water. And I recall a provocative commentary by another physician who said that he never takes a shower unless he’s visibly dirty. Yikes! He claims that he remains in excellent health, has supple skin and non-greasy hair, and doesn’t broadcast any unpleasant odors, at least according to his wife.

Despite the lack of evidence that daily showers with post-shower squeegeeing are appropriate, I continue with this ingrained routine. Perhaps for no better reason than that I enjoy showering (though not squeegeeing). I certainly can’t defend my behavior on any rational grounds. But I do it anyway.

Now that I’ve admitted my culpability in behaving irrationally, I feel I’ve immunized myself against being accused of being judgmental when I cite examples of things other people do without good reason. I might start by mentioning folks who are grimly determined to drink at least eight glasses of water a day. This, despite that apart from unusual circumstances (for example, hard exercise when it’s very hot outside) there’s absolutely no evidence that drinking fluid, other than when you’re thirsty, is of any benefit. In fact, there are several studies that suggest that drinking extra water is actually not wise. Some water guzzlers believe that inducing more frequent urination is useful since it “flushes toxins” out of the system. Such people should know that it’s well-established that peeing more does not eliminate more toxins. It just dilutes the same amount of toxins that the kidney excretes regardless of fluid intake. But will I tell all this to people I see schlepping around those huge Nalgene water bottles wherever they go? Of course not. That would have about as much effect as someone suggesting that I change my unnecessary and wasteful showering behavior. They’ll do it anyway.

On the other extreme, there are people who refrain from drinking any liquids at all during a meal because of their belief that doing so will “dilute the enzymes” in their stomach, impairing the digestion of their food. I won’t go into all the reasons why this is simply not true but will just say that it’s a quite unnecessary restriction. As opposed to glugging eight glasses of water throughout the day, drinking some liquids during a meal can be pleasurable, helps the food go down, quenches thirst, and, if anything, is likely to enhance digestion. But would I ever try to convince believers that they are needlessly limiting themselves by foregoing liquid while they eat? Of course not. They’ll do it anyway.

Then there’s gluten. Only one or at most two percent of people actually have “gluten-sensitive enteropathy,” as we in the GI biz call it, or as it’s better known, “celiac disease.” But a far higher proportion believe they have adverse reactions to gluten (“non-celiac gluten sensitivity”). Symptoms include not only abdominal pain and nausea but diarrhea (for some), constipation (for others), brain fog, headaches, anxiety, depression, fatigue, joint pain, and rashes, to name a few. As opposed to celiac disease, there are no blood or tissue tests to confirm the presence of non-celiac gluten sensitivity. It’s a do-it-yourself diagnosis depending simply on the person’s belief that they’re sensitive to gluten. I won’t go into all the reasons why non-celiacs who say they are sensitive to gluten are very likely actually not. I’d just point out that people who claim gluten sensitivity generally experience symptoms only when they know that they’ve eaten the stuff. In “blinded food challenge studies,” subjects are randomly given either regular bread, or similar-appearing bread made without gluten. Almost without exception, people who are certain they are sensitive to gluten can’t distinguish which version of bread they’ve eaten based on subsequent symptoms. Despite all the evidence, I’d never suggest to a person who eschews gluten to give it a try. They’ll continue to avoid it anyway.

Continuing on the food theme, we make rice two or three times each week in our beloved Zojirushi rice steamer. It makes great rice. Along with other fans, we affectionately refer to our appliance as “The Zoji.” When we first got it I watched a Zoji video about how to prepare rice for cooking. After putting a carefully measured portion rice in the special pot, you are to quickly rinse and drain it three times. Then stir the rice vigorously with your clawed fingers (ten circuits clockwise, then counterclockwise, then again ten clockwise), then rinse it, and repeat this finger stirring a total of three times. But you’re still not done—this sequence is followed by three more non-stirred rinses. The idea, say the Zoji mavens, is to wash out as much of the husk fragments as possible, which enhances the quality of the cooked rice. So even though it’s tedious, I’ve followed this recipe for years. Occasionally I’ve heretically wondered whether such a carry on is really necessary. Indeed, when my wife makes rice she’s much less compulsive than I am, just giving it a quick rinse once or twice, then chucking it into the Zoji. And I have to admit, her rice doesn’t seem at all inferior to the rice I so carefully prepare. But does this alter my rinsing behavior? Alas, no. If the Zoji pros tell me how I should wash rice, how can I defy them? I do it anyway.



So there’s copious evidence that I and many—probably most—of my fellow humans do things that are unnecessary, irrational, or both. I wonder how much time we waste over the course of our lives, and how much aggravation we self-inflict, by adhering to such needless routines. But alas, the combination of belief and habit is very potent–they work in concert to sustain behaviors, no matter how irrational. Moreover, I do appreciate that there’s a place for rituals in our lives. They help stitch the day together, and can give order and comfort. But if they aren’t altogether pleasant, and if they involve unwelcome time and effort, there’s reason to examine them and see if they’re really worth continuing.

The good news is that occasionally such behaviors are actually changeable. Here’s one tiny example: for years before starting a fire in our wood stove, I opened a window. The theory was that doing so increased ventilation into the stove, making the fire start more readily. But a few months ago, in my haste to warm up the house on a particularly cold morning, I forgot to open a window. Nonetheless, the fire started just fine; in short order the house was warm and toasty. So guess what? Now I never open a window before firing up the stove. This is not only a little time saver, but it means I don’t have to remember to close the window once the fire is blazing, which I often forgot to do, letting lots of precious warm air escape.

