Defending the Lob, Managing the ICU and Emotional Intelligence

The lob shot.

As a goalie, it’s my nemesis. It was my major weakness in college and even more so today. Standing (or more appropriately treading) 6’3″ tall, with an even longer wingspan, I have always been eager and ready to explode up and out of the water, my arms outstretched, to intimidate a shooter. My height, along with my gangly arms and a quick first reaction, are great tools to disrupt, alter and ultimately block my opponents’ shots.

But my kryptonite is the lob shot. It turns my strength against me. A patient opposing player, by waiting a split second, lets my aggressiveness work against me. By allowing me to rise up and out of the water first, a shooter can then release an agonizingly slow arcing shot, up and over my now sinking self, to then drop into the opposite corner of the net. I react. They wait. And I’m beat.

When I correctly anticipate the lob, it’s demoralizing for the shooter. With minimal effort, the ball is not so much blocked as “caught” in humiliating fashion, usually deterring the shooter from another. But when my legs have already committed to a direct shot, all I can do is swivel my head and watch as the ball takes its time, teasing and taunting me, just out of arms reach, and lands in the net.

In college, it took a while to develop patience. To dial back my brashness, my impulsivity. Wait that extra split second. Take in the arm angle and the eyes of the shooter. Trust myself and my abilities to make the block even if I delay for a brief moment. My teammates challenged me with lobs over and over again in practice, until finally a change occurred. Thinking, instead of just reacting. Using my frontal cortex, instead of my primitive brain. And for a while, I had the upper hand against my nemesis, and my opponents as well.

Tempering my first reaction has never been easy, either in or out of the water. My initial response to life’s challenges tend to be more reactionary and visceral. In one’s college years, that lack of patience and emotional intelligence is somewhat expected, if not the norm. Not so much when in mid-life and caring for the critically ill or teenage children.

The ICU will never be mistaken for an Olympic sized pool. And my children, despite how it may feel, are not opponents on a challenging team. But the unique nature of an ICU and family dynamics make both areas ripe with opportunities for a battle between my brash, impulsive tendencies and my more mature, deliberate and thoughtful side.

The space that exists within the confines of the ICU is awash with challenges. Rooms are filled with the tension that accompanies the acuity and intensity of critical illness. ICU physicians are tasked with navigating multiple health care professionals, who frequently have honest differences in opinions, and sometimes supercharged egos and attitudes as well. Families and surrogates of patients, residents, nurses and students all operate in this landscape, within their own sphere of swirled thoughts and emotions. There are a multitude of relatively quick decisions that need to be made. Do I intubate or not? Do I send them on a road trip for a CT or stay in the more stable confines of the critical care unit? Do I commit a patient to an invasive procedure with potential complications or hold off and continue with the status quo?  But it’s not just the decisions themselves. There is a qualitative component as well. Do I take the extra time to explain my thought process to the nurse, resident or student at the cost of delaying decisions for the next patient? Do I provide more than a cursory update to a family as I exit a room, or do I sit down and invite them to share their angst and fear. Do I do so at the cost of delaying the start of my office and the patients waiting there? Do I share my inner head voice and its whispers of fear, concerns and self-doubt? Or do I project unwavering confidence and certainty? Challenges lie not just in making decisions, but in the manner they are carried out and executed. To grow, not just as a competent clinical doctor, but as an empathic physician as well, one needs emotional intelligence to navigate such complex waters.

These days, back in the pool, I find my old nemesis is back to taunt and haunt me. My height and wingspan may be unchanged, but the same cannot be said about my explosive move up and out of the water. Over-eager and anxious to defend a shot on goal, I now have the added challenge of being a bit slower and quite lower out of the water. I don’t have the luxury of waiting that split second anymore.

I find history repeating itself, with my current teammates showing the way. They challenge me in practice, frustrating me with lob after lob. But they are not content to stop there. They let me know that I may be the only one in the net, but I am not alone in defending it. Through their efforts in games, fighting for position, and playing a team defense, they buy me back the time I have lost. They remind me to trust them. And in turn, trust myself, allowing me to tap into my thinking brain in order to defend the lob.

My experiences with the team continue to parallel my life. Just like success in the net is a result of a team effort, so it goes in the ICU. I’d be lying if I said the years have not affected the excitement and enthusiasm of the young attending physician I used to be. There is now a component of fatigue and burnout that I often need to shake off before rounds. Some days it feels that I am on an island when dealing with a crisis or challenge. That is neither true nor accurate. The nurses, residents and students, along with my physician partners are teammates too. Together, the challenge of taking care of the critically ill seems less daunting, giving me the time and space to harness my thinking brain.

