Losing, Loss and Living

Losing, Loss and Living

Jesse James will forever live in infamy.

No, not that Jesse James.  He already lives in infamy.  I mean the tight end Jesse James, number 81 for the Pittsburgh Steelers.  You know, the guy who caught the touchdown pass that finally put an end to Tom Brady’s decade-and-a-half dominance of the Steelers and cleared the way for a run to a seventh Lombardi Trophy.

At least for five minutes, he did.

Sports is weird that way, especially in the age of replay.  There was a brief alternate reality in which the Brady Burden had finally been lifted, and Ben Roethlisberger and company were the undisputed rulers of the AFC and odds-on favorites to win another Super Bowl.

Then replay official Al Riveron delivered the fatal diagnosis: James’ “catch” was dead, because it “failed to survive the ground.”  Hope was snatched away.  An entire city deflated like the footballs at Gillette Stadium, except this time Brady would gladly admit he was at fault.

An entire city deflated – like Boston watching a ball roll between Bill Buckner’s legs, Buffalo watching a field goal curve Wide Right, or Cleveland watching the seconds tick off the game clock while JR Smith does . . . something.  Or maybe just Cleveland, period.

The deflation happens because fans are invested.  They love their teams, decorate their bedrooms in the colors, wait anxiously for Friday so they can wear a team jersey to work instead of a suit and tie, and cancel family obligations so they can watch the game.  They bleed black-and-gold, orange-and-blue, purple-and-teal (Charlotte Hornets).  The team’s struggles become the fans’ struggles and their victories the fans’ victories.  When they win, especially when they win a championship, it is a moment of elation that the fans treasure forever, and the team inevitably says, “This is for you!  We did this because __________ fans are the best fans in the world!  Without your support, we never would have come this far.”

And when they lose, it is like the end of the world.  Especially when the loss comes in a pronouncement that sounds like a terminal diagnosis: The ball did not survive the ground.

Perhaps this sounds familiar to those of us who have suffered life-threatening illnesses:

The tumor markers have risen.

There is a new shadow on the scan.

Sports may feel like everything, but life is everything.  Save one life, says the Talmud, and it is as if you have saved the entire world.  But just like rooting for a sports team means investing in 30:1 odds of drunken ecstasy by signing up for 1:29 odds of ending the season in defeat, saving lives means touching death way more often than we’d like to admit.  As one of my classmates in my navy medics’ course wrote on the board one morning, “Life is the only 100% fatal disease.”

If we’re lucky, most of us are in some kind of relationships in our real lives that are every bit as passionate as the way the most dyed-in-the-wool fans feel about their teams.  Whether it’s a marriage, a lifelong friendship, our connection with our parents or our siblings or our kids, there is probably someone in our lives that we truly love – and by love I mean someone about whom we feel that when they get a cut, we bleed.  Their struggles are our struggles and their triumphs our triumphs.  And their even the possibility, the fear, that they may die is as awful to us as the fear that we ourselves might die.  We would do anything to keep that from happening.  And if it does happen, we are laid low.

I build my entire worldview of medicine around the idea that healers ought to feel this way about the people we care for.  If a person is created in God’s image, then someone trying to heal that person ought to feel like their death would be the end of the world.  That healer ought to be ready to stare down Death on their behalf.

And touching Death, confronting it, holding its hand and punching it in the mouth, all leave marks.  Death is the ultimate source of ritual impurity, the invisible stain that distances us from God, makes it impossible to be a part of the community until we can scrub it off somehow.

In Healing People, Not Patients, I wrote about a late night in the cardiothoracic ICU where I went to work on my white coat with a bottle of peroxide to remove a blood stain.  Death, real proximity to death, leaves stains that peroxide won’t remove.  I have people I care for whose entire identities were reshaped by the death of a loved one.  One person recently told me that his father’s death in his 80s made him suddenly feel like he was next – one minute a caregiver in mid-life, the next an old man whose time was up. 