Eliminating behavior that’s irrational, or simply unnecessary, can save time, and sometimes really improve the quality of life. Maybe we should all examine some of the things we do that are bothersome or time consuming, and consider whether there’s really good reason for us to persist. And then make a change and see what happens: Dare to eat a slice of toast. Leave that Nalgene home. Drink a nice glass of water with dinner. Speaking for myself, I’m not yet ready to stop showering daily, but maybe I’ll try cutting down the squeegee use to every other day. And even rinse the rice a bit less assiduously. No telling what I’ll do with all the extra time.

A million ways to meet your Maker

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If there are fifty ways to leave your lover, there are a million ways to meet your Maker. Some are common, some rare.

Many years ago I cut an article out of the newspaper reporting a freak accident in Page, Arizona. James and Adalene Beckwith were placidly motoring along, parallel to the shore of Lake Powell in their 21-foot cabin cruiser. Just as they passed beneath an overhanging cliff, “a huge chunk of sandstone” broke loose and smashed into the boat. What were the chances of that? Adalene was taken to Page Hospital with critical injuries, while James sunk to the bottom of the lake. At the time of the article’s publication his body had not yet been recovered.

A distant relative of mine, also a gastroenterologist, was in good health when he experienced an episode of viral gastroenteritis. While sitting on his sofa reading, he suddenly vomited, aspirated, and died.

Although it remains uncertain, a single person in recorded history is thought to have been killed after being struck by a meteorite. The victim was a 40-year-old bus driver named Kamaraj, who was standing on the grounds of a college in Tamil Nadu, at the southern tip of India. The fateful meteorite apparently had Kamaraj in its sights when it formed somewhere in space millions of years ago: at that point it began its extended trip through the universe that ended by destroying the bus driver’s life on February 6th, 2016. This was of course an extraordinarily unlikely event, but the unfortunate Kamaraj was just as dead as if he had crashed his bus (odds of death in a motor vehicle accident are about 1 in 106).

It is estimated that several thousand people die of lightning strikes each year. This translates to a lifetime risk of death by lightening of about 1 in 180,000. So I guess it’s more likely that you’ll be taken by lightning than win the lottery, but don’t count on either happening. For perspective, the chances of your life ending by a fall are 1 in 111.

Sadly, freak occurrences sometimes affect not just one, but many. I went to Haiti with a medical team a few months after the 2010 earthquake that killed an incomprehensible 230,000 people. During our outdoor clinics I heard horrific stories of people who, through a long chain of circumstances, found themselves in the wrong place at the wrong time. The sister of a friend of a Haitian physician I worked with needed a single credit to complete her nursing degree. She chose a course that met in a particularly poorly constructed building. Even though she had been assigned a seat right next to the door, the first shock wave was so strong that it instantly brought the structure down. Her brother found her body half in and half out of the doorway, buried in debris. So sad!

On a somewhat more optimistic note, chance events can also lead to one being spared death by a whisker. The cousin of the same physician was supposed to begin college on the day the earthquake struck. The first class met in a building in Port-au-Prince. But much to his chagrin, he’d been distracted, and missed the registration deadline. Thus, he wasn’t permitted to attend any courses. This lapse saved his life—the building where the college classes took place was completely destroyed. All eight floors were smashed together in a terrible pancake stacked crazily on the ground, killing every student.

Freak boating accidents can be deadly, as was the case in Lake Powell, but can also unexpectedly spare lives. Twenty-five years ago some friends of ours were becalmed in their 35-foot sailboat, far out at sea. A crew member pointed out a power boat way in the distance. No one thought much about it, even as it got progressively closer—everyone was sure it would alter course. But it kept coming, at full speed. Those aboard the sailboat began to get concerned. Several waved their arms, increasingly frantically, to get the attention of the pilot. Disconcertingly, the boat didn’t alter its speed or its course, but seemed to have a bead on our friends. Finally, it rammed into the sail boat at about 30 mph, ripping a four-foot hole in its side. The Bayliner’s bow went up onto the sailboat’s deck with such force that the mast broke, and the steel rigging snapped. Two crew were thrown into the water, and several others were knocked down on the foredeck, where they could see the bottom of the Bayliner looming above them. One crew member narrowly escaped decapitation by a whipping shroud. Miraculously, despite some extensive bruises, no one was seriously hurt. How could this horrible collision have happened? It turned out that the inexperienced skipper of the Bayliner had locked the wheel and gone below deck “for a few minutes.”

So, extremely unlikely events can cause fatalities and, thankfully, be occasionally associated with miraculous escapes. This leads to contemplation of the multitude of near-misses each of us inevitably experiences in the course of our lives without even being aware of them: the truck driver who suddenly jerks awake just before his rig drifts over into oncoming traffic; the little colony of staphylococcus growing on the aortic valve that are fortuitously destroyed by white blood cells just in time to prevent the development of fatal endocarditis; the shooter with a trunkful of guns heading for the movie theater whose car wouldn’t start.

In my first year of medical school, during a lecture on the menstrual cycle, the Ob-Gyn professor marveled at the incredible complexity of the hormonal symphony necessary to trigger ovulation each month. “What’s amazing,” he said, “is not all the things that can go wrong to interfere with ovulation. It’s that women ever manage to get pregnant at all.” I take his point a step further and express my amazement that any person is ever able to survive past childhood. There are a million ways to meet your maker–life is precious and fragile. Please be careful, everybody!

Why do anything at all?

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“Why do anything at all?” my daughter asked. Though it was a very reasonable question it still startled me since I’d not considered that option. We were standing at the bottom of the set of steps that led to the upper garden area (“the back forty,” we called it). The twenty steps were made of old railroad ties in the front with gravelly soil overgrown with weeds behind them. My idea was to dig out the soil behind the ties to a depth of about 5 inches, lay down landscaping fabric, then fill the holes with fresh gravel.

