Night-float

Last week I started on night-float which means I'm the doctor in the hospital on-call between 5 at night and 7 in the morning. So if anything goes wrong with one of the patients in the middle of the night, I get paged. Some people try to take cat-naps during the night and then stay up part of the day when they're not at work. I elected for complete day-night reversal so I've been staying up all night and then sleeping all day. And although I always kind of feel like I'm in a weird kind of fog these days with my circadian rhythm all screwed up, I've actually really enjoyed night float.

The hospital at night is so quiet and deserted and I like the feeling of being one who keeps watch until the morning. There's also a sense of team-work with the nurses who are on overnight which isn't quite there during the day.

My favorite thing though has been having enough free time to just have some good conversations with patients. At the beginning of the night I like to go check in on most of those I'll be responsible for over the next 14 hours. When I'm seeing patients during the day it's always very focused on getting a medical history and doing a physical exam and the time is always short. But at night I just round by myself and check in with people. Sometimes I'll do elements of a physical exam but usually it's just me saying hello, letting the patients know that I'm the doctor responsible for them overnight and asking if they have any questions.

Without the usual day-time expectations of doctoring I've been able to have some interesting conversations with some elderly patients. I listened to the life story of a 95 year old gentleman last night. He told me of his one-armed grandfather who was a doctor in Mississippi. He told me of fighting in the Philippines and New Guinea in WWII, of coming back after the war to Rhode Island, of how he met his wife when he saw her getting on the train and helped her with her heavy suitcase, of how she sent him a post-card with the Empire State Building on it, of how he stole her away from the rich man she was to marry, and of raising a family with her in Texas. Then he told me of his sadness when she died in '98 and how the first thing he does "if he makes it through the pearly gates will be to go to the complaint desk." This saddened me but I understood. He was still telling me his story when we were interrupted by the "beep beep beep" of my pager. As I rose to answer the page I could tell he was thankful that someone had listened and he asked me to come back again. If he's still in the hospital tomorrow night maybe I'll stop by to hear some more.

I also spent some time with a 91 year old man who told me of his time stationed in Morocco after the war and how he and his wife toured Europe in the early 1960s.

Thankfully there haven't been any emergencies over the past few nights I felt like I couldn't handle. But I know that they will come and I know that like every other thing I felt like I couldn't handle being an intern (and there have been a great many) that with God's strength and providence I'll get by.

On the first night I drove to the hospital, dreading the 14 hours ahead of me, feeling relatively alone and responsible for so much, a prayer came to mind which is one of my favorites from the Compline service in the Book of Common Prayer. I thought of myself and the nurses watching, of my patients suffering and perhaps dying and of their families weeping. So this is my nightly prayer this week...

Keep watch, dear Lord, with those who work, or watch, or weep this night, and give your angels charge over those who sleep.

Tend the sick, Lord Christ; give rest to the weary, bless the dying, soothe the suffering, pity the afflicted, shield the joyous; and all for your love's sake.

Amen.

Reformation Day: "All works are condemned"

Now, if there must be error, those who say that the grace of God is priced high, and account it dear and costly, err less shamefully and presumptuously than those who teach that its price is a tiny trifle, and account it cheap and contemptible. Paul, however, pounds both errors to a single pulp with one word when he says that all are justified freely, without the law, and without the works of the law. The assertion that justification is free to all that are justified leaves none to work, merit or prepare themselves, and leaves no work that can be said to carry either congruent or condign merit. By the one cast of this thunderbolt, Paul shatters both the Pelagians with their total merit and the Sophists with their tiny merit. Free justification does not permit you to set men working for it, for free donation and preparation by working are manifestly incompatible. Furthermore, justification by grace does not permit you to regard the worthiness of any person, as Paul says in the eleventh chapter [of Romans]: 'If by grace, then it is no more of works; otherwise, grace is not grace' (v. 6). So, too, he says in the fourth chapter: 'Now to him that worketh the reward is reckoned, not of grace, but of debt' (v. 4). And so my good Paul, the scourge of 'free-will', stands undefeated! He lays low two armies with a single word! For we are justified without works, all works are condemned, whether small or great; Paul exempts none, but thunders impartially against all.

-Martin Luther,

The Bondage of the Will

The Heavens are telling the Glory of God

My last post made me think of one of my favorite pieces of classical music from Haydn's "The Creation." I liked what the Wikipedia article had to say about Haydn and his creation of this masterpiece:

It was also a profound act of faith for this deeply religious man, who appended the words "Praise to God" at the end of every completed composition. He later remarked, "I was never so devout as when I was at work on The Creation; I fell on my knees each day and begged God to give me the strength to finish the work."

