And I will see you

(For travel in Asia, go to 11/2008-1/2009 & see link below right; backpacking: Grand Canyon 4-7-2009, Winds 9-12-2008, Maroon Bells 7-21-2008, Bandelier 5-23-2008, Big Bend 3-12-2008)

I was in and out of Dong Ha, the furthest north big base in South Vietnam. This was before Dong Ha was built up. From there we would go to places like Gio Linh and Khe Sanh and out in the hills to the Hill Fights. I’d been in the Hill Fights for several weeks with 1/9 and some of my gear was lost or damaged, like someone had bled all over my flak jacket and it stunk. So one evening I was going through the discarded gear outside the aid station, which consisted of several shacks with sand-bag walls and stretchers with wounded men lined up inside on something like saw horses. I was shuffling around in piles of bloody flak jackets, helmets, web gear, bayonets, ammo and so on and it was dark and misty and evil with the guys inside and the smells and the mud and I felt like a ghost or ghoul or something and was pretty freaked out. I found what I was looking for, though. Photo (above left): Karen people waiting in hallway outside the clinic

So let it go, uh-huh
And so fade away
Let it go, uh-huh
And so fade away
Walk away, walk away (from Bad, U2)

I worked for several years in home health care – the early days, before it was a business. One of the areas I worked was the Cedar Springs Housing Project and one of my patients there was a man living alone with head and neck (oropharynx) cancer with extensive regional involvement, pronounced lymphadenopathy, and cachexia. He had pain, of course, and he treated it with morphine and Vick’s Vapor Rub. He was very sick. Mostly he crawled from his pallet on the floor by the door to the kitchen and bathroom of his small apartment.

Some of the people I worked with thought he should be put in a nursing home or wherever, “so he could get better care.” He knew better and was committed to staying in his apartment. The only food he could take was liquid and he really like eggnog (Ensure was a rare commodity then). The eggnog was a challenge because it wasn’t Christmas time. So I went on ever-widening quests to find the eggnog and discovered that if you look hard enough, it’s there. Photo (above right): father & daughter

So he stayed home for several months and finally went to Parkland where he died.

Some of the details

(For travel in Asia, go to 11/2008-1/2009 & see link below right; backpacking: Grand Canyon 4-7-2009, Winds 9-12-2008, Maroon Bells 7-21-2008, Bandelier 5-23-2008, Big Bend 3-12-2008)

Sorry no photos. The storm last week fried my computer and some other things at the same time. As I wrote in the intro to this journal, I hope when I get old(er) someone will read these to me and I can remember some of the details of how life was.

How life is: I’m writing today sitting in the front room where all the books and many of the artifacts are (thangkas, images, betel gear, textiles, photos, etc.). It’s about the rainiest day I can remember, in the US, anyway. Electricity is still off. Leslie tells me it rained most of last night, while I slept.

David has my car and Nora picked me up to go to the clinic. When we got there, there was water in the pharmacy, work area and rooms 4 & 5. Soon it started raining again. I mopped for awhile, and then the 1st patient was ready and I started working my way quickly through the 2nd and 3rd and on and the water was rising despite several people (the usual type crew – children of two of the promatoras, several students, a volunteer) bailing and mopping and then the electric went out, but then came back in a few minutes. We were sloshing through water about an inch deep in the pharmacy and hallway and now exam rooms 2, 3, 4, and 5 and someone pointed out when we had power we were in some degree of danger of shock. Of course. So we closed the clinic, finished getting meds together for the last patients and Aaron and his students finished with the Burmese people in the hallway.

(Every time there is a big rain the water comes up through the floor into the clinic. We’re in the basement of a 104 year old church (it’s beautiful) and the drainage system doesn’t work very well. For several years we had “sewer gas” in the clinic in the mornings. That wasn’t very pleasant. Now the gas is gone, but the water is still an issue. It’s always interesting.)

So we piled into Nora’s little red car – Nora, me, Julio, Fabi, and Roxana – and started to my house. Columbia flooded and cars stalled in water up to their windows. Same for Gaston, Swiss, and not as bad on Live Oak and when Nora started slowing as the water deepened I’m saying, “Don’t stop, don’t stop.” (You say stop, I say go. You say why. I say I don’t know.) We got to my house and everybody dashed in through sheets of rain and there we were, more or less all piled up in the front room except now Leslie was there and that’s good.

Making me crazy: a few days ago someone asked me for help with psych meds (probably Symbyax or lithium SR) for a homeless person with bipolar. I told him we’re short on these meds and in fact, are switching some of our patients from more effective to less effective because we’re running out and cannot afford to buy them. I also told him that since the person he was advocating for is homeless, he could get care and meds from Parkland or from the Homes (homeless healthcare) van that actually comes to the Stewpot, where the man in need of meds is often found. And I also told him that we only care for people who cannot get services from Parkland and that our energy and resources are finite: if we care for Parkland-eligible patients, we won’t be able to serve those people with nowhere else to turn.

After this conversation he and I and others heard a talk from a well-known physician, including a brief discussion of the shortage of meds for poor people world-wide.

After the talk, the man who had approached me for meds again approached me to say that the patient’s doctor would call me – well, he says, the doctor won’t have time to call, but someone else will (assuming, I guess, that I have time to talk). I again explained our situation and my friend Shirin (who works with the Homes team one day/week) explained about services for homeless people. At some point I kind of lost it and said with some degree of passion, “We’re fuckin’ dyin’ out here, man.” That kind of closed it down, but what can I say.

Starts with a B: my first patient of the day was a woman asking that we help her with meds from an unusual set of Rxs and no distinctive set of signs and symptoms and no papers indicating a diagnosis. She had no money and had been sick with no meds for more than a month. Her diagnosis started with a B and we finally got it: brucellosis! Yes, she said, that’s it.