Are we destined to sink deeper into despair each time we fall short of saving a life until there’s nothing left of us?  To be “ritually impure” forever?  Or is there a peroxide for the soul?  A stain remover that can allow those of us who dedicate our lives to healing others to feel whole and cleansed again? 

Amazingly, there was a biblical concoction that did exactly that, a spiritual stain remover: an unblemished red heifer that has never done any work, cedar wood, hyssop, and some crimson stuff (no, not just any crimson stuff.  You know, Crimson Stuff).  All you had to do was slaughter the cow, get the high priest to sprinkle the blood seven times in the direction of the Tent of Meeting, and then throw the carcass on a big fire with all the other stuff, saving some of the hyssop for later.  Once the fire was completely out, someone else would gather up the ashes of that whole conflagration and put them in a safe place.  Whenever someone needed their soul cleaned after a close encounter with death, they just took some of the ashes, mixed them in a vessel with clean water, then had someone who was already clean dip some hyssop (see, I told you you’d need the hyssop later!) into the water and sprinkle it on them.  Then they would wash their clothes, wait until nightfall, and bam!  Clean again!

But here’s the hitch – you, and the high priest, and the guy who shoveled up the ashes?  Now all of you are unclean!  You made the stuff that made the other guy clean again – and somehow ended up unclean?  That would be like the whole crew at the peroxide factory coming home from work every day covered in blood!  It doesn’t make any sense.  (Don’t worry – even King Solomon couldn’t make sense of it).

That happens in medicine a lot, though.  Cardiologists in the cath lab, putting a stent in someone’s heart in the nick of time to prevent them from dying from a heart attack – while wearing radiation badges that remind them of the creeping toxicity of their repeated exposures to little doses of radiation that could someday be the death of them.  Doctors researching cancer drugs in labs where hoods suck up most – but not all – of the fumes that may, just possibly, be carcinogenic themselves.  Neurosurgeons who operate from before dawn until after dusk, day after day, year after year, saving people’s brains while steadily fraying their own nerves.  Each one provides a remedy that heals the patient – while killing the healer.

How do we heal the healers, then?  Where are our ashes and hyssop?

Around 15 years ago, the medical community finally decided that the ashes and hyssop we needed were just plain and simple rest.  Even superhuman healers needed time away from work to sleep, read, be intimate with our partners, develop hobbies and argue with our in-laws about politics.  Not to allow us this respite was just asking for one more harmful medical error to be made, one more sleep-deprived resident to total her car on the way home from the hospital, or even one more physician suicide.  Residents, the most overworked segment of the physician population, finally got work hour limits, the kind that truck drivers and pilots had had for years.  They could go home and cleanse their souls while someone else took their place.

But one afternoon about a year ago I had a ‘eureka’ moment.  I was trying to take a nap when one of my partners who was on call texted me to clarify something that only I would really know the answer to.  I started grumbling about being disturbed from my nap when I wasn’t even on call when I realized: when you make the commitment to value someone else’s life and well-being as highly as your own, and that someone isn’t well, the only way you get to rest is if someone else picks up that commitment.  If I am sleeping peacefully at night, it is because there is a whole network of people out there contending with the pain, the tragedy, and the loss that would otherwise be my responsibility.  There are lab techs finding crazy abnormalities in someone’s blood sample and rushing to report it.  There are my colleagues fumbling for their phones to read text messages about vomiting children at 3 a.m.  There are emergency physicians who have to attend to the crisis of pain, or bleeding, or just not being able to tolerate being sick any more, with only partial information and none of the benefit of my long relationship with the person to go on.

When I am at work, sometimes until 9 or 10 at night, it is because my family and friends have accepted the old party line: doctors are busy, work late hours and do serious work.  Everyone gives us a wide berth, cuts us slack when we are late or absent, and “understands” how stressful our jobs are.  But there exists a fine, invisible line between the indulgence people show the doctors in their family and circle of friends and the frustration and disappointment of those same people when they realize those doctors are never there for bedtime, soccer games, plays or birthdays.  If I am working late at night, it is because not only I, but many people I love, have put my career in the healing arts ahead of their personal happiness.