Chorus:

The heavens are telling the glory of God.

The wonder of his works displays the firmament.

Gabriel, Uriel, Raphael:
To day, that is coming, speaks it the day;
the night, that is gone, to following night.

Chorus:
The heavens are telling the glory of God.
The wonder of works displays the firmament.

Gabriel, Uriel, Raphael:
In the all the land resounds the word,
never unperceived, ever understood.

Chorus:
The heavens are telling the glory of God.
The wonder of his works displays the firmament.

The Heavens Declare the Glory of God

I snapped this picture this morning during rounds. I'm thankful for reminders of God's presence and sovereignty, especially during challenging times.

(Picture is Mt. Rainier at sunrise, casting a shadow on the clouds)

C.S. Lewis on Tyndale and Protestantism

In reality Tyndale is trying to express an obstinate fact which meets us long before we venture into the realm of theology; the fact that morality or duty (what he calls ‘the Law’) never yet made a man happy in himself or dear to others. It is shocking, but it is undeniable. We do not wish either to be, or to live among, people who are clean or honest or kind as a matter of duty: we want to be, and associate with, people who like being clean and honest and kind. The mere suspicion that what seemed an act of spontaneous friendliness or generosity was really done as a duty subtly poisons it. In philosophical language, the ethical category is self-destructive; morality is healthy only when it is trying to abolish itself. In theological language, no man can be saved by works. The whole purpose of the ‘Gospel,’ for Tyndale, is to deliver us from morality. Thus, paradoxically, the ‘Puritan’ of modern imagination—the cold, gloomy heart, doing as duty what happier and richer souls do without thinking of it—is precisely the enemy which historical Protestantism arose and smote.

- C.S. Lewis, English Literature in the Sixteenth Century

In search of PNW History: Centralia

I got off work from the ICU earlier than expected today so I headed home and attempted to take a nap. Unfortunately I had already consumed such a quantity of coffee that the attempt at napping was a failure. So I decided to go on a small adventure to the nearby town of Centralia, Washington about a half hour south from where I live in Lacey, Washington. Centralia has always interested me but even with having probably driven past it about 500 times going north and south on I-5 between the Portland area and the Puget Sound area I had only stopped at the stores and restaurants right off the freeway, I had never been to the historic down-town.

My interest in Centralia had begun at an early age during some sort of history class at Maple Grove Middle School in Battle Ground, Wash. My, perhaps a bit morbid, curiosity as a teenage boy was piqued when I heard the story of a gun-fight and massacre which had occurred in my own home-state of Washington. I never forgot hearing that story and for close to 20 years I've wanted to go check out where the events took place.

On November 11th, 1919, Armistice Day, a conflict between the local chapter of the Wobblies (Industrial Workers of the World) and the local American Legion erupted when the Legionnaires, marching in the Armistice Day Parade came under attack. It seems that there are very different versions of what exactly happened that day from the Wobblies and from the Legionnaires. One version of events would have a Wobbly firing on and killing one of the legionnaires as he stood on the parade route which precipitated the rest of the conflict and the further killings. The other version would have a small group of legionnaires breaking off from those marching in the parade to attack the IWW Union Hall and the Wobblies firing upon the legionnaires in self-defense. Whatever happened exactly, four legionnaires were shot and killed by Wobblies and five others were wounded. One of the Wobblies, also a WWI veteran, who had been arrested for the killings of at least two legionnaires was seized by a mob, beaten and then hung to death from a bridge on the evening of November 11th.

So this afternoon I headed down to Centralia and drove the mile east of the freeway to the historic downtown area that I've wanted to drive for many years but had never seemed to have the time. I was happy to find some free public parking and was pleased by my first impression of the city with its many small businesses and sidewalks busy with pedestrians. I started walking, figuring that I would find something historic without having to ask any questions or consult any maps. My first find was a park with an impressive memorial to veterans who have fallen in WWI up to the current wars in Iraq and Afghanistan. It turns out that this statue called The Sentinel was initially erected in 1924 in honor of the four legionnaires killed. From the park I headed back into town and decided I would ask people if they knew where the events of that November day in 1919 had taken place. To my disappointment the people I asked, including an older couple and long-time residents of Centralia, had no idea what I was talking about.