As Emily aptly pointed out, this scheme would involve a great deal of work. A much easier alternative would be to simply pull the weeds. But as we agreed, that would be a very temporary fix because the weeds were embedded in hard dirt and gravel. Thus they couldn’t be cleanly removed and would begin to grow back as soon as they were plucked. My plan of deep excavation-and-replacement would be a more satisfying long-term solution. But still, the weeds would inevitably return. So why do anything at all? Particularly since despite the luxuriant crop of weeds, the steps were quite easy to negotiate.

Emily shrugged and wandered off. Simply doing nothing seemed the rational and appealing course. While contemplating doing nothing, I picked up my shovel and gave it a few hefts. Then I idly poked at the dirt and started digging into step number one. I found myself getting into a pleasing rhythm. There was something unexpectedly satisfying about biting into the gravelly dirt, extracting a little weed village, and chucking it into the nearby wheelbarrow with a resounding thunk.

Then, to my surprise, I decided to activate my initial plan, and resolved to do two steps a day. The more I did, the more compelling the process became. In fact, after finishing the big dig behind the railroad tie of the second step, I found I couldn’t stop. Up came the weedy soil of step number three, then four, then five. And in addition to the digging, I found unexpected pleasure in maneuvering the loaded wheelbarrow into the woods and tipping out its contents to fill a convenient depression in the earth. I thought about how the foreign material would settle into its new home and become a breeding ground for the adherent weeds, soon becoming indistinguishable from the earth around it.

So I dug and I dug. After several hours of steady shoveling, I suddenly realized that all twenty steps had been mined. But I still couldn’t stop. Now it was time to begin filling in the pits behind the railroad ties. First, I had to put down the landscaping cloth to prevent weeds from creeping up from below. So I unrolled the cloth on the front deck, and with a chalk stub sketched out the area I wanted to cover. It was so quiet that I could hear the scratch of the chalk as I drew it across the black fabric. Then, as I cut along the line, a gentle puff of white dust was thrown up, which delighted me. The scissors made a soft honking noise, which rhymed with the sound the Canada geese down by the water. As I drew and cut, I felt a deep sense of peace.

Reverently, I placed the fitted cloth at the bottom of the first step. Then I grabbed two plastic buckets and filled them with ¼ minus basalt gravel, which was waiting for me in the driveway, in the bed of my pickup. With some effort I lugged the heavy buckets back to the steps, poured their contents into the hole, and repeated the process until the gravel was level with the wood in front of it. Carrying those buckets back and forth reminded me of my time doing medical work at a refugee camp in northern Uganda. Throughout the day there was a steady procession of people transporting incredibly heavy buckets of water for several kilometers, from a well back to their tents. Of course, the buckets were far heavier than mine, only women did this work, and the women often carried them on their heads. While toting the gravel I was somehow communing with those hard-working women. And felt in awe of them.

I cut more cloth, carried more gravel, and filled more holes. After finishing step number six I was getting pretty hungry, so finally stopped. The waiting dinner, made by my sweet wife, was delicious, and I went to bed feeling quite satisfied.

The next morning, after a quick breakfast I was back at the steps. The routine was now very familiar, and the rhythm of the work even more pleasing. By midday the job was done. The weedy steps had been transformed into smooth, gray gravel behind dark wood. I marched up and down to test them out—lovely! Were the sleek, unform steps any easier to navigate than the former weedy ones? Well, no, not really. But was I still glad that I had done all the work? Absolutely.

So it turns out that my response to Emily’s question wasn’t rational. Doing nothing would have saved time, money, and blisters. But still. The work was very satisfying. It gave me good exercise and allowed me to commune with things I might otherwise have missed. I will long remember the sensations and feelings I experienced—the subtle sound of the scissors cutting the landscape cloth, and the puffs of ejected chalk dust as it was severed. Becoming aware of the honking geese. Feeling connected to those heroic Ugandan women toiling with their heavy buckets of water. And the sense of accomplishment as I regarded my twenty beautiful steps. Sometimes I think, it’s reasonable to do things that are completely unnecessary.

Impending delivery at 35,000 feet

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About 5 hours into the flight from London to Boston a voice came over the speakers: “If there’s a doctor or other medical personnel on board, please make yourself known to a flight attendant.” Unlike many doctors who seem to dread such an announcement, I always welcomed one. Not only did providing medical care make the time pass, but more importantly it gave me the opportunity to help someone.

I quickly pushed the call button, and a flight attendant walked down the hushed aisle to my seat. She asked to see identification proving that I was a physician. After she was satisfied that I really was a doc, she told me the story: There was a 32-year-old woman in row 46 who was 26 weeks pregnant. Her water had broken, and she was going through a pad every five minutes. Would I talk to her? I briskly walked down to row 46 and saw an anxious-looking woman leaning on the shoulder of a man I took to be her husband. I quickly learned that her water had actually broken in the terminal at Heathrow, but for some reason she and her husband still elected to board the plane. They both seemed a bit bemused and disconnected from the reality of the woman’s situation. I learned that this was her first pregnancy. And that she had a master’s degree in something or other—she was not a dummy. It amazed me that neither she nor her husband realized that having ruptured membranes meant it wasn’t a good idea to board a transatlantic flight.

By this time several other “medical personnel” had found their way to row 46—there was an ER doc and two nurses–a surgical nurse and, fortuitously, a labor and delivery nurse. We quietly conferred in the aisle, mutually rolling our eyes that our patient chose to board the plane. All were in agreement that she needed to be examined. So we had the flight attendants set up an examining room in one of the galleys—they spread blankets on the floor, brought in several containers of medical supplies, including a baby delivery kit complete with forceps. Our patient was led to the galley, helped to the floor, and the curtains were closed to afford her a semblance of privacy. Since I had been first on the scene, I appointed myself to do the examination, even though by training I was a gastroenterologist who had last delivered a baby during medical school, perhaps 20 years previously. In the heat of the moment I didn’t think to defer to the OB nurse, who was clearly more experienced in this realm than was I. While the others watched, I put on exam gloves, got down on my knees, and felt for the cervix. My fingers encountered the baby’s crown, and a cervix that was probably dilated to 4 or 5 cm.