And above all, there are the people I care for themselves.  I get to take a break from being the doctor, to close my office for the weekend, to go on vacation, but they do not get to take a break from their illnesses.  Despite what the TV commercial for one of our local insurers says, they don’t get to decide when to have their big asthma attacks and when to throw their backs out.  They also don’t get to decide when their mother’s cancer diagnosis or the big downsizing event at their jobs will destabilize the delicate balance in their mental health.  They cannot schedule their lupus flares around my nap, or my trip to Colorado.  They are the ones who wait patiently for my return, call my office to deal with dedicated but unfamiliar nurses and colleagues in my absence, or snap and go to the emergency room to subject themselves to the noise, chaos, and even abuse for bringing in their “non-urgent” problem. 

If my soul is being restored, if I am becoming pure again through rest and time away – if I am at home, getting to experience the crushing defeat of watching Al Riveron overturning Jesse’s catch – then it is my colleagues and patients who are the ones stoking the fire and gathering the ashes for me.  And I am always in their debt for that.

And honestly, I’m in their debt for the time that I spend in the presence of their pain and suffering also.  Because it turns out that those moments of defeat, of hardship, of death and the fear of it, are in some ways both the impurity and the ashes that cleanse it, all rolled into one.

A couple of years ago, sportscaster Curt Menefee, from FOX NFL Sunday, wrote an entire book on moments like the James “catch” that wasn’t, called Losing Isn’t Everything.  Instead of looking at the great triumphs in sports history, he looked at the losses – the great collapses and gaffes, including some that had made some of the triumphs possible.  If you’re from St. Louis, for example, you remember David Freese as the hero of game 6 of the 2011 World Series, and ultimately as the MVP of a Series where the Cardinals were one strike from losing and came back to win.

If you’re from Texas, or at least the DFW area, David Freese is the crusher of your hopes and dreams.

Menefee looks at stories like Ron Washington, the manager of the Texas Rangers’ team that was on the receiving end of Freese’s heroics, or Craig Ehlo, whose failure to stop a shot by Michael Jordan a couple of years before Michael Jordan was really MICHAEL JORDAN helped to propel Jordan to that next level.  Some took defeat hard, spiraling into drug addiction, divorce, and depression – much as many patients and physicians do when confronted with serious illness and the failure to bring it to a resolution.  It sapped the joy out of life.  But buried in that litany of failures were also stories of people who reinvented themselves, fought back stronger, or even just made peace and moved on.

There are those who believe that the paradox of the red heifer is that life often – or maybe even always – forces us to engineer purity out of the impure.  The stain of death is inevitable; we need the ashes of the red heifer to use, “When a man dies in a tent.”  Not if a man dies in a tent, but when.  Yes, there will be tents where no one dies today, or this year, or for a long time, just like there will be a team every year that wins the championship.  But in most of the tents, someone will die.  In 29 other cities, there will be someone new for Curt Menefee to write a story about.

And when, not if, that happens, something better might come from something awful.  Some time ago I lost a patient who was a dear, delightful person, in part because they never complained – including, it turns out, never complaining of a symptom that might have alerted us to the disease that killed them until it was too late.  But it was not too late to alert that person’s spouse that they, too, had that symptom, and perhaps ought to come see me and demand (and demand they did) to be tested for the presence of an earlier, curable stage of the disease – which we found and treated.

Healthier relationships.  Forgiveness.  New careers.  Art.  These are the things that emerge from the ashes.  Not a phoenix, a rebirth of a creature identical to the one that was consumed, but something, new, different, wiser.  Losing and loss are indeed, not everything – but they are an essential ingredient of living.

Dr. Jonathan Weinkle

Dr. Jonathan Weinkle is an experienced primary care physician seeking to fix our broken healthcare system by returning the focus to the relationship between human beings. His new book, Healing People, Not Patients, gathers together ancient wisdom, medical science, and the experiences of one doctor to draw a portrait of a partnership—a medical covenant—not just between doctor and patient, but also including receptionist, nurse, transporter, and radiology technician.

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