Category: reflections

Derecho: Straight Line to Iowa

As the yard waste collection worker approached our small, neat bundles of small tree branches tied up with twine, he just shook his head. He and his partner picked them up by the twine and tossed them in the truck. For a moment, I was afraid they would refuse to collect these relatively tiny remnants of the most devastating inland hurricane to smash Iowa in over a decade. It’s known as a derecho, which is Spanish for “straight line.” It refers to the straight-line winds which were clocked at well over 100 miles per hour on August 10, 2020.

The governor has requested federal aid. People died, many were injured, left homeless, and without power or means of communication for days which is extending to over a week now. Crops were ruined.

Trees and homes were ripped apart and scattered over the land. We knew when it ended that the cleanup job would be unimaginably hard. So that made the requirement to make tidy bundles of twigs festooned with twine all the more surreal. We and neighbors stacked the tree debris as neatly as we could in separate piles, never doubting that the city would understand that we were caught short. We just didn’t have time to stock up on twine in anticipation of a derecho.

The piles were left and so we thought, that’s understandable. The city was caught short as well. Then we heard that the reason they were left was that the bundles were not gift-wrapped.

So, we wrapped them up. It turns out it made the difference between allowing the piles of twigs to sit there and rot the grass underneath—or getting them collected.

It reminds me of a line from the movie Men in Black 2 in which the neurolyzed Agent K as the punctilious postmaster gently scolds a customer for failing to submit a “properly wrapped” parcel— “Brown paper and triple twist twine are the preferred media; thank you for your time.”

On August 10, 2020, the wind screamed like I’ve never heard it before. I made several trips to the basement in anticipation of a tornado, but we got something just as terrifying—the derecho. The power was off for a little over a couple of days. It took about a week before I got cell phone and internet access back. Thankfully, we were not injured and we had a roof over our heads.

Later in the week, we saw a long line of cars outside of a local hardware store—people waiting to buy $700 generators. Later that same afternoon, the power came back on. They’ll be ready next time.

Right after the storm stopped, I went out to get our mail (yes, the post person was out, believe it or not!). My jaw dropped when I noticed the fallen Maple tree in our front yard. We were lucky it didn’t fall on our house. I didn’t have a chainsaw. I cut it up with a 20-inch handsaw. My wife and I trimmed and stacked the remnants in our driveway. I didn’t think of triple twist twine at the time.

The last derecho I remember in Iowa was the Corn Belt derecho in 1998. I was an Assistant Professor in the University of Iowa Hospitals & Clinics Psychiatry Department. I remember pulling a tree branch off the roof of the house my wife and I had recently purchased. The streets were full of downed trees and in some cases were impassable. One of my colleagues called it a straight-line windstorm, the first time I’d ever heard of such a thing. I hoped I would never see such devastation again.

On the other hand, Iowans will make a straight-line comeback.

Bent Out of Shape

It never occurred to me that my smartphone (an iPhone 6) might be damaged. I thought the Otterbox case was just getting old and stretching out of shape. A guy asked me if my phone was bent and I told him that it was just the cover getting stretched. He looked at me with a doubtful expression.

Looking back on it, I suspect the real problem had been growing (literally) for at least several months. I noticed that the case was starting to crack, so a few days ago, I simply removed it.

The screen of my smartphone had separated along the sides by several millimeters—enough to peek inside and see a long rectangular black shape. That turned out to be the very swollen battery. I had no idea the battery was rectangular and took up much of the middle space of the inside of the phone.

In fact, it was rapidly taking up more space by the day. The long sides of the touchscreen were completely separated from the back and it was secured only by the top and bottom ends—barely. The phone worked fine, though.

I first bought the phone five years ago, at the urging of my residents. I had only just got a flip phone several years before. By the way, I just retired from my position as a consulting psychiatrist at an academic medical center.

I remember the day I got the smartphone in the store. I bought the Otterback case and clip so I could carry it on my belt and, uncharacteristically had filled out the warranty card for both. The phone has not been out of the case since then.

