Decisions

thinking

I knew the moment when my career in pediatrics was over.  I was in the fourth year of my med-peds residency,  taking overnight call in the pediatric ICU.  Nights were busy, stressful and I was alone.  A young boy came in as a pediatric  motor vehicle trauma, (unrestrained) when his father hit another car. Dad was ok (although severely distraught), but the five year old towhead boy in front of me was not, with his head immobilized in a “C” collar and a breathing tube down his throat.  His brain had swelling from a “shearing” injury that resulted from the decelerating forces applied to his neurons on  impact.  He wasn’t in a coma, but definitely not alert or able to listen and follow commands. But absolutely awake enough to be thrashing about from the discomfort of the breathing tube and his immobilized head and the IV’s in his arms and the catheter in his bladder.  Mom and Dad watched helplessly at his bedside. Standard of care for someone on a ventilator with these tubes is to receive continuous medication for pain and anxiety.  The neurosurgeons were adamant against it as it would cloud their ability to assess changes that could signify more swelling of his brain. If we gave those medicines, they would need to do a surgical procedure to put a “bolt” or pressure monitor through his skull,  to continuously measure for potential increases in swelling and pressure.

Standing a few feet away, I watched those parents.  The dad was a wreck, wracked with guilt, fear and anguish. Mom was fighting back tears,  avoiding eye contact with her husband while grasping her son’s hand.   I stared at the boy, with the same blond hair as my own 4 year old son, wrestling with my own emotional distress over the situation… and I wrote an order in the chart to give him a small dose of  morphine.  And with that decision  my future as a pediatric critical care physician ended before it even started.  You see, that order to give that young boy morphine was the absolute worst decision an MD  could have made.  I acted at the moment as a “parent” not a doctor. I wanted to relieve the pain/suffering for the boy and his mom and dad. But the dose I gave was not enough to make him comfortable. But it might have been enough to cloud our ability to detect subtle neurologic change. And with my decision, I neither helped the boy nor his parents. But I did  put him at increased risk of a delay in diagnosing further brain swelling.  I acted with my heart not my head.

It’s been almost 12 years since that night. I decided to focus and train in adult critical care.  Critical care does not always mean comfortable care. By its very nature, many interventions (breathing tubes, dialysis catheters, bedside drainage of fluid collections, placement of chest tubes) are uncomfortable and often downright painful. But in these critically ill patients, medications such as morphine and ativan can make low blood pressure worse, alter mental status, and lead to respiratory failure. It is by no means black and white; one or the other…and finding that balance for individual patients is an ongoing battle and challenge in the ICU.

I passed on training in pediatric critical care. It was too difficult for me to have an appropriate “emotional” distance.  Although not easy, it has been “easier” for me deliver this “critical” care to adults;  children being just too innocent and frankly feels too close to home.  Over the past 12 years I have (as many MD’s do)  come up with my own coping strategies for dealing with the the stress of these situations.  Many physicians approach patients and their families with a cool, clinical, but detached demeanor.  Others find solace in alcohol or other mind numbing substances.  My approach has not been to shy away from engaging patients and their families. I have not avoided difficult discussions whether it be a new diagnosis of lung cancer or an end of life discussion with someone dying on a respirator. But I have tried to compartmentalize the stress of the ICU,  leaving it behind as I use my thirty minute commute to transition back home to my family.  My wife and kids would probably tell you that the drive home is not nearly long enough  as I  often can polish off a box of wheat thins and a jar of peanut butter within moments of being home, and I have been known to lash out at the kids for things as mundane as “breathing” after particularly challenging days.

So again, here lies the balance….How can I be the doctor I want to be? Engaged with my patients, but not too emotionally invested.  Thoughtful about my approach to the “invasive” nature of interventions yet mindful of their pain and suffering.  And how to still save part of myself for when I get home to be fully invested and an active participant in my family’s life?

This is where training for triathlons helps bridge my two worlds.  There is something about the rhythmic crush of gravel during a run under my feet, or the weightlessness of my body as my arms cut through the water, or the air going in and out of my chest while watching the pavement glide under the front wheel of my bike to help me wrestle with my demons. I may not have shed a tear over the 25 year old newly married young man who died this past week in my ICU, but he was on my mind during my runs this week and I have been able to get some closure on the role I played with him and his family during the  last few days of his life. And my ability to think  free of distractions, during a bike trainer workout, of a productive approach to talking to my son  led to the best conversation I have had with him in a long time.  Now I don’t mean to suggest that after every five hour bike ride I come into the house all refreshed and ready to engage my family with  boundless energy,  leaving all my worries behind. But If I am going to try and find some way to sustain a career in critical care medicine as well as navigate the troubled waters that a fifteen year boy with his learner’s permit can create, while also trying to understand the challenges my twelve year old daughter presents,  “Iron” distance training might not be enough…..