Though our patient wasn’t having definite contractions, our little team agreed that she could deliver quite soon. I communicated this to one of the flight attendants. Soon the captain emerged from the cockpit and met me just outside the exam room. I told him our concern, pointing out that a 26-week-old neonate would be just on the cusp of viability, and asked him how much further it was to Boston. He said it would take about three hours. Was there an airport any closer? Yes, he said, Gander. It was about an hour away. I had no idea where Gander was, but later learned that it was in Newfoundland, the most eastern bit of North America. During the first transatlantic flights it was the usual taking off point for planes heading east—they landed in Ireland, the westernmost part of Europe.

I asked the captain if there was a neonatal intensive care unit at the hospital in Gander (if there even was a hospital in Gander). “Oh, yes there is,” he said without hesitation. So I advised him to redirect the plane to Gander. He should call ahead and have emergency help ready to take our patient to the hospital. Though it seemed like the right thing to recommend, I went back to the galley and talked to my newfound colleagues, who supported my decision.

The captain returned to the cockpit and soberly announced that due to a medical emergency the plane would be diverted to Gander. The OB nurse stayed with the patient, and the others and I returned to our seats.

Soon we landed on a long, dark runway. This was unlike any airport I’d ever encountered–I didn’t see any other aircraft. The blinking lights on our plane’s wings revealed snow plowed up to about 15 feet on either side. The pilot officially announced our arrival, and informed us that the outside temperature was 20 below. We were advised to stay in our seats while the emergency was dealt with.

Looking out my window to the tarmac far below, I saw an ambulance approach the plane. Clearly, the terminal—if there indeed was a terminal—wasn’t equipped with a jetway big enough for a 747. Instead, a portable lift topped by a big square platform was waiting nearby. Two medics extracted a gurney from the ambulance and placed it on the platform, then hopped on. It scissored up to one of the exit doors, which was opened by a flight attendant. The very bundled up and cold- looking EMTs wheeled the gurney onto the plane and were directed down the aisle to the examining room. Soon our patient, swathed in blankets and strapped firmly to the gurney, was wheeled back down the aisle with her husband in tow. I got up and followed the entourage to talk to the EMTs. I told them key details of the situation and answered a few questions. Then I said to the lead EMT, “Wow, this place seems so remote. I can’t believe there’s a neonatal ICU near here!” “There isn’t.” he replied. “The nearest one is in Halifax. That’s a two-hour flight.”

My stomach flipped, and I was speechless. I fished out a business card from my wallet and gave it to the husband, who I hoped hadn’t heard what the EMT guy said. “Best of luck,” I said, “and please let me know how things go.”
I returned to my seat and watched our swaddled patient get loaded into the ambulance, which drove away in the darkness to who knows where. I never heard back from the husband.



Over the years I’ve thought about this woman many times. Where was she taken by the ambulance crew? Where and when did she deliver? And, of course, did the baby survive? Although at the time I felt quite confident that I’d handled the situation well, in all my retrospective musings I’ve never had good feelings about it. Neither the woman nor her husband were very communicative, but I have an uneasy sense that I didn’t do as much as I should have to try to draw them out about why they chose to get on the plane. Maybe they were desperate to get back to Boston for some important reason—a dying relative? A vital Christmas commitment? I don’t recall giving them any say in whether we continued on to Boston or diverted to Gander. But even if I in fact asked for and received their endorsement for the diversion, was that the right thing to suggest? Even if there really were an NICU in Gander, she may not have delivered for many hours, and Boston would have certainly been a better place to be for the care of a very premature baby. I also think I was foolish to have trusted the captain’s glib assurance that the Gander hospital had an NICU. Did he even understand what I was asking him? On reflection, why would he know anything about the facilities of a hospital near an airport where he never flew a plane? Clearly, I should have asked to communicate directly with the hospital, and probably to an obstetrician, who could have provided expert advice on the best course of action.
This experience highlights the responsibility we take on when we make decisions for others. Though perhaps most obvious in the case of physicians, police, judges, and of course parents, at times we all make choices–some trivial, some momentous–that affect other people. And no doubt, just about everyone has regrets about a decision they made that had unfortunate consequences. That’s life—none of us is perfect. But because of their potential effect, I believe that we have an obligation to carefully consider all our decisions, especially those that may affect others. Which, I guess, is pretty much all of them. For my part, I aspire to be as thoughtful as I can in making a recommendation, suggesting a course of action, or otherwise deciding something that may impact others.

(photo by Annie Klein)

I’m a Woofer!

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I’m a Woofer! Two years ago I took an intensive 5-day course to become a Wilderness First Responder (WFR), or “Woofer” as we affectionately call each other. We Woofers are trained to deal with injuries and illnesses in a “low resource environment,” such as a backpacking trip in the boonies, where proper medical care is a long way away. We learned what to do about fractures, heatstroke, third degree burns, dislocations, near drowning, spinal cord injuries, massive bleeds, and allergic reactions. Not to mention back country heart attacks, spider bites, and anaphylaxis.