"The Sentinel"

I remembered that I had read a detailed account of the events on Wikipedia so I pulled out my iPhone and pulled up the page on the Centralia massacre and sure enough it had a location of where the events had taken place, 2nd and Tower streets. So I started walking in that direction. As I got closer to my destination the buildings began looking less and less historical and more and more run-down but I thought maybe I would at least find a plaque or something. But when I got to 2nd and Tower there was basically nothing there, just a grassy lot, a bowling alley and a nursery nearby.

Historic downtown Centralia

This event in Washington State History inspired bitter feelings for

many years. So maybe the people just wanted to forget about it and move on. I can understand that. But as a history-nerd I was a little disappointed. I wanted to find something more. But it was interesting to finally see a town I have driven by many times. It was also good to find a small diversion from all-consuming medicine. Hopefully in the future I'll also have time to go and explore some more local historic places and write some more posts like this one.

The Lord Provides: ICU

It's amazing how quickly I can go from being completely overwhelmed by anxiety, thinking "what have I gotten myself into," with this whole medicine thing to thinking "I'm glad I'm a doctor." The beginning of this week were some of the most anxiety-filled days I've ever experienced. I could barely sleep. I was confounded by my own inadequacy.

But yesterday I felt confident for the first time in the ICU, a rotation I started a week ago. I got my first "procedure" as a new intern. As we rounded on our patients in the morning we decided to do a lumbar puncture on a man with altered mental status. The year-2 resident asked for one of us interns to volunteer to do the procedure. He was my patient so I figured it would be bad form for me not to volunteer. So I said I would do it, thinking to myself that I would really just try to do it but probably not succeed. When I told one of my fellow interns what I was going to try to do later he quoted Yoda to me saying, "Do or do not... there is no try." Going into the room, about to perform the lumbar puncture, I asked for God's mercy and I asked for success in getting this procedure.

The other resident and I gowned up under the watchful eye of the ICU attending. I first injected the morphine, just under the skin, then toward the patient's spine where the large lumbar puncture needle would travel. After he was all numbed-up I inserted the much larger needle, first hitting bone then redirecting once and then going much deeper. I felt the deep tissues "give" three times, each time hoping that I had reached the spinal canal with it's precious cerebrospinal fluid (CSF). Each time I felt a give I would withdraw the stylet from the barrel of the hollow needle hoping to see clear cerebrospinal fluid drip from my end of the needle. After withdrawing the stylet twice I thought to myself, "alright, as I expected the resident will have to take over but at least I tried." I replaced the stylet and went a half centimeter deeper with the needle. I felt the tissue give once more. I removed the stylet and there it came, a sight for sore eyes, perfectly clear fluid dripped from my end of the needle, CSF, the last give had been the dura surrounding the patient's spinal canal and now the tip of my needle was within the spinal canal, among the cauda equina of the spinal cord, draining a miniscule quantity of CSF which would help us to diagnose the cause of our patient's problem, potentially guiding us in the treatment of an encephalitis.

Admittedly a lumbar puncture is a pretty simple procedure. But I have seen it unsuccessfully attempted by residents in the past so my success in completing it was definitely not a given. I had only tried it once before my third year of med school and had been unsuccessful then. I left the hospital Friday night happier than I've been in a long time.

And while I am very thankful to God for my success and my current happiness, it does bother me that it takes something like this to make me happy these days. For I know the King of the universe, and I know about His cross, His shed blood in my place, for my sins and the sins of the whole world. I know about His glorious resurrection on the third day when He erased all doubt about His victory over sin, death and the devil. Knowing all of this I should be continually rejoicing and I should be able to obey the words of my Lord, "Therefore do not be anxious (Matt 6:31)." But I fail miserably and I fail daily. And knowing my failure to "trust and obey" I am redirected again to the glorious gospel of God's grace, that my standing with God is not based upon my success or obedience but solely upon Christ's righteousness. And while I often foolishly fail in trusting God to bring me through the every-day trials and struggles of life, I do trust God with complete certainty in one area. And I know that this trust, this faith, has not been manufactured or achieved by me but has been given as a free gift of His grace. And this faith is that Christ died to save sinners, even a sinner like me.

This is my Father's world;

why should my heart be sad?

The Lord is King; let the heavens ring!

God reigns; let the earth be glad!