Ultra running anyone?

Reset

back pain

One month. Actually one month three days to be exact since I did Ironman WI.  The physical stress on my body has passed and along with it most of the intensity behind the wave of emotions and excitement that followed.  Having finished the race on such a personal high, it left me like a meth addict craving for more. (Yep…been watching  Breaking Bad almost non-stop…almost done with season four!)   It took me all of a post-race shower, 3 slices of pizza on state street, and watching a parade of inspirational midnight finishers to start my brain spinning forward to 2014.  Visions of winter marathons and spring bicycle time trials filled my head as I wondered what building off this new level of fitness could bring!  Yoga and Pilates would help my congenital flexibility deficiency.  My nutritional focus would only continue to grow  into new realms of anti oxidant loaded foods. I even bought a packet of chipotle seitan to try.  Yeah me…the guy who lived on Burger King in High School and Taco Bell in college.  Those post race endorphins are pretty powerful stuff.

Although my brain was riding high, my 42 (soon 43) year old body had a different opinion of things.  It fired its first warning shot two weeks later after getting on my  bike.  A beautiful Saturday morning…perfect for riding. A little on the cool side but a great excuse to show off my new long sleeve “Ironman Finishers Jersey”.  Although I felt ready to rock and roll, my left knee took exception and stated so five minutes into the ride.  A “hiccup” I thought. Just a little more time. Only two weeks. I had earned some time off right?  A thirty minute run a few days later went fine.  And I was only a weekend away from getting back into my groove!

The second warning I failed to notice.  It was too subtle and only in hindsight did I recognize its signifance.  The neck and upper back strain that had been building up all week I tried to ignore. My ill fated mid-week yoga session (see  Disequlibrium) did not help and I shrugged it off before getting in the pool that Friday evening. 2500 yards later, a twinge under my right shoulder blade seemed reasonable for not having been in the water for 2 weeks.  I went to bed excited to set a 6am alarm (yeah…I know..6am and alarm when put together should never be associated with excitement).

My body decided though, at 4am, to make sure I paid appropriate attention as my upper back spasmed so bad breathing was painful. Despite the lack of oxygen currently making its way to my brain, the irony of the situation was not lost. Having just swum/biked /ran 140.6 miles three weeks earlier, I was now barely able to get out of bed, much less down the stairs to some Motrin and what I hoped was some left over flexiril.  I would spend the majority of the weekend moving only to change my position on the bed to find the least amount of strain and pain.

I now find myself on day twelve of “injury # 1” on my road to IM WI 2014.  One bike ride, a 30 minute run and 2500 yards in the pool and I’m already out of commission.  And with no workout to anchor me, I find myself having no reason to  pass on the Lou Malnati’s pizza, or the Ben and Jerry’s Pint of Ice Cream (Cinnamon Swirl…WOW!) or the Blue Moon / Sangria filled Happy Hour or the Fried Calamari or the Gyros or the….well..you get the picture….Life has become one giant evolving buffet!

The inability to workout (versus the lack of desire)  is having a profound effect.  I often  grumble trying  to squeeze  in an hour swim on a busy midweek day. But I find with no workouts to focus on,  the  days seems to just evolve around me as opposed to being an active participant dictating how things will unfold.  Now no one will ever confuse me for an “organized” person. But it has become quite obvious my daily workouts provide more than just exercise. When trying to BALANCE a week of workouts, I am an expert on the 3 day weather forecast (optimizing running outside),  participate in laundry (gotta have my favorite clean running socks),  dishes are done (along with an array of water bottles and hydration systems), and the fridge is stocked with a better array of nutritionally dense (yet often odd looking) foods. Snacking gives way to prevent stomach cramps on the run.  Television takes a back seat to stretching.  Late night TV gives way to much needed sleep.