In addition to classroom learning, the course included lots of simulations, culminating in a late-night final exam. In the exam we dealt with an MCI (mass casualty incident, just in case you didn’t know), in the deep woods of Fort Ward on Bainbridge Island. Turns out that a group of campers were peacefully sleeping in their tents at the base of a cliff when, in the middle of the night, there was a major rockslide. We Woofers-in-training were rushed to the scene. In the dark we had to locate the victims, who, despite their grave injuries, had somehow been able to leave their tents and scatter throughout the woods. Once we found them–their wounds highlighted by the fake blood that glistened in the light of our headlamps–we had to diagnose and treat the grisly injuries they had sustained. Fortunately, the patient with a spinal cord injury that I ministered to survived, and I passed the course.

Then just a few weeks ago I took a three-day refresher course to maintain my Woofer credentials. (Technically, I’m actually a “Wumper”—WUMP stands for “Wilderness Update for Medical Professionals”—but it comes down to the same thing.) This time the MCI was a serious earthquake. My poor victim was a 91-year-old woman (both in the script and in real life) who, while trying to escape a collapsing building, was impaled in her right chest by a three-foot length of rebar. She heroically, but unwisely, yanked out the rebar. Thus, when I found her, she was experiencing severe bleeding, shortness of breath, and a nasty sucking chest wound. Once again, I was fortunate to be able to stabilize her (and, along the way, confirm that her real pacemaker was still working properly), and passed the course. So I’ll continue to be a certified Woofer for the next two years.

Why, you might ask, did I decide to become a Woofer in the first place? No, I’m not planning to scale Mt Everest, or even do the Pacific Crest Trail. But I live well within rumbling distance of the Cascadia Fault. We’re told that a massive earthquake (Richter 9 or so) is overdue, and reasonably likely to occur sometime during the next fifty years. That is, The Big One could happen long after I’m gone. Or tomorrow. (Or, as in the simulation, a few weeks ago!) When it comes our island will be completely cut off from medical care—the ferries won’t be running, the bridge to the mainland will be in shambles, and there won’t be electricity, or even cell service. (That’s why a year ago I earned a ham license; now I have to get around to learning how to use my transceiver!)

So in anticipation of The Big One I joined the Bainbridge Island Medical Reserve Corps, and became a Woofer to boot. After the shaking stops, I’m to report to our local “disaster hub”, one of twelve on the island. My hub is at the Seabold Church, about 0.8 miles from our home. It should be an easy walk, assuming I’m able to hop over all the fissures in the earth en route. At the church, where there’s a big trailer stocked with all sorts of medical supplies and emergency gear, My fellow Woofers and I should be in a position to treat earthquake-related injuries as well as chronic health conditions.

But even if the hubs are activated in my lifetime, the things I’m likely to deal with compromise only a small part of the skills I was taught in Woofer Academy. What about all the other things I learned and was tested on? The chance of my ever needing to care for a scorpion sting is about on par with the chance of my having to treat someone struck by lightning. So I wonder: what was the point of spending so much time, energy, and money learning stuff I’m very unlikely to ever use?

Here’s my answer, or perhaps rationale, for becoming a Woofer: First of all, it’s quite possible that a disaster, natural or man-made will in fact occur when I’m in a position to help. As a physician I’d feel terrible if I had no relevant skills and just stood around helplessly while people were suffering. So even if most of my Woofer learnings won’t be called upon, and even if I recalled only some of the useful ones, I might be able to help someone who otherwise would receive no assistance. Second, there’s pleasure in learning new things, or relearning old ones, even if they aren’t of practical use. Third, ya never know! Though I doubt that I’ll ever find myself trekking across the desert and encountering someone with heatstroke or strolling atop a glacier and stumbling over a person with frostbitten toes, other situations may arise where what I’ve learned could help. In fact, just a few months ago there was an announcement on the ferry for any medical personnel on board to report to the second mate’s office. I did, and was led to the bottom of the staircase that went down to the car deck. A man had tripped and fallen, sustaining some nasty facial lacerations (this time the blood was real). I was able to help check him out and, when a crew member appeared with a medical kit, stabilize him until the boat docked in Seattle and the EMT crew came aboard and took over. It felt good to be able to give my sudden patient help and reassurance.

The Big One might not occur in my lifetime, and the hubs may never be activated. Thus, I may never be called on to apply a tourniquet to stop a radial artery bleed, or start an IV to treat serious dehydration, or splint a fractured tibia. But there’s still a great deal of satisfaction in knowing how to do these things, whether I’ll ever use them or not. I’m glad that I’m a Woofer

Old wine

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When we lived in Chapel Hill, an obstetrician named Vern Katz delivered our daughter. Subsequently we became friends with Vern and his wife, Debbie, who was also an obstetrician. One day when they were at our house for dinner, Debbie told us that after they delivered a baby, grateful parents would occasionally give them a gift. Vern said that one time he was given a bottle of champagne. He and Debbie drank a glass each, then tossed the rest down the kitchen sink. Afterwards, on a whim Debbie looked it up and found that the champagne sold for well over $100. Oh no, she’d said ruefully to Vern, what have we done?

I thought of this story when I recently opened a bottle of 1996 Saint-Julien (Chateau Ducru-Beaucaillou, in case you wondered). I bought it more than 25 years ago to be stored, according to wine maven Robert Parker, until it peaked between 2018 and 2035. So it patiently rested on a wine rack under the stairs for the requisite passage of time and the right occasion. Which turned out to be my birthday. Before I uncorked it, I looked up how much it was going for these days. To my surprise, many high end wine shops still had it in stock. The price varied over an astonishingly wide range, from a low of a mere $235, to a top price of $998.99, plus $50 for shipping.

I opened the bottle with great anticipation. The cork crumbled slightly, but I managed to extract it with only a few crumbs falling into the bottle. Then I lovingly poured the wine into a decanter, which was given to me years ago by the same daughter that Vern had delivered. Next, like a knowledgeable consumer, I let the wine sit in the decanter for several hours to “open up.” Then I poured some wine into my class, carefully swirled it, and took a sip.