There are moments when instinct and gut reactions are critical for success. But when I am able to bring both parts of my brain to a challenge, the enthusiasm that comes with  impulsivity and brashness along with the wisdom that accompanies maturity and thoughtfulness, good things happen. Not just in the pool or ICU, but in life as well.

 

Seventeen-years-old and into the Great Wide Open..

sand

Into the great wide open..
 Under a sky of blue”
                  -Tom Petty

In the absence of moonlight, the summer lake house had been pitch dark when we arrived. The five of us had made a spontaneous late-night decision to drive from the northern suburbs of Chicago to Michigan City, Indiana. Now, as dust particles dance in the glow of the morning sun streaming through the windows, I wake up in the large room known as the “dorm.” In other far too small single beds, three of my friends are refusing to acknowledge the start of the day.

The bed squeaks as I swing my feet onto the floor and walk outside to the concrete patio. The house sits on top of a bluff overlooking Lake Michigan. The cool morning air has not yet given way to the sun’s warmth. Peter is already up, coffee in hand. Slowly, the rest of the crew makes their way outside to sit on the stone steps that wind down to the street; Lake Michigan and the beach just on the other side. Hungry, we dig into a box of day old Dunkin Donuts brought from home.

It is the summer after our high-school graduation and we are at Peter’s summer house for a few days. A weekday or weekend? It doesn’t matter. Every day now feels the same. High school is behind us, yet college still feels far ahead in the distance. For the moment, there are no homework assignments, or grades to worry about. The ninety-minute drive to the beach house is as much a declaration of our growing independence as it is a fun forty-eight-hour getaway to squeaky white sand and mid-summer sun.

Still in our shorts and sweatshirts from yesterday, we eat the donuts and drink bad coffee. We talk about the Cubs and summer jobs. We retell inside jokes and repeat favorite movie lines. The afternoon will be filled playing catch on the beach, with the Cubs game on the radio, and cooling swims out to the sandbar. Our personal journeys lie ahead, but for the moment, we are carefree and at ease.

The memory of drinking coffee on the patio before spending the day on the beach is still vivid thirty years later. The cool rock on the back of my legs. The bitterness of that flavored coffee. The hot sand squeaking under my feet. My shoulder, sore from throwing the baseball all day long. The sun’s heat burning my back while lying on a sandy blanket. Swimming to the sandbar. Nowhere to be, nowhere to go. My future completely unwritten.

I didn’t recognize the significance of that day, or that summer, in real-time. I guess that’s the nature of being young and feeling immortal. Maybe it’s the slow and gradual accumulation of responsibilities that come with a job or marriage or children, that enable us to appreciate the days when we could just lie in the sand and bake in the sun. That summer, listening to the Cubs game on the radio with friends, the weight of future responsibilities had not yet entered our world.

Thirty years later, I am, once again, at a place in my life where things are yet unwritten. After 13 years as a pulmonary critical care physician, I chose to start working part-time in July. I have already encountered a few hiccups and speedbumps along the way, but this time I am able to appreciate the freedom and opportunities that lie ahead.

I am attending a TEDMED conference this week. Within the overarching theme “Limitless,” the talks highlight issues of medicine, both directly and tangentially. I am eager to see which talks will directly apply to me and what I can bring to the table. What mix of critical care medicine, parenting, water polo, and writing brief narratives stories related to those topics might spark a conversation with my colleagues? I am no longer a seventeen-year old kid lying in the sun, with no real responsibilities, but my future does require a similar shift in my mindset. And as I hear Tom Petty’s voice singing in my ear, I am focusing, not on what limits me, but on how limitless the possibilities are.

Running into the Light

The hotel bed was warm and soft. Outside, it was cold and dark. My plan was to get up early and run. When on the road, I feel the need to start my day at dawn and put in some miles. I had prepared for cooler weather here in Southern Oregon, but not this cold, with the thermometer hovering just above freezing.

But the views the day before, driving from Medford to Klamath Oregon, had been stunning. Open expanses of hills and mountains. Tall pine trees, intense and green, pointing to the blue sky made clearer in the high altitude. My body is always a bit more alive when the chill from cool air is tempered by the warm sun streaming, unfettered by clouds above. I was hoping to catch a bit of this magic on an early morning run.