2 truths

From the scarcity of blog posts lately perhaps you can guess that the last few months have been challenging for me. This is true. I can say with certainty that I've never in my life worked as hard as I worked when I was on my CCU rotation in August. I truly felt burned out by the end of that month. September has been a bit of a much-needed breather but even my current rotation is very hard work compared to medical school or anything else I did before that.

It has been a mentally exhausting few months and what makes it more difficult is that it's very hard to see much light at the end of the tunnel. I know I am slowly adjusting to the realities of being a resident physician but this adjustment has not been pleasant nor fun.

Two spiritual truths have given me much comfort at times over the past month or so. Thinking about both of these truths has pretty much been birthed at Hockinson Apostolic Lutheran Church where I've been attending whenever I have a 2-day weekend and thus can make the 2 hour drive home to Battle Ground. I was reminded of one truth through hymn-singing and the other through hearing it preached.

The first truth I was reminded of is "He Leadeth Me." We sang this hymn, penned by Joseph Gilmore in 1862 as he meditated on the 23rd Psalm, one Sunday last month and I couldn't get it out of my head. This is one of the rare times when I'm very thankful for a song I can't get out of my head. The refrain goes:

He leadeth me, He leadeth me,
By His own hand He leadeth me;
His faithful follower I would be,
For by His hand He leadeth me.

Some of the verses are:

He leadeth me, O blessèd thought!
O words with heav’nly comfort fraught!
Whate’er I do, where’er I be
Still ’tis God’s hand that leadeth me.

Sometimes mid scenes of deepest gloom,
Sometimes where Eden’s bowers bloom,
By waters still, over troubled sea,
Still ’tis His hand that leadeth me.

And when my task on earth is done,
When by Thy grace the vict’ry’s won,
E’en death’s cold wave I will not flee,
Since God through Jordan leadeth me.

That Sunday night, not looking forward to the long and difficult week ahead, I sought the Lord and worshipped Him, singing this song. I was overwhelmed by the joy it brought me to think that no matter what I face I can be confident that "He leadeth me." A friend recently text-messaged me a verse from Isaiah which confirms this promise of God to lead us, the text reads, "For I, the Lord your God, hold your right hand; it is I who say to you, 'fear not, I am the one who helps you (Isaiah 41:13)." When I think of the most difficult days of being an intern, when I want to run from the hospital, truly this truth is "with heav’nly comfort fraught."

The second truth I was reminded of is a truth all Christians should look forward to, that is, Christ's return at the end of the age. I heard two men mention the imminency of Christ's return while preaching, first at the Amboy Grange and then at the Hockinson church by Pastor Holmgren. I realize that the return of Christ is something that Christians have expected in their own lifetime throughout the history of the church. But hearing it preached by men whom I respect filled me with much excitement and also provided great relief. Thinking that "He will come again" and that He could come at any moment made me realize how little and transitory are the worries that tend to completely overwhelm my thoughts lately when thinking of all of my responsibilities as an intern. When we see Christ coming on the clouds all these things which seem so overwhelmingly important will fall down as nothing as every knee shall bow and every tongue confess that Jesus Christ is Lord.

So in the midst of much struggle the Lord is providing for this wretched sinner who deserves none of His goodness and who has yet been showered in His goodness since the day I was born. O to grace how great a debtor daily I'm constrained to be!

Maranatha! Come Lord Jesus!

Chesterton: Drink

Jesus Christ also made wine, not a medicine, but a sacrament. But Omar makes it, not a sacrament, but a medicine. He feasts because life is not joyful; he revels because he is not glad. "Drink," he says. "for you know not whence you come nor why. Drink, for you know not when you go nor where. Drink, because the stars are cruel and the world as idle as a humming-top. Drink, because there is nothing worth trusting, nothing worth fighting for. Drink, because all things are lapsed in a base quality and an evil peace." So he stands offering us the cup in his hand. And at the high altar of Christianity stands another figure, in whose hand also is the cup of the vine. "Drink," he says, "for the whole world is as red as this wine, with the crimson of the love and the wrath of God. Drink, for the trumpets are blowing for battle and this is the stirrup-cup. Drink, for this is my blood of the new testament that is shed for you. Drink, for I know of whence you come and why. Drink, for I know of when you go and where."

- G.K. Chesterton, Heretics

Battle Ground Buzz

For any Clark County readers out there or for anyone interested in the goings-on of a small town in Western Washington state I'd like to recommend a new website started by a friend of mine:

Battle Ground Buzz

Battle Ground is where I grew up and I'm pretty convinced it's the best place on Earth.