One of the residents created a picture of me and a smartphone in a setting from the movie 2001: A Space Odyssey. The point was my awkwardness with modern technology. Little did I know that the black monolith would eventually come to signify so much more later—in the form of a long black battery that would go bad, eventually warp my phone and possibly even explode. It reminds me of the bowling alley scene in Men in Black 3 in which young Agent K holds a large phone to his ear while Agent J warns “Don’t put that up to your head!”

Anyway, I took it to a cell phone store, thinking I would have to shell out hundreds of dollars for a new phone. I must have made a singular impression on the salesman. Because of the pandemic, he was wearing a mask and I was wearing a shield so he could see my facial expressions as well as my white hair as I moaned and groaned about the high cost of cell phone plans and phones. Maybe out of sympathy, but probably also partly because of a desire to get me out of the store away from listening customers, he recommended CPR. That’s not cardiopulmonary resuscitation. It’s short for Cell Phone Repair and their little shop was right around the corner within walking distance.

I wasted no time and the guys there were very helpful, quickly diagnosed the problem as a swollen black monolith battery, donned Explosive Ordnance Disposal suits, and applied the fix. They replaced the bad battery, squeezed my phone back together and it took less than an hour. They charged me $60, which was a far cry better than the $600 I had initially thought I was going to have to give up.

They also urged me to claim the warranty on my Otterbox equipment instead of charging me $50 for what they carry in their store. They assured me that Otterbox would likely honor the warranty. In fact, Otterbox charged shipping only and tracking information indicates delivery will be tomorrow.

I’m nearly bent back into shape.

ADDENDUM : Actually, Otterbox even cancelled the shipping charge. Delivered, assembled, and back on my belt before 1PM 8/7/2020. I definitely recommend Cell Phone Repair.

Homesickness After Retirement

It has been only about 3 weeks since I retired and—I am not living the dream yet. I’ve always been a worrywart and I find that I’m worrying about a lot of things: money, things to do, the future. If you just heard me say that I’m loving retirement, then you’d probably guess I’m not telling you the truth.

That was the point of starting the blog in the first place, to tell the truth about what the journey to retirement and finally getting there is really like for me.

My guess is that I’m in the early stages and the angst will probably pass. On the other hand, I have more than once considered going back to work. I could talk myself into it pretty easily. On the other hand, the pandemic and other upheavals have changed the environment where I used to work as a general hospital psychiatric consultant.

It’s not the same world. And I’m evolving too. Right now, I feel lost. It occurs to me this is a lot like homesickness.

Ironically, that’s pretty much how I felt when my wife and I first moved to Iowa City over 30 years ago so I could start medical school. Even then, I felt out of place. I’d been the proverbial older student all through undergraduate years and never felt like I quite fit in.

I nearly quit medical school in the second year. It was a struggle to stick it out. I wanted to return to what I had been so comfortable doing in the past. I worked for a consulting engineer firm as a survey crew tech and drafter. I got really comfortable in the culture, which is why I started off majoring in engineering. I let go of that pretty quickly. I got homesick. But I didn’t go back.

I came down with homesickness a couple more times after I started working as a psychiatric consultant in an academic center. Twice I left for private practice because I thought I would like working in “the real world” of medicine. I paid dearly for that. At those times, I went back home.

This anxiety, tension, and longing for the familiar now that I’m retired is a lot like homesickness. I guess part of the cure is time.

New Mailbox

Well, it has been almost two weeks since my last day of work. That was called my “termination date,” which strikes me as an ominous term. We now have a new mailbox because we moved in June. The mailbox is a sign of moving away from the old way of life and moving toward a new life as well as a new home. A new beginning follows the termination.

There’s a lot of stuff coming to the new mailbox on the curb outside. We’re getting a mix of new things in the outer mailbox—the same is happening in my inner mailbox. Sorting the mail in both is definitely a challenge right now.