But that was yesterday. Today it is just dark and cold. But I am motivated to work hard, because my trip to Oregon is to support the hard work my son has been doing for several months. So I roll out of bed and put a wool shirt on. I lace my shoes with ungloved hands and put a cap on my head. The lodge where I’m staying sits above a small basin at the back nine of the only golf course around for miles. I find a path that winds around the course and settle in for a quick 3-mile run.

I am two and half miles into the run that almost wasn’t. My breathing reveals I am working harder than normal, given the short distance travelled. The pace on my watch does not reflect the 5000-foot altitude and the steep hills I have already encountered on this winding path in temperatures near freezing. But running here in Klamath Falls in the chilly morning is breathtaking. The hills and mountains rising above the rolling valleys have an extra dimension that the mundane view of houses, lawns and parks on my normal suburban route back home lacks. I feel small, yet more connected to the world around me. The stunning landscape is tempting me to do another loop on this 3-mile trail, my numb fingers and calves, aching from the hills I have already climbed, are telling my otherwise.

The solitude of my morning abruptly changes when I see a fellow runner a football field’s length ahead. My pace quickens, along with my breath, as I start to pull even. From behind, I can tell he is a runner. His calves are hardened and strong and his gait is rhythmic and efficient. I am envious of his gloved hands. I try not to startle him as I say hello. We exchange quick pleasantries, both acknowledging the beauty of this morning.

“How far you going?” he asks.

“I was thinking three.”

“Care for some company?”

It would be rude to rebuke his offer. I don’t really have the breath to explain I’ve already done three miles and that my hands are numb and my calves are on fire and that I live in Illinois where it’s really flat and just about sea level. But I also realize I wouldn’t mind some company to share this morning.

“That be great.”

He tells me his name is Ron, as I shake his gloved hand. He is an ex-marine, having moved from San Diego to Klamath ten years ago to retire. He runs almost daily, exceptions being some of the bitter and brutal cold days that roll in every winter. He asks how I’m feeling, and with the numbness of my hands no longer as prominent, I tell him I’m fine.

So he takes me toward the top of a bluff. As we climb, he shows me the potato fields in the valley below. We talk about the thirty-one marathons he’s done and my eight Ironman’s. He tells me his runs by Crater Lake are his favorites. I tell him runs around Lake Mendota are mine. He describes hard winters in Klamath balanced by three hundred days of sunshine. He recalls the market crash in 2007, just as he retired and the subsequent rebuilding of his life these past ten years. We talk about our children and the challenges of raising them. And as we run and chat, the hills and miles go quicker, as I am no longer focusing on pain or my rising heart rate and rapid breathing on the hills.

The climb to the top of the bluff ends and the view does not disappoint. We stop for a brief moment. The chill I feel from my sweat and the cool air is tempered by the warmth of the sun, now risen, unfettered by any clouds in the sky. I want to steal this moment. The past few months have been challenging for my family. Beauty, and the potential that is all around us, has been difficult to see and appreciate lately. But on this day, with the sun rising, I know for the first time in a while, it’s not just me feeling the potential that lies ahead.

The run down from the bluff is a bit easier.  My watch beeps, telling me I’ve hit the seven-mile mark. Ron drops me off back at the lodge. We shake hands and I watch him, with his efficient gait continue on alone.

I stay outside for a few moments, my heart and lungs thankful for the break. Sun and sweat, aching calves and frozen fingers all co-existing. It feels good. Validation for leaving the comfort of my bed. Evidence of my morning effort. Proof that hard work can help me escape the cold and the dark. I am grateful I decided to leave darkness behind this morning and run into the light.

Ch Ch Ch Changes..

“Ch-ch-changes
Don’t want to be a richer man
Ch-ch-ch-ch-changes
Turn and face the strange
Ch-ch-changes
Just gonna have to be a different man
Time may change me
But I can’t trace time”

-David Bowie

Months have passed since I last wrote.  Thoughts, musings, topics have flittered frequently through my head. But in the general chaos and anarchy that I call my life, (we are often living hour to hour in the Topin household)  as soon as these thoughts gain some traction, something comes up and steals my head space, my bandwidth. And I get wrapped up in the whirlwind of my world.

But something of late feels a bit different.  The ebbs and flows and highs and lows that seems to be the backdrop of my life..seem to no longer feel right…The familiarity of the cyclical nature of things feels…no longer safe..or comfortable…but constricting, and obstructing.

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