So, what have I learned? First, I miss working out. Its absence leave a void bigger than the hour or so it would have occupied.  It is my anchor…my center and helps me approach the rest of the week in a more BALANCED way.   Second, there is a mind/body struggle going on. My mind has visons of setting  personal bests and setting new records. My body is reminding me I’m no longer 21.  And for time being, the body is winning that struggle, making me RESET.  Reset the fitness gains I had made. Reset the confidence in what my body is capable of doing.  There are just under 11 months till Ironman 2014. It is both a long and short period of time. But I will start from the beginning.  Ill take the energy and enthusiasm of my “21” year old mind against my 42 year old body (along with some help from my sports medicine docs, physical therapists and ART/Chiropractors) and a large bottle of ibuprofen, as I start the journey again.

Building Blocks

 

buildong blocks WaterPolo

Its 9am Sunday morning and I’m standing on a humid pool deck staring across at the  blank faces of thirteen high school water polo players. Most of them I have never seen before and don’t have a clue as to their names. They are  looking back at me.  Sort of.  At least those that are not looking at their iphones or zoned out listening to music with their earbuds.  But they are MY players.. My team!  At least for today.  And I am wondering how I got myself in this situation.

About 18 hours earlier, the email came across my iphone.  “High School Water Polo Tournament Tomorrow!!!!!! Players Needed! Please respond ASAP!”  My son plays sporadically for a club team based out of a neighboring high school run by my friend Claire.  We have known each other for a few years having played on the same Master’s team.  I let her know my son is available if needed. The text that comes back says:

“yes needed! Also short a coach. Interested?”

I reflexively reply:

“NP” (text speak for No problem…learned that from my kids being the hip Dad that I am)

With visions of Bobby Knight or Phil Jackson swirling thru my head, I see myself challenging these currently “faceless” kids to play  above their ability. I’ll share my  years of knowledge, wisdom and love of the game, and they will  play beyond their years and bring home victory!

But what I see right now is nothing like the visions I had the day before. The team in my head was tall…REALLY TALL….and ripped!…Kind of like a bunch of Michael Phelps.   Lets just say this team was a bit more diverse.  From freshman to seniors,  5″3 to 6 feet tall the team was quite a mix of shapes and sizes. Three goalies (Three? How do I find playing time for three goalies?) And I don’t know the names of more than half the kids.  I had some sort of pre-game pep talk loosely planned in my head but right now I can’t get the attention  of the two kids listening to music.  With three minutes left to go before game time, I’m still trying to figure out a starting line up (when in doubt, go with seniority and the kids that have been there the longest) when the whistle blows to start..

Game 1 : As soon as the game begins, I’m in over my head. I’m trying to figure out who will be the first subs. Easy…first three on the bench (if only I knew their names).  Now I’m trying to figure out who will come out.   Figuring out who people are with a water polo cap on and half under water is hard enough, but when you don’t know their name to begin with, it becomes comedic. “you in the speedo…no..the other one..yeah you…sub out”  Not to mention there are two brothers Leo and Rodrigo who look quite similar and I will continue to confuse them for the rest of the tournament.  I find myself spending minutes figuring out substitutions instead of watching and offering any type of strategy (which seems to be desperately needed as we are quickly losing by quite a lage margin) It’s not till the half, that I have a chance to collect my few thoughts.  Now I have thirteen tired, frustrated and short of breath players looking at me for direction.  No zen like observations come to mind (thanks for nothing Phil) and yelling at them (coach Knight) doesn’t seem quite appropriate right now. Three…Three things. Somewhere I heard that the most a team can focus on are three things.

Ok guys…rough start…One, we are going to play a press defense.  Play them tight. Two, first option on offense, we go to the hole set. Three, get back on D quicker. Don’t watch the turnover..just get back on defense and help the goalie! Lets go.!”

Final Score 5-15.  Names memorized on team: 7 of 13 (but I knew four of them already)

GAME 2: Starts right after game 1. Starting line up is easy. Same as last game. I’ve got some sense of what my team can do. Who are the fast swimmers (or not so slow). Who can shoot, who is not playing defense.  I try to figure out how to keep at least 3-4 stronger players in while peppering in some of the more novice kids.  I’m still hampered by the “name” thing but at least I’m able to watch the game and finally able to offer some specific advice by the fourth quarter. We lose the game, but play them even for the last 6 minutes. And a bonus, I get to see my son score two goals!

Final Score 7-13  Names memorized: 10 of 13

Game 3:   After a 50 minute break, the team is ready for one last hurrah.  3 kids have left leaving me with 10 (unfortunately the three whose names I have not figured out are all still here…including Leo and Rodrigo).  A slight modification to the starting line-up and we are good to go.  Our defense is having some trouble with their huge hole set.  I modify to a foul and crash defense to adjust and it seems to work. Our counterattack is working and going into the last quarter we are down only  one goal.  I rest the strongest players for the first minute of the 4th. And when they come in, they are swimming hard.  We trade some goals and with 1:30 left  still trailing by one, I call time out.  The team swims over and now they are looking at me…I mean really looking at me, waiting for me to tell them what to do!  But this time, I know what to say.