So how was it? I think I’d rate it as pretty good. Whaaat? you say: A thousand buck bottle of wine was just “pretty good”? Well, it did have a somewhat complex nose, and the taste was multilayered. But ruefully, I have to report that as much as I wanted to love it, it didn’t really knock my socks off. And the rest of the family with whom I shared the bottle (including the Vern-delivered daughter) agreed. Maybe it wasn’t kept at the optimal temperature for the quarter century I’d stored it. Or maybe (in fact, probably) my taste isn’t all that discerning. But whatever the reason, to be perfectly honest I have to say I’ve enjoyed some less than 10-dollar bottles of wine more (like the one on the right in the photo). But knowing the price of this precious Saint-Julien, we drank every last drop. And savored it as much as we could. I admit that if it were an eight-buck bottle of wine I could even imagine that I might have emulated Vern and Debbie by pouring the last bit down the drain.

But when you think about it, didn’t Vern and Debbie actually do a sensible thing? If they’d had enough to drink and weren’t particularly enamored of the taste, why should the price tag matter? Maybe they were sensible not to be influenced by the cost, and just do what felt right.

When we lived in France, we fell in love with a Chagall lithograph displayed in an art gallery in our village. Feeling extravagant, we bought it, and were supplied with fancy documentation proving that this was a very limited-edition lithograph, and indeed by Chagall. But it occurs to me, what if the lithograph was a forgery and the documentation faked? If we knew it was a counterfeit Chagall, would we like it less? Theoretically no, since it would remain the exact same piece we bought and loved. Why should its provenance matter? A bit more subtly, would we perhaps have been less drawn to it in the first place if it were by some unknown artist rather than Chagall? I must admit, probably so.

Which brings up the issue of intrinsic versus extrinsic value. I believe that our subjective response to something is informed to a greater extent than we’d like to think by our awareness of its value. For example, knowing the rock on the ring is a diamond rather than a rhinestone surely enhances its perceived beauty. And it seems quite likely that we would be less reluctant to admit that we didn’t particularly like that thousand-dollar bottle of wine or the painting by Picasso or that book by Philip Roth than if we didn’t know the cost or the artist or the author.

So maybe wine should be tasted without knowing the price, paintings be displayed without the artist being identified, and novels read without disclosure of the author. Doing so would allow us to evaluate these things without prejudice. This is the same principle as in clinical trials of experimental drugs–something that I’ve spent much of my life designing. Because knowing the treatment assignment has a powerful effect, the trial must be “double blind,” meaning that the drug and the placebo pills look identical and are coded. This prevents the response of the subject or the evaluation of the physician from being influenced by knowing what treatment the subject was randomized to.

Perhaps the same principle should apply to the way we regard people we’re meeting for the first time. Arguably, our impression shouldn’t be influenced by their degrees or their accomplishments or their net worth. But simply by the way they act and what they have to say. I don’t know how one can “blind” details of someone’s background on the first meeting, especially when we already know about them, or they’re introduced by an admiring friend. But I suggest we should consciously try to minimize the influence of their resumes on how we feel about them. Maybe this can be done to some extent by an act of will—we should focus on what they are saying and how they are behaving, and try to keep at bay the knowledge of their credentials. With this approach, someone whose pedigree is equivalent to a 1996 Saint-Julian may turn out to be less interesting than a person whose background resembles a humble ten-buck red blend.

I contain multitudes

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I hold two different people in my bones. About two years ago I had a cheilectomy on my right big toe. In this rather gruesome procedure, bony overgrowth is scraped off the joint space to reduce pain and increase mobility. To help facilitate the formation of a new joint, the podiatrist mixed “cadaver collagen” with my blood, then applied the resulting paste to the two bone ends. Then about a year ago I had oral surgery to repair bone regression at the base of a tooth (number 5, in case you wondered). This time “cadaver bone” was grafted into my jaw. I’m pleased to say that both procedures were successful. Ah, the joys of getting older and having the ol’ bod wear out!

Having dissected cadavers in medical school, I was interested to learn more about how the cadaver collagen and cadaver bone were obtained. So I asked my dentist if there was some big depository where human bones were dumped, then ground up and aliquoted out for various transplant uses. No, she said, the material always comes from a single person, who had consented to donating their post-mortem bones for such purposes. A single person? That got my attention; this was more interesting than getting a slurry of random bones. Why, I asked, did the material come from just one cadaver? She gave a very cogent answer: If anything goes wrong–for example rejection or infection–it would be much easier to identify the source if it came from a single person. So when the transplant is performed, the serial number on the bottle is entered into my medical record. If a problem arises, the dentist or the podiatrist can report it back to the company that generates the material, and they can alert other recipients and recall the other bottles of bone derived from that same person. Likewise, my dentist or podiatrist will be told if another patient with whom I share a bone has a problem.

As I said, this was a startling revelation: I now know that I house bits of the bodies of two particular people. I can’t help but wonder who they were. Male or female? Young or old? What did they look like? Where did they live, and how did they die? And what motivated their altruistic donations? Whoever they were, the fact is that two other people are living within me. I find this interesting, and perhaps, a little creepy. But I’m sure the feeling is much more intense for recipients of a kidney, or especially a heart. In those cases it’s a discrete organ performing a vital function that was inserted into one’s body, not merely human-sourced calcium hydroxyapatite.

It’s widely reported that people who have received organ transplants, especially hearts, say they feel the presence of the donor. Sometimes, as I understand it, this leads to a dialog with that person, and can even result in an alteration of the recipient’s personality. I find this quite credible. While I’m not in conversation with the people incorporated into my toe and my tooth, I’m certainly grateful for what they have selflessly given me.

