Choose Life

A friend, a high school teacher, recently told me about a bad week in his school.  A sophomore girl committed suicide.  Whatever reasons she may have had seemed inadequate to her friends and family who were left behind to pick up the pieces.  The teachers were depressed, the kids were frazzled and confused.

I remembered a kid named Mark, the first person I knew to attempt suicide.  At the age fourteen, despondent over the breakup from his first girlfriend, he started a car in a closed garage and sat behind the wheel, waiting for the end.  Fortunately, someone came along, opened the door, shut off the car, and got help.  For a few months, he disappeared from school.  I never found out what he had been thinking or feeling.  To me what he did remained a curiosity.

A few years later, midway through my first year as a neurosurgery resident I got a stat call to the emergency room to take care of the victim of a motorcycle accident.  By this time, I was already inured to trauma.  Tragedies happened every week, and the victims were often complicit in their demise.  The car accident victims had often been drinking; the motorcycle riders rarely wore helmets.  And most fatalities were well over the speed limit as they approached their final crash.

So I wasn’t surprised to find a twenty-one-year-old man with a gut full of cheap wine and a head split open by a telephone pole.  As I worked alongside the rest of the ER crew trying to save his life, more details of the accident flowed in.  He had hit the pole at the bottom of the hill at a T-intersection in West Haven.  Every intern and resident knew the intersection because it was on the route to the VA hospital where all of us took some of our rotations.

I tried to imagine how the motorcycle could get up to a high speed and miss everything soft to hit that pole, and started wondering if this was truly an accident.  Then one of the nurses looked at the patient’s name and said the story seemed familiar.  She pulled the records and found that his brother had hit the same pole with his motorcycle on the same day two years earlier.

Little doubt remained.  This was no accident.

I have a brother who is a year older than me.  We both rode motorcycles.  Since I knew the corner and the pole, had a brother, and rode a motorcycle, I couldn’t help but envision the accident, and try to understand why he had made the decision he did.  I couldn’t.  So I worked hard with the rest of the team to save his life so he could have a second chance like my friend Mark.  But he died within twenty-four hours, and I was left to wonder.

I didn’t understand.  Because up until then, I had never experienced true despair. 

Then, a few years later, in the months and years following my wife and oldest son’s cancer diagnoses, I faced the certainty of mortality for the first time–not as an idea, but as a gut-true reality.  Every one I loved would die, maybe soon, maybe years later, but their death and my death was certain.  Any accomplishments and experiences of ours were temporary and nebulous.  Existence seemed meaningless.  I began to wonder not why people committed suicide, but why people didn’t.  When I came up against the reality of death and the inevitability of chaos, I found it impossible to turn away.  Only ties of love to my family and my duties to my patients kept me from complete despair.

Then, one Good Friday, I sat in my back yard and smoked a cigarette (a little suicide, I called it) and observed that this was the day that even the church recognized death as inevitable.  Because the only thing certain in life are death and taxes.  Then I asked myself what other things were certain, in other words, what composed reality.

I came up with time and space and matter.  The first two were infinite, the last is not currently comprehensible, our theories of physics taking us into smaller and smaller particles or waves all behaving under the odd rules of quantum theory, and the more recent the untestable hypothesis of string theory.  And all three, time–space–matter, are interchangeable by Einstein’s equation.  I was overwhelmed by the vastness and complexity of the universe and my tiny part in it.

Then the thought came to me (I like to think of this as a vision from God) that all of this incomprehensible but orderly universe was a manifestation of the mind of God.  And though my part is small, I am a thought in the mind of God.  I am created, I am part of the magnificent whole, I am not forgotten.

After Jesus got baptized and spent forty days being tempted in the wilderness, he moved to Capernaum and started preaching His primary message, the one subsequently referred to as “The Good News.”  Crowds gathered to hear this message which is summarized as: Repent, for the kingdom of heaven has come near. (Matt. 4:17, NIV)

When I read this I thought repent meant to stop sinning, so the passage seemed to say stop sinning or you’ll be punished, a message that is obvious and what religious people and parents have preached to the rest of us since before the beginning of history.  I couldn’t understand why this was either “good” or “news.”

But repent means something much simpler that makes the passage much more complicated (and surprising).  It means turn away.

But turning away from the reality of chaos, pain and death is difficult.  That reality is so overwhelming that it seems there is no other choice but to accept the inevitability of darkness.

But there is a separate reality, just as real, that involves order, healing and life.  This is the kingdom of heaven.

The Good News is that you can turn away from chaos, pain and death–the kingdom of darkness–and choose to believe in the kingdom of heaven–the kingdom of light and life.  It’s right here, right before your eyes, an arm’s length away.  Just turn around.  You can choose life.