I’m still working out how things will be in the new home, and in the new life stage. I’m wrestling with a lot of new goals, both practical in the outer world and psychological in the inner world.

There is good news in the mailbox, and some not so good. Retiring meant moving away from a daily work schedule which kept me occupied and focused on being a specific kind of person for a long time. I was a psychiatric consultant in an academic medical center. I played a specific role, had specific tasks and challenges which brought specific rewards and frustrations.

That mailbox was always crammed full of stuff and, while a lot of it was good news, some of it was junk mail. I was often rewarded for my work as a consultant and as a teacher. On the other hand, my focus was frequently on work, which left an imbalance elsewhere in my life. Work itself was often full of obstacles.

Now, the new mailbox is full of surprises. Many of them remind me I have a new skillset I need to develop as a retiree. The junk mail consists of things like anxiety about the change in my identity (fireman to retiree), boredom, and frustration over the need to learn how to fix a loose faucet handle instead of catatonia.

There will always be psychological junk mail. The thing about that kind of junk mail is that I can’t just toss it in the garbage. In the last month, I’ve lapsed in my mindfulness practice because of all the tasks of moving and making the transition not just to another home—but to a new identity.

I’ll be working on getting back to mindfulness, although I remember the message sent by the UIHC director of the Mindfulness Based Stress Reduction (MBSR). It was prefaced by a quote:

“I am thankful that thus far today I have not had any unkind thoughts or said any harsh words or done anything I regret. However, I need to get out of bed and so things may become more difficult.”

Sylvia Boorstein, Mindfulness teacher and author.

My mindfulness mat is rolled up in a room downstairs. My mind is also rolled up—tight around thoughts that are impossible to avoid or deny. Another quote from Sylvia about self-talk:

“Sweetheart, you are in pain. Relax, take a breath. Let’s pay attention to what is happening; then we’ll figure out what to do.”

Sylvia Boorstein, Mindfulness teacher and author.

The Firefighter Retires

I’m writing this post today because this firefighter retires tomorrow—and I’ll probably be very busy and too weary at the end of my last day on the psychiatry consult service to write. In fact, I’ve been too busy and tired to post for the last several weeks because we’ve been in the process of moving. Does that ever really end?

I can tell that what will really end at around 5:00 PM tomorrow is my career as a general hospital psychiatric consultant. It has been a long time coming. I’ve been on a 3-year phased retirement contract and going back and forth between wishing for it to end sooner and being scared to death as the final day approaches.

There are those last things: handing in the keys, the white coats, the parking hang tag and the like. I’ve cleaned out my office and somebody already wants it. I’m surprised that I’m just the tiniest bit territorial about the place, which is strange. I never spent much time in it because I was always chasing consults around the hospital.

I’ve never retired before. I wonder what the rules are. I still don’t know how to answer everybody’s question: “What are you going to do?”

There is the “new” house. It’s actually an older home, which fits my status as an older person, I guess.

The floors squeak and creak, a lot like my joints. There are little jobs and slightly bigger jobs to do for which I’m painfully aware of the need to develop a whole new skill set—or at least relearn them.

It’s about new noises and new animals. A fox trots across our yard occasionally. I’m used to deer, but we’ve never spotted a fox on our lawn. It has a rusty coat streaked with a lot of gray. It looks old. But it’s a good hunter and more than once we’ve seen it carrying a big mouthful of something that might have put up a pretty good fight.

I’m touched by the well-wishers, and those who say thanks for the memories. Just about every day of the last week, I’ve seen and done something at the hospital which makes me say, “That is what I’ll miss.”

One day to go.

Kudos to the Goodenough Psychiatrist for Blog Post “The Perfect Balance”

I almost never write more than one post a day, but I’m pretty impressed with the blog post “The Perfect Balance” by The Goodenough Psychiatrist. It was very thought-provoking and the Stuart Ablon Ted Talk on Collaborative Problem Solving was refreshing.