But when you think about it, transplants are merely one example of how others are incorporated into our lives. Obviously, we receive substantial chunks of DNA from our parents, and, through them, from previous generations. We carry this genetic material, and are influenced by it in myriad ways.

And of course we also assimilate non-physical attributes from family, neighbors, teachers, spiritual leaders, and friends. These incorporations, some intentional, others quite unconscious, inform our mannerisms, proclivities, values, interests, wisdom, humor, passions, and many other things. Thus, we are far from being the distinct and autonomous entities we usually think we are. Rather, we’re quite permeable beings with others flowing in and out of us all through our lives. For all of my transplants, both physical and non-physical I’m grateful, and give thanks. They work together to make me who I am: I’m an integration of a huge assortment of people that I’ve internalized over the years. As Walt Whitman so aptly put it, “I am large, I contain multitudes.”

Water, water everywhere

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I’ve nearly drowned three times. The first time was when I was about ten. My mother took me to one of her childhood haunts, Jones Beach, on Long Island. She used to swim there in the summers when she was growing up in Brooklyn. It was warm and sunny the day I nearly drowned. As usual the beach was shoulder-to-shoulder. I shed my clothes down to my swimsuit, charged into the water, and dove heedlessly into the first wave I encountered, which turned out to be much bigger than I’d bargained for. It unceremoniously picked me up and flipped me over. I swam hard to get to the surface. Just as it seemed my breath had totally run out, my head rammed into the sandy ocean bottom–I was so disoriented I swam south instead of north. Having lost all sense of direction, I thoroughly panicked, semi-blacked out, and was miraculously delivered to shallow water by another wave. From there I was able to crawl up on the sand and catch my breath. I don’t think I swam any more that day.


Many years later I was living in Thailand with my then-wife, Phyllis. For a little break from work, we drove to Phang-nga Bay, in the southern part of the country. The scenery, which was later featured in the James Bond film, The Man with the Golden Gun, was spectacular. From there we drove across the peninsula to a beach on the east coast, facing the Gulf of Siam. It was straight out of a travel poster: the ocean was glistening blue with regular foamy waves, and the wide, pristine beach was fringed with billowing palm trees. And it was totally deserted. The water was deliciously tepid, and the offshore breeze held all sorts of enticing tropical smells. Ecstatic about being in this touristic idyll without the tourists, we plunged into the sea. Just a little way from shore we began to feel a current coursing around our legs. It tugged us into deeper water, gently and teasingly at first, and then with overwhelming insistence. Soon, like leaves in a rushing stream, we were carried out to sea. We tried to fight against the current, but its force was overwhelming.

After being pulled helplessly away from the land for what seemed like forever, the undertow finally released its grip. We were tiny specks of humanity, bobbing on the surface of the vast, indifferent sea. We’ve got to swim back, I said stupidly. But Phyllis, who was a poor swimmer, was already tiring and starting to panic. We drifted yet further out to sea, and I mildly thought, oh, so this is how my life will end. Then my survival instincts kicked in. I wrapped my arm across Phyllis’ chest in mechanical memory of the “water rescue” maneuver I learned for my swimming merit badge. Hefting Phyllis, I swam diagonally toward the distant shore. It took forever. I have no recollection of what, if anything, I was thinking or feeling during this desperate rescue. But finally, I felt sand beneath my feet, and we staggered out of the clutching water and collapsed on the warm, welcoming sand.


Less than a year later we were back in the water. This time we it was in western Nepal. While visiting Pokhara we decided to rent a dugout canoe and paddle around Lake Phewa. The green hills surrounding the lake stair-stepped higher and higher, transitioning first to terraced rice paddies, then more serious mountains, and ultimately, in the distance, to the snow-covered Himalayas. It was as idyllic as the Thai beach, though in a quite different way.

In the middle of the vast lake we bobbed in the sun-sparkled water. Stowing the paddles on the rough bottom of the boat, we snapped endless photographs. Then, after taking a grand Himalayan panorama, I put my camera down next to the paddles, laid back against the stern, and closed my eyes. In the bow, Phyllis did likewise. I might have dozed a bit, but was tugged back to consciousness by an insistent breeze that hadn’t been there before. When I opened my eyes, I saw dark clouds assembling above the mountains. “Look, Phyllis,” I said, casually, pointing to the horizon, “I wonder if it’s going to rain.” She said it might be prudent to head back. I agreed. We began to paddle toward the dock, which was barely visible in the distance. The massive canoe didn’t move very fast.

The breeze became even more assertive, and the sky notably darkened. Then the air began to cool. As we paddled faster, the first drops of rain tickled my face. We were still a long way from shore. A black sheet formed overhead, and soon it was raining hard. Then extremely hard. I grabbed my camera and tried to shield it on my lap, but my jeans were soon soaked. Anyway, with my increasingly frantic paddling the camera ended up back in the bottom of the boat. The wind and rain were now heading directly toward us, indignantly slapping us in the face. Progress toward the distant dock slowed further.

I noticed that rain was beginning to gather in the bottom of the boat, sloshing back and forth against my camera. I tried to grab it, but soon concluded that getting to shore had a higher priority than keeping the camera dry, which anyway seemed an impossible task. The accumulation of water in the canoe made it sit lower in the lake, so I had to adjust my paddling stroke. Then the wind really picked up, and idyllic Lake Phewa began to look ominously like the ocean—there were actually waves, even some with whitecaps. As those waves slapped against the side of the boat. some sloshed over the gunwales. Now my camera began floating forward and backward along the floor of the canoe, as if it were doing laps in a pool, and the canoe sank lower and lower in the water. I don’t remember all the things reeling through my mind in my panic, but no doubt Jones Beach, and certainly the undertow in the Gulf of Siam, figured prominently.