Big Man Down and the Procession of Life

There was a man in New Haven known for his size, his vast appetite for food and drink, his violence, and he feared not man nor God.  He stood six-foot-six and weighed an estimated 400 pounds.

One night he angered his girlfriend.  She revved his car, a sizable 1970’s style sedan, and threatened to run him down on Howard Avenue.  He stood in the middle of the street and dared her to do it.  She made one pass and swerved at the last minute narrowly missing him.  She turned the car around, and he laughed, daring her to try again.  This time she didn’t swerve and she didn’t miss.  After the impact he was dragged another full city block before falling free in front of the ER entrance at Yale-New Haven Hospital.  An ambulance still had to be called because none of the hospital personnel who rushed out could lift his massive frame onto a hospital gurney.

Once in the emergency room, he proved equally difficult to evaluate.  He was too large for the CT scanner, and X-Rays penetrated his thick flesh poorly leaving blurry images and much guessing about internal injuries. Cervical spine x-rays had been able to penetrate only as low as C-3.  Normally all seven cervical vertebrae can be seen on x-ray, or in very large individuals perhaps only five or six, but in his case the lower four vertebrae were completely obscured by his massive shoulders.

One thing that was clear: he was paralyzed from the waist down from a fracture at the lower thoracic/upper lumbar spine.  Surgery was scheduled for the following day.

The operation was long and difficult with much blood loss. Whether it was successful or not became quickly irrelevant when he woke in the recovery room now paralyzed from the neck  down.  Further efforts at x-rays of his cervical spine determined that he had a fracture at C-4 and now a new cervical spinal cord injury.  Unable to breathe adequately, he was left on the respirator, an endotracheal tube placed during surgery remaining as his airway.

Up until this point I had little involvement in his care.  My primary responsibilities were in the research labs, and I covered the clinical patients only one night per week and one weekend per month.  But when Saturday rolled around, he was still intubated, and dependent on the respirator in the Neuro ICU, and I was the sole resident on-call for the weekend.

On Saturday morning rounds, the staff neurosurgeon, also covering for the weekend, told me the patient needed a tracheostomy and we should do it that day.  I had done enough tracheostomies–the procedure itself didn’t intimidate me–but this case frightened me.  I argued that the procedure would be difficult, and ENT consult should be considered, and it wasn’t an emergency.  The procedure could be done the following week when plenty of back-up help was available, perhaps even in the OR where adequate light and and equipment would be available.

The surgeon would have none of it.  Back then, neurosurgeons did tracheostomies on their own patients.  To consult ENT or another surgical service would a sign of weakness, and neurosurgeons never admit to weakness.  Why mess up a busy operating room schedule with an annoying procedure like a tracheostomy that could be done off hours in the ICU?

I argued my other responsibilities to the seventy-odd patients under my care.  He simply said to call him as soon as my routine work was done.

My routine work was not done until six PM.  I called the staff physician, hoping the late hour would put him off, but he remained undeterred.  He showed up a the NICU at eight PM determined to help.

A trachea is normally immediately beneath the surface of the skin at the throat, often less than a quarter inch from the surface.  In this patient the trachea was a good four inches deep in the neck.  The standard retractors and indeed the tracheostomy tubes themselves were too small.  The light was poor, and we struggled for two hours over a procedure that normally takes thirty minutes.

At last he had an airway in the trachea.  I sutured it in place and tied it around his neck for good measure.  The staff physician went home, and after fielding the calls and tasks that had accumulated during the time I was involved in the procedure, I went to bed.

At two AM, the phone rang.  The patient had coughed out his airway and was now in respiratory distress.  I ran to the NICU and tried to replace the tube, but after the recent procedure the path from the skin to the trachea is no longer easy.  All the recently dissected tissue planes provide false passageways even in normal individuals.

I struggled to find the trachea and a tube large enough to reach it, but working alone and with poor light, I was frustrated and unsuccessful.  His breathing became more and more labored.  I called the resuscitation team, but they too were unable to re-intube him in the conventional manner.  His heart rate slowed and he lost consciousness as I struggled to find his trachea.

Then he died.

It’s a great thing to do a good tracheostomy.  Lives are saved in hospitals (and sometimes restaurants) frequently.  But sometimes it doesn’t work.  It’s been over forty years.  I stood between the big man and his death, and I failed.

I didn’t kill him exactly.  His girlfriend in her fury bore the legal responsibility.  Alcohol intoxication, lust, anger, and hubris (standing in front of a speeding car twice!) had a lot to do with it.  And I was only the last person in a line of medical providers who failed to stand between him and the hereafter, and between the girlfriend and a murder charge.