A little over 3 ½ minutes into the video, Ablon says something interesting about conventional wisdom which helps cast doubt on blindly trusting it. When he remarks that conventional wisdom commonly fosters misconceptions including teaching that the earth was flat, it reminded me of a scene from Men in Black (I confess, one of my favorite movies). Agent K says, “A person is smart. People are dumb, panicky dangerous animals and you know it. Fifteen hundred years ago everybody knew the Earth was the center of the universe. Five hundred years ago, everybody knew the Earth was flat, and fifteen minutes ago, you knew that people were alone on this planet. Imagine what you’ll know tomorrow.”

His remarks highlight the challenge to those who break with conventional wisdom, which can sometimes be isolation.

It takes courage.

Please Take Your Seat

I brought my camp stool home from my office at the hospital yesterday. For the past several years and up until the time of the COVID-19 pandemic, I used it while interviewing hospitalized patients as part of my job as a consultation-liaison psychiatrist in the general hospital. I stopped only when I wondered whether carrying around an object which could be contaminated with the virus was a safe thing to do.

A colleague lent me the little chair when he and his colleagues on the Palliative Care Medicine consultation service started using them. I asked him whether he wanted it back and he graciously said I could take it with me now that I’m retiring—and use it as a camp stool (in a way, saying “Please take your seat”). For many years prior to getting the stool, I had been finding a chair or sending my trainees to find one for me. I felt more comfortable sitting eye to eye with patients and I got the impression that my patients appreciated that as well.

I got a lot of positive feedback from patients, family members, and other hospital staff about the little chair. I think it helped break the ice with patients and was a great opener, especially if they felt well enough to express a sense of humor— “Hey, doc; you don’t need nunchucks; I promise I’ll be good!”

There are a few papers in the medical literature supporting the usefulness of sitting with patients. Most authors assert that it helps build rapport and increases the patients’ perception of how interested their physicians or other health care clinicians are in their welfare (see the reference list below).

Once, when my original little chair broke beneath me during an evaluation for catatonia in one patient, the stool abruptly became a novel catatonia assessment tool.

The patient was mute but there was little evidence otherwise for catatonia, one of the chief features of which is the inability to react to any stimulus in the environment. I was seated on the chair explaining in detail the intravenous lorazepam challenge test for catatonia (which often interrupts the episode of muteness and immobility).

I was sitting in front of the patient but facing the family and the consult service trainees while expatiating on the topic. As I was droning on, I heard a sudden pop—and I fell flat on my fundament as the chair collapsed beneath me.

My audience exploded in loud laughter, and pointed at the patient. When I turned to look at him, he was convulsed with silent mirth.

I considered this a negative test for catatonia in this case, though impractical for regular use.

My colleague gave me a replacement camp stool, more securely built. However, he mentioned he might give up using his as a result of my accident which, incidentally, befell (rimshot) another doctor on his team. I’m not sure whether I’ll use the little chair. If I sit on it too long, my legs go numb. I think that’s about 10-15 minutes, about the length of time mentioned in one of the studies below. It didn’t seem to influence the positive perception of the visit—but it did make me walk funny.

I probably spend about the same time with patients now that I don’t use the little chair. But I don’t feel right about it. I’m always reminded of what Hackett said:

“As a matter of courtesy, I sit down when interviewing or visiting patients. Long accustomed to the ritual of making rounds, many physicians remain standing as a matter of course. Standing, physicians remind me of missiles about to be launched, poised to depart. Even if that is not necessarily true, they look the part. Patients sense this and it limits conversation. In addition, when standing, the physician necessarily looks down on the patient. This disparity in height is apt to encourage the attribution of arrogance. Looking down at a patient who is prone emphasizes the dependency of the position. Sitting at the bedside equalizes station. Sitting with a patient need not take longer than standing with him.”—Thomas Hackett, in MGH handbook of general hospital psychiatry, 1978.