We need the ball back! Switch back to a straight press defense.  No drop on the hole.  I want the defenders on the crown ready to counter.  They are tired. We are not!”

The defense holds, and Denilio has broken early for the counter. Our goalie makes a great pass to him and on the breakaway scores to tie the game!  Our defense holds up for the next minute and the game ends.

Final Score 12-12. Players names memorized 10/10.

The kids leave exhausted but excited to have improved and played a great competitive game and I’m feeling quite a bit better about my coaching prospects. My record is still 0-2-1 but ended on a positive note. Even better, I got to watch my son score 3 goals for the tournament.  And as I drive home to try and catch the second half of the bears game with my son, I think about how this fits with the big picture of BALANCE.

I wanted to be this dynamic coach who could teach, challenge and motivate right out the box. Just like I want to have this BALANCE. Now! Today!  I want to be that dad who has the boundless energy,  always knows the right thing to say to his wife and kids.  That team player at work but still home in time for an hour run before dinner.  I frankly sucked as a coach for the first game, just like last weekend was pretty horrible for any  BALANCE.   But after using the first two games as BUILDING BLOCKS,  I’ll leave it to the kids to say what kind of coach I was by the end.   And as I reflect back on THIS  weekend as a whole, it was certainly better than the prior.  There were some BUILDING BLOCKS here as well.  Family yoga on Saturday despite a bad back, making progress on redoing the upstairs bathrooms, coaching my son in the tournament, watching together the Bears lose to Detroit.  No major drama. In fact mostly mundane. But those are the BUILDING BLOCKS for sustainable balance. Not every weekend can be a family hike in Moab Utah or surfing in Hawaii.  Those don’t sustain BALANCE. They are fun and exciting and add flair and a dramatic backdrop. But its the smaller moments, that build off each other that add some depth and can act as an anchor. It does not happen in one game,  and as I’ve said before, not one weekend. But some of the pieces are already here and its time to start building off of them.

 

Disequilibrium

yoga

About a week ago I wrote my first blog about BALANCE. How I hope the journey to another Ironman triathlon will allow me to find more balance in life and continue to gain valuable insight.  So it was with enthusiasm I looked forward to my week. To throw myself into my family with visions of healthy home cooked meals shared while telling  stories of our busy days.  Mornings filled with pre dawn runs, before zipping to work  for another challenging day in the ICU.  A weekend started off with a crisp autumn morning bike ride, a family working together to clean a garage, a Badger and Bears football game to watch and get excited about. SO much opportunity to actively pursue QUALITY time with my family and friends.

So in the movies, a song would play in the background and slowly build to a crescendo as these events occur one after another, as everyone smiles and the energy is flowing. The dinner meal is eaten, the run is done with the sun rising in the background.  A life saved in the ICU followed by some dramatic cinematography of  trees whizzing by as I shift gears and fly on my bicycle. The garage now immaculate as we work together to sweep the last bits of dust off the garage floor, culminating in a Badger and Bears wins with my son and I high-fiving each other over another touchdown.  That is the movies. Reality is quite different.

No meal was cooked. Franky I don’t think I made it to the grocery store.  I passed out most evenings before 9pm. Didn’t make it to water polo at night and was too tired to drag myself out of bed to run in the am.  I barely made it to work on time and was running behind all day trying to keep my head above water.  I don’t think any life was dramatically saved, but there was plenty of drama at my office between partners as we struggle with an uncertain future in healthcare.  My knee was in so much pain after 15 minutes on the bike, I was forced to turn back by my riding partner. The garage is the same as it ever was. My teen-age son and I are barely talking after a rough weekend and I think I saw my daughter for about an hour sandwiched between  birthday party sleep overs and midnight bat-mitzvahs.  The Badgers and Bears were the only things that followed the script!