There is a poignant story in the Luke 7:11-16 in which Jesus and his followers are entering the town of Nain just as a funeral procession meets them on the road.  The dead man is the only son of a widow. Jesus, against all common sense and against the Jewish tradition that to touch the dead that renders one ritually unclean, stops the procession, touches the body, and raises the young man to life.

It’s an easy story to slide over.  Jesus was healing people all the time; now he stepped up the game and healed a dead kid, a widow’s son no less.

And it is all of that.

But Jeff Hoy in his Words of Faith (Stopping the Procession. Words of Faith.5-11-18.Dr.Jeffrey D. Hoy © 2018 draws attention to the metaphor.  Normal life in the world is a procession toward death.  It’s where we’re all headed.  We fear it, we avoid thinking about it–we don’t touch it.

We handle our despair in different ways.  Some of us party–eat, drink and be merry, for tomorrow we die.  Some of us exercise, diet, take vitamins, avoid germs, obsess about safety, putting off for today the looming disaster of our end.  Some of us become religious, earning our place in heaven so we don’t have to worry about our end on earth.

Some of us, for example, me, learn about medicine and how to cheat disease and death, and, as we win daily battles, we hold onto the illusion that we will win the war.  But sooner or later, we meet the procession of death.

Backed by 2500 years of medical tradition, a 500 year history of surgery, an armamentarium of drugs and surgical procedures, my medical procession is powerful against impending death.  I put out my hand, I touch the corpse, the boy rises, the procession stops.

Sometimes.  This time I put up my hand, I touched the corpse, and the procession rolled over me.

Because I’m not Jesus.

In reality, the death procession never stops.  The medical procession can only slow it down.  The death procession only stops when the people weeping and wailing and those carrying the coffin stop believing in chaos and death and start believing in purpose and life.  Believe you are a child of God, believe you are loved, believe you are made for a purpose, believe that when your body dies you will exist on a new plane of experience–even when all that belief is beyond your intellect and your sensory experience.  Then the procession stops.  Then you can turn around and join the procession of life.  You can walk with Jesus.

The death of the big man with the failed tracheostomy is but one of many experiences that haunt me after forty years in medicine.  The sense of failure is pretty big when someone dies and you feel like you could have, should have, done something better to prevent that death.  It is easy to slip into despair camouflaged as a supposed “realism,” which is only cynicism after all.  One learns to go on, live in the moment, do the good one can do, and let the rest go.  It’s possible to live like that.

But if I want to live with joy instead of despair, I have to turn around and join the procession of life.  I have to walk with Jesus.

After the Seizure: Day 5



I’m home, out of the hospital, and ready to get better. I have to get better. If I don’t all of the plans for my life and our marriage will go out the window.

I’m supposed to get used to the drugs and start feeling less sleepy. Things are supposed to get better. But I remember having cancer, how nothing was ever the same again. I had stared death in the face, lost my hair and a third of my body weight. Then I’d prepared to die bravely.

But now I had no idea of how to coexist with the drugs that suppressed not only my epilepsy, but also my awareness and my emotional affect. I had no idea of how to live with impairment.

The green couch, though splattered with stains from feeding babies, served as a good place to rest while I stared out into space. My two-year-old son and infant daughter hovered in the background, probably making a mess. I’d just called my friend to switch on-call shifts for the last requirement of my CPE, chaplain-training class. In a little while my wife would be home and I would go down for a four or five hour afternoon nap. In one day I’d gone from being a highly autonomous individual with serious responsibilities to being a man who couldn’t drive, couldn’t think straight and couldn’t be trusted to watch his children for more than an hour or two.

My circumstances changed in an instant, but my plans, my identity and my values changed at glacial speed. Throughout CPE training I’d seen myself as one of the smartest and best educated of the students. I’d been selected from over more than twenty people for the single spot in the residency program. My strengths were an ability to listen and “put the dots together.” My classmates described my ability to “put the dots together” as my propensity to hear about an experience ten or fifteen years ago and connect it to something one of my classmates or patients was doing or saying in the present day. I could also write very detailed, in-depth papers about my conversations with patients. My weakness lay in being emotive; even before the drugs I had trouble sharing the emotions of grief or pain with my patients, their families or my fellow students.

It was very important to me to be perceived as being one of the smartest and best educated. I did not want to re-experience the childhood taunts I had suffered as I struggled to overcome dyslexia. In adulthood I wanted to find a profession where my skills and intellect were valued. I’d already been a construction worker, a mailman, a warehouse worker and a teacher. I’d gone to seminary and finished with good grades and good recommendations because I was sure that God loved me and would find a place for me to love Him, serve Him, and maybe even let me take home a paycheck. The chaplaincy seemed like a good fit.