References:

Johnson RL, Sadosty AT, Weaver AL, Goyal DG. To sit or not to sit?. Ann Emerg Med. 2008;51(2):188‐193.e1932. doi:10.1016/j.annemergmed.2007.04.024

Swayden KJ, Anderson KK, Connelly LM, Moran JS, McMahon JK, Arnold PM. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ Couns. 2012;86(2):166‐171. doi:10.1016/j.pec.2011.05.024

Strasser F, Palmer JL, Willey J, et al. Impact of physician sitting versus standing during inpatient oncology consultations: patients’ preference and perception of compassion and duration. A randomized controlled trial. J Pain Symptom Manage. 2005;29(5):489‐497. doi:10.1016/j.jpainsymman.2004.08.011

Orloski CJ, Tabakin ER, Shofer FS, Myers JS, Mills AM. Grab a Seat! Nudging Providers to Sit Improves the Patient Experience in the Emergency Department. J Patient Exp. 2019;6(2):110‐116. doi:10.1177/2374373518778862

Merel SE, McKinney CM, Ufkes P, Kwan AC, White AA. Sitting at patients’ bedsides may improve patients’ perceptions of physician communication skills. J Hosp Med. 2016;11(12):865‐868. doi:10.1002/jhm.2634

Let Nature Speak

While we were out for a walk on the Terry Trueblood Trail today, for a change, my wife gave me the idea that we should just let nature speak. The frogs were in full voice. It was impressive. As we walk, we usually start off by talking a lot. We point out interesting birds and flowers and comment on all we see and hear. The further we go on the trail, the quieter we get. Pretty soon, we don’t talk much at all. We walk at a slower pace. We just listen.

Usually, after we return home, I make a video and try to match it with some kind of music. Nature has its own music, though. Today, we just let that happen.

Mother’s Day for a Robin

Happy Mother’s Day! The blog post for today is a little unusual because it’s about a “mother” robin who built a nest on April 9, 2019 and is still sitting on it as of today. It’s unusual because she’s been sitting on the nest for at least a couple of weeks now even though there have been no eggs in it. We can’t figure why she’s sitting on an empty nest.

Things got started relatively well. In fact, after building the usual sloppy nest, the mother robin laid two eggs in it. That was the largest number of eggs we ever saw. The number went down from two eggs to one to none over a couple of days or so.

“And then there were none.” I never read Agatha Christie’s book by the same name or saw the TV miniseries on which it was based several years ago. On the other hand, death played a role—a natural one—in the case of the very devoted mother robin.

The robins built their nest in an evergreen tree right below one of our windows. What was nice about that was that I never had to creep up on them, see them thunder out of the tree, mess with the branches around the nest, snap photos—and leave a scent trail for large predatory birds.

Now, speaking of predatory birds…I never saw any of them this time. I know last year I heard a heavy flapping noise (like bedsheets on a clothesline) outside of my office window and opened the blinds just in time to see a huge crow or turkey vulture take off from our front yard tree. Its beak was full of house finch nestlings. I swore I would never again engage in monitoring bird nests in that way.

This time there was only circumstantial evidence of nest robbery. My wife saw broken egg shells on the ground under the tree but it’s not clear exactly when she saw that.

But mother robin still sits on the nest. I have not been able to find any information about this behavior in nesting birds.

It’s not that birds never display odd nesting behavior. One of E.B. White’s essays, “Mr. Forbush’s Friends,” published in the Essays of E.B. White (White, E. B. (1977). Essays of E.B. White. New York [etc.: Harper and Row), describes a great number of these peculiar behaviors. One quote: “Had pair of Carolina wrens build nest in basket containing sticks of dynamite. No untoward results.”

I did wonder why our mother robin built a nest so visible from the sky. That was as bad as building a nest in a basket of dynamite. I know we have a tendency to anthropomorphize animal behavior, but I’m having trouble explaining this mother robin’s persistence in sitting on an empty nest. There are no new eggs; yet she acts as if eggs are there. Is she grieving? Is she hallucinating? How long will this go on?