So, as this week started, I hoped to find some saving grace.  Something to help me find my center. To be an anchor to the DISEQUILIBRIUM I am currently feeling.  And there it was…..YOGA!  For years I have contemplated this.  First I am the LEAST flexible person I know. Seriously, I can barely touch my knees much less my toes.  My hamstrings I think stopped growing when I was 12, but my legs continued  until college leaving me with some serious flexibility issues. It has been one of my biggest limiters  to training  over the last several years and has led to many of my injuries.  But even more hopeful, was this mind/body/balance thing I’ve heard of with yoga. The breathing, focusing, inner reflection part that seems just perfect for what I’m trying to achieve.  So it is with some trepidation along with some hopeful enthusiasm, I signed up for my first session with Dahn Yoga uptown. I was  scheduled for an orientation 20-30 minutes early, to help me “assimilate” into the class.  So after a crazy day at work, with major tension working its way into my upper back and my right hamstring and hip flexor already in a knot, I race home, change clothes, and jump back into the car and head to the studio.   Let’s just say the drive over was the highlight of the experience. I’m not sure my writing can do justice to the next hour and half.  But I will try.

After walking in at 6:30 (for a 7pm class), I briefly meet the Yoga Master (nice man, mid 30’s, obligatory goatee and loose fitting clothes). I receive my orientation pamphlet to read as he disappears into a room. Five minutes later I’m done with orientation and have 25 minutes I guess to kill. I’m now in a “lobby” with numerous books (energy particles, Chakras, mind/body connection).  Then my eyes seize on a small “globe” of the earth floating above a mirrored base. Literally floating. I realize it must be a magnet (smart guy that I am).  I watch it spin and think what a perfect metaphor in front of me for BALANCE as this globe slowly rotates, perfectly centered defying gravity floating above the base. After a few minutes I can’t help myself. I must touch it. Feel it. Appreciate its balance!  So as I touch this perfectly BALANCED globe; THUNK!  The magnet has now pulled the globe onto the base, making a noise that echoes through the studio.  I’ve have literally just unbalanced the Earth.  I look around. No one is there. Quickly I try and separate the Earth globe from the base. I try to float it above just like I found it.. THUNK!! Again that magnetic thing. Now I look around for the hidden camera that must be somewhere aimed on me. I start to sweat. It’s 6:50. The “master” is bound to check on me (or the loud noise coming from the lobby) and people will soon be arriving for class. A few more tries and a few more THUNKs and I realize this is hopeless.  I can’t balance my own life at the moment, no way I can balance the Earth. I leave it pinned at an awkward but hopefully not too noticeable angle and quickly sit back down and await further instruction.

But further instruction never comes. As 7 pm rolls around, about 15 people stroll in, take off their shoes and head to the studio room in the back. The master still seems to be indisposed to either orient me or check out strange noises from the lobby, so I finally head to the studio myself.  What follows over the next hour could not have been further from what I have pictured as a yoga class in my head.  Now, I’m sure not all yoga involves warrior poses, downward dog stretches, and chanting with the legs crossed. However, hitting myself in the stomach for a 10 minute warm up, followed by jumping jacks and running in place for another 10 is not what I had envisioned. But I was  still hopeful we were going to work on some awesome pose that will loosen up my hamstrings or work on my knotted back.  But I’m teased by another 10 minute block of balancing on one foot with my eyes open and closed.  Then, there  are about 10 minutes  of some mild stretching where I start to think, this is it…Warrior pose here I come!  But then some Enya like new age music starts up and we are told to close our eyes and “feel” the music and “listen” to our own “rhythm” and move to the “voice” inside our bodies. Over and over the master tells us to just listen to ourselves.  I can’t help but open my eyes and peek. There is probably some bad yogi karma that I have just cursed myself with but I don’t care. 15 people are all moving to their own unique “beat” as there really is not much of one in new age music. All the time MY voice is telling me to “move” next door to Subway and Starbucks for a 6 inch  veggie sub and a Venti Americano.  Class wraps up with 5 minutes of breathing while lying flat on my back, and I’m still left with tight hamstrings, a sore back, an unbalanced Earth in the lobby and a craving for a Subway sub!

So, what have I learned over the last several days? What insight have I gained. First, life at the moment is not quite balanced. I would call it a state of DISEQUILIBRIUM.  The balance though I am looking for is not going to come by forcing it all into a weekend, or captured by taking  a yoga class.  It’s going to be through a process. Two weeks of minimal conversation with my son is not made up over a three hour Bear’s game. And one family dinner does not counteract evenings glued to our smart phones.  But a good weekend can be a building block  for more meaningful conversations and interactions  during the week.  Better BALANCE is going to come through persistence and consistency not by “crash forced family weekends” and definitely not by listening to Enya and finding my inner rhythm.  So, DISEQUILIBRIUM 1, BALANCE 0  is this weeks score, but I’m playing the long game on this one.