Now, sitting on the green couch in my living room, feeling numb and dumb and tired, I had no idea of how I could continue.

I still struggle to believe it, even now, but much of my suffering came from  illusions and deceptions that I’d constructed about myself. I’d struggled with learning how to read and get through school, so it became very important for me to think of myself as smart and have others perceive me as smart. I’d struggled to find a place in the adult world, so it became very important to think of myself as very qualified as a chaplain or minister, and to provide valuable help to others.

I’d suffered pain, disappointment and frustration. I had to believe that God would use me to alleviate those conditions in others. We always try to give away to others what we want the most for ourselves; it is to us our most precious gift.

What I didn’t know then, and continue to learn now, is that my picture of myself as a smart, super-qualified, valuable helper was going to have to die so that God could rebuild me into His humble servant.

Mustard Seed Medicine


Patient Number One was seven years-old and alone.  The numbered tickets had been distributed in advance of the clinic day to two hundred patients in this town in southern Haiti.  The tickets were a tool to avoid a riot at the door to the church/school, because there had been no doctor in town for years and the needs were great.  Pews and school desks had been rearranged to form a registration area, an area to measure height, weight and visual acuity, a makeshift pharmacy, and four examination stations with providers and interpreters.

Number One wended his way through the matrix and arrived at a chair in front of me, a skinny black kid in a sky-blue shirt and navy blue slacks–his school clothes.  He spoke only Creole; I spoke only English.  Benson, a Haitian interpreter, sat next to me.

I was filled with a kind of altruistic excitement.  I was prepared; I had studied the diseases of Haiti that were unfamiliar to me–malaria, typhoid, tuberculosis, AIDS, cholera.  I had knowledge, skills, and tools to do some good.  I was ready to alleviate pain and suffering.

Number One was under-sized for his age and underweight for his height, at least according to the American height and weight charts we had brought with us.  But he looked healthy.  I asked if there was anything special he was concerned about.

Benson interpreted his reply, “Sometimes he doesn’t feel like eating.”

I asked a string of questions about nausea or vomiting or abdominal pain, then examined him, looking into his ears and his eyes, gently touching his neck and his abdomen, and then listening through the stethoscope, his breath and heartbeats sounding so close.

A pretty healthy kid, I thought to myself.  I wrote a prescription for our pharmacy to give him an anti-parasite medicine and a supply of vitamins.  As a last question, I asked how long it had been since he didn’t feel like eating.

A minute or two passed as Benson and Number One exchanged words several times.  Then Benson turned to me and said with a voice and expression that indicated the story was a common one, “His parents had a very successful little grocery store here.  Their neighbors thought they should share more of their good fortune, and when they didn’t, the neighbors killed them.”

Benson shrugged.  Number One continued to fix his eyes on me with no change of expression.

And I’m giving this kid vitamin pills.

I get a patient like Number One and I am smacked out of my complacent belief that I am making a difference simply because I am practicing medicine.  I wonder if all the children got their vitamins and grew to be strong and bright, would they still kill each other?  They’ve been doing it in Haiti for a couple of hundred years; there’s no reason to think it will change now.  Why bother with the vitamin pills?

I am tempted to despair, to go home and take care of my own, and let the world take care of itself or go to hell, whatever it chooses to do.  But now I’ve heard the boy’s heartbeat, I’ve listened to him breathe, I’ve looked into his deep brown eyes, and he’s no longer an abstraction, no longer Number One but a real boy; he’s flesh and he’s blood and he’s somehow connected to me.

“Jesus told them another parable: “The Kingdom of God is like a mustard seed, which a man planted in his field.  Though it is the smallest of all seeds, yet when it grows, it is the largest of garden plants and becomes a tree, so that the birds come and nest in its branches.” (Matt. 13:31-32. NIV)

Everyone holds a mustard seed.  It’s that thought that maybe you should make a phone call, make a visit, or make some cookies for someone who needs to hear that someone else cares.  Maybe you need to enroll in that course, the one that has no practical value but gives you skills the Kingdom needs.  Maybe you have the opportunity to change from the job that pays more to the job that cares more.  It’s all a question of how we handle our mustard seed.  Do we brush it off and let it float away in the wind, because it’s a little thing and doesn’t really matter?  Or do we plant it and water it and wait years for it to grow?

So I give him the vitamins and I give him the anti-parasite medicine, and I see the next patient.  And the one after that, and the one after that.  And keep going all day long.  Because I believe that we are all children of God and we should care for each other, one mustard seed at a time.  And I find that belief easier than despair.