Maybe some of you know what this is all about and I welcome your comments. Until then, it looks like for this robin, Mother’s Day is endless.

The Robins are Back

The robins are building their Hurrah’s nests in our back yard again. That’s about the only thing that has not changed. The COVID-19 (C-19) pandemic has changed just about everything else in our lives.

I wear a face shield now at the hospital. We’re told to wear it as much as possible, like putting on our clothes in the morning. Don’t we leave them on all day? The shield keeps you from touching your face, which is why it’s better than a face mask. However, I’ve noticed something about wearing the face shield for much of the day. Before I describe it, let me give you analogy: If you’ve ever worked detasseling corn when you were young a long time ago, you might remember what happened when you closed your eyes at night and tried to go to sleep. I saw corn fields—miles and miles of corn fields. When I opened my eyes, the vision would disappear. But as soon as I closed my eyes again, I saw the vast corn fields.

It’s crazy, but I have a similar sensory after-effect when I doff my face shield–sometimes I still feel the headband. The pressure of it is just the same as if I were still wearing it. I suppose it’s because I cinch it too tightly. But if I don’t, it slips down my brow, pushing my eyeglasses down my nose.

Another change—I’m a Consultation-Liaison (C-L) Psychiatrist, so I’m used to washing my hands in between patients in the hospital. Now, I’ve got something I’ve never had before–alligator hide patterns on the backs of my hands. They’re dry and cracked. I don’t count the number of times I wash my hands, but it’s a lot more frequent than I used to do. It’s not uncommon for health care professionals to wash hands 75-100 times a day in the C-19 era. I have to use hand cream conscientiously—something I almost never did.

I’m less comfortable being closer than several feet away from people. I tend to hug the walls and corners in stairwells, where I now encounter more people than I ever have before. I guess the message everyone hears is “Stand by me—six feet away if you please.”

I don’t shake hands anymore. The lines into the hospital sometimes lead to crowding while we wait to have our temperatures taken and answer the screening questions about whether we’ve had fever, cough, shortness of breath, etc. It’s perfunctory most of the time, because virtually always the answer is “no” and everybody is in a hurry.

I don’t carry my little camp stool with me anymore, which allowed me to sit down with patients and have face to face, eye level interaction. I’m distinctly uncomfortable standing over them because I haven’t done that in years. If there is a chair in the room, I’m hesitant to use it because, like the camp stool, I worry that it might carry C-19 virus on its surface.

I used to evaluate psychiatric patients in our emergency room by simply going there and seeing them face to face, either in their rooms or, when it was really busy (which is most of the time), in the hallways.

I just used a remote telehealth interface platform using an iPad the other day, which allows me to interview patients from my office, in order to avoid the risk of contagion. It was a little slow and awkward, and I was uncomfortable that a health care professional had to be in the emergency room to hold it up for the patient—who was covered in blood. I felt a little guilty.

I used to round with medical students and residents on our patients. We were the movable feast, a sort of MASH (Mobile Army Surgical Hospital) unit, more like Mobile Unifying Shrink Hospital (MUSH). Unifying means unifying medicine and psychiatry. The medical students are not permitted on the wards now, in order to protect them. It’s awkward rounding with only one resident at a time, although another resident can do other things like chart review and telephone relatives for collateral history. I get in the hospital earlier nowadays, and see many non-C-19 patients alone without trainees, preparing for the C-19 surge when I expect we’ll get many more consultation requests to help care for C-19 patients with delirium and depression. It’s a one-man hit-and-run psychiatry consult service and efficiency is mandatory to meet the demand.

I see patients by myself for another reason. Try as we might, C-19 positive patients will slip through the screens. Many are asymptomatic but contagious, and any test will have false negative results. The idea is to expose the least number of health care front line staff members as possible. Faculty capacity is stretched pretty thin, which is pretty much the situation everywhere. I have to choose. I’m older. I’m weeks from retirement. I’m afraid.

But robins don’t have the burden of choice. They obey their instinct every spring, just the same.