By now we were thoroughly soaked, and the chilly rain had expunged all traces of the warmth endowed to us by the now non-existent Nepalese sun. Peering out through my rain-soaked glasses, I noticed that when I could catch a glimpse of the dock it seemed slightly closer than before, which gave me a ray of hope, if not of sun. But with each crashing wave the inertial heft of the huge hollowed-out log became more and more apparent.

I desperately scanned the sky, looking for even a hint of the return of the sun, and even more hopefully, for a rainbow like the one that God had produced for Noah, promising no further mass drownings. But I saw neither. The water in the canoe was now almost up to our knees, blurring the distinction between the inside and the outside of our vessel.

However, just as I started to wonder about how our families would get the news of our watery demise, the sky brightened a little. And more importantly, the distant dock was getting notably closer. We continued to paddle, not just ourselves and the canoe, but also a bathtub’s worth of water.

As the alert reader will have surmised, we eventually made it back to the dock. The guy who owned the canoe concession was standing patiently under a sagging rain-filled awning. He shook his head as we approached, and vaguely smiled. He helped us, our drenched rucksacks, and my underwater camera out of the depths of the canoe and tied it up to the dock. It must have taken him an hour to bail it out.



So how do I process these frighteningly close calls? For instance, why was I spared when I could have so easily perished on each occasion? Well, for starters I could thank any angels I may have acquired over the years for keeping me afloat time after time. Some people who have recovered from serious illness or a bad accident believe that they were saved “for a reason.” If this were true in my case, I have no idea what that reason was; some would say I had best find out. No matter the mechanism or reason for my salvation, I should certainly take these occurrences as a sign that I ought to be more mindful of lurking dangers, particularly around water. But I wonder how many times my life has similarly hung by a thread, when I was completely oblivious of immanent catastrophe–a boulder perched on the edge of a cliff that I was hiking beneath that kept its balance, a drunk driver who managed to jerkily pull over to the side of the road just before I drove by, a mentally ill person with a knife sizing me up in a crowd before being distracted by a crying baby.

In any case, I am certainly thankful that for whatever reason, be it luck or providence, or perhaps no reason at all, I was spared each time. And I really strive to be mindful of all the riches and joys of my post-near drownings life that I’ve been so privileged to experience.

Would a permanent sunset be just as beautiful?

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Probably to avoid doing homework, during my freshman year of college my roommate and I commonly stayed up half the night in earnest but otiose discussions. One that I particularly remember was a heated debate about whether a permanent sunset would be as beautiful as a transient one. I know that I passionately argued my position, though I can’t recall which side I took. Of course it really didn’t matter—the debate itself was the point.

After we’d pretty much exhausted that topic at about four in the morning, I still wasn’t ready to quit. So in my usual provocative style I tried to further wind up my roommate by asking him why he thought that a sunset was beautiful anyway? Why couldn’t it be seen as an ugly, oozing orange sore? What precisely made it beautiful, and who decided? That kept us busy until the sun came up. Fortunately at that point we were both so tired that we didn’t initiate a similar discussion about the beauty of sunrises; we just went to sleep.

I think of the sunset debate just now because for the first time in at least ten years our orchid, a white phalaenopsis, is in bloom. And by anyone’s standards it is beautiful indeed. The spike started growing, exhibiting tentative buds, just before we left for the UK. I was sure the show would be over by the time we returned home a month later. But joyfully, the spike had merely grown by another few inches and the tentative buds were slightly less tentative. Over the following six weeks growth continued in slo-mo. Now we’re in the midst of a glorious profusion of milky white blooms with delicate dustings of lemon and chartreuse toward their centers. Unlike many other plants, orchids seem to hold their flowers for a long time, though not quite approaching the arrested sunset of freshman year. Hmm… What if they indeed lasted forever, like plastic orchids? Would I still regard them as so beautiful? I guess my answer should depend on which side of the sunset debate I was on, but as I said, I can’t recall.

In contrast to the long-blooming phalaenopsis, there’s the Amorphophallus titanum, native to Sumatra. It’s more commonly known as the “corpse plant” because the flower, that blooms only once every 7 to 10 years, emits a ghastly odor. (Given the smell, its infrequent blooming is probably a good thing!) Very strangely, despite the rarity of flowering, the huge blossom (it grows to a preposterous ten feet) lasts a mere 12 hours before it wilts. I suppose whoever took the side of the beauty of transience in the sunset debate would have to argue that the bloom must be extremely beautiful, no matter how bad it smelled.

It occurs to me that the transient-permanent debate could be brought to bear on human life. That is, would life be just as beautiful if we were immortal? There’s an extensive collection of stories and legends describing someone who, through a granted wish or fancy science or striking a deal with the devil, becomes immortal. Certainly sounds like a great option. But, according to virtually all these stories, as the years-or centuries–go by it becomes clear that the immortal one is not a happy camper. They have no sense of urgency, no impetus to accomplish anything, and just sort of hang around, decade after decade. And why not–they have all the time in the world. Maybe such a life would indeed be ultimately empty and undesirable, but my suspicion has always been that such stories are told mainly as a rationalization, to comfort the reader about the inevitability of death.

So given that I was quite happy to take either side in a freshman debate about transience and beauty, how do I really feel about whether an immortal life could be a happy one? Well, I don’t know. I can see how a perpetual sunset might become a bit stale. On the other hand, mere hours of enjoyment of the flowering Amorphophallus titanum, even if the blossom were incredibly beautiful and didn’t stink, would be too brief to be really satisfying. So maybe our orchid is a good compromise—it doesn’t last a boring forever, but hangs around long enough so that we can really drink in its beauty. Perhaps we evolved–or were designed–to last 80 or 90 years as the perfect compromise between an endless sunset and the corpse plant’s brief blossom.