That’s interesting. Less than 100 cases/year in the US every year and here she was with scripts for 6 meds. We did the best we could, substituting TMP/SMX for rifampin and extending the course of treatment from 2 weeks (what was up with that!) to 6 weeks. So she didn’t get the optimum medications, but at least treatment is now for the proper length of time.

Ballin’ that jack: 52 year old man, complaining of elbow pain. Denies injury. Works digging with a shovel and pick; runs a jackhammer. Oh, right, a jackhammer. I gave him the strongest NSAID we have and some ideas re other measures, but I’m not very optimistic. So I’m making a point of really looking whenever I see someone running a jackhammer in the hot Texas sun and thinking about a 52 year old man doing that and no options. No other jobs out there. Just that. Grateful for it.

I been ballin’ a shiny black steel jack hammer
Been chippin’ up rocks for the great highway.

Doctor say I better stop ballin’ that jack.
If I live 5 years gonna bust my back, yes I will.

I hadn’t seen her in awhile: a woman came in with her two children. She used to come to the clinic and help, read to children and so on. Last time I saw her, her sister-in-law had beaten her up and she was traumatized a little physically and a lot mentally and spiritually. She moved and now was back 4 or 6 years later and her daughter, 5 or 6 years old then is now 10 or 11 and is like a Mexican Valley Girl, with all her gear and clothes and make-up and what not and still a sweet and innocent smile.

A Great Dog, Sadness

13 or 14 years ago Leslie saw a stray dog running free on our street with the dog-catchers after him. He got away from the dog-catchers and Leslie brought him home and he immediately ran from our home. I saw him later that day and thought, what a great looking dog and I brought him home. And so Judo (AKA Buddy) came to live with David, Leslie, and me. His first night with us it was snowing or sleeting and we tried to keep him inside, but he was going kind of crazy, howling and throwing himself about, so around 1am, I let him out in the back yard. I had some straw for the garden and I piled some up close to the back door, made a kind of hole in the top, got him in there and put some more straw over him. He slept all night, curled up, warm and cozy. As our friend Jay put it, he was saved.

David named him Judo, meaning “divine wind.” For months and months he would escape the back yard and at the end of the day turn up on the front porch. He would bring stuff home, like a horrible turkey carcass or a big piece of moldy cheese or most notably, a deer leg – and then another deer leg. He was always a little or a lot wild. It was several years before anyone would put their face close to his. We tried for awhile to find another home for him, but he was a tough sell – fortunately for us.

Judo was half golden retriever and half pit bull. His fur was gold and his head was big and his jaws were impressive. He was a warrior. He loved to fight and every male dog (especially the uncastrated ones) he caught out was sent running and crying or ended up on its back in abject surrender – except for Mr. G, an equally bad boy (chow) that Buddy hated and was hated right back with equal fervor. Their fight was epic and bloody and though Buddy got the best of Mr. G, the fight wasn’t over until Leslie soaked them both down with pepper spray. He was the King of our street.

Except where other male dogs were concerned Judo was a sweet dog. Well, he wasn’t sweet to cats, raccoons, opossums, squirrels, and rats. But he was sweet with humans and female dogs, especially our good old Goldy. Maybe he wasn’t all that sweet. He never tried to get people to play (except for David and me). He never, ever played rough with us – too much of a warrior for that, I always thought. Maybe the best words for me to use to describe him are warrior and dignified.

See him jumping up on the trunk of the car, to the roof, across the hood, to the ground and away. See him leap at the black lab barking, running at him (Buddy never barked as a threat - he always went in silently or with come kind of roar) and see him take the lab down to complete capitulation and whirling in the air (literally) to race up the driveway after the cat that apparently thought he could just walk around any old time. Hear him talk, "Heelllooooo." See him leap up and then over the 5 foot high wall of the Christmas tree fort. See the greatest yawn and stretch, stretching. And every morning, beside my side of the bed - Good Morning to you too. Ahhh, Buddy.

Here is a journal entry 7/2006: Buddy went down for a long count. He hurt himself lunging trying attack two other dogs. For a couple of days he could barely stand until he'd had at least an hour of aspirin on-board. Even with the aspirin, he would fall over when he tried to lift his leg to urinate. Today he's eliminating in every way and able to get up and down without much difficulty. And, when he came inside this afternoon he was helicoptering. AV (Always Violent) Buddy.

Over the years he became uncannily skilled at predicting where we would walk and he would lie down in our path. Door-lying we called it, and he got really, really good at it. It made things interesting going to the bathroom or down the hall in the middle of the night - "Dammit Judo!" Here is another journal entry (3/2009): Door-lying (see photo above), teetering, friendly, earish, innocent (see photo below), perfesser, helicoptering, sensitive nose Buddy, awww, just plain sensitive, donutting, truck-stopping, cute, annoying, always violent, sincere, tufted, awkward-lying, hopeful, appealing, publicity pooping, handsome, noble (see 1st photo) Buddy!

The back injuries happened several more times, and each time recovery was a little slower. His hips were somewhat dysplased and this became more pronounced over time. He’s been on daily aspirin for more than a year and for about the same length of time, unable to negotiate more than a few stair-steps. For the past several months, he’s stumbled 1-2 times every time we walk (which is every morning and every night). His right foot drags when he walks. He has had increasing difficulty lying down and getting up. He has also lost about 90% of his hearing and has cataracts.

The day before yesterday, David and I were working on Judo’s dog house and while we were doing that Judo took one of his trademark giant leaps. It was his last one. Since then he had terrible difficulty lying down and getting up. He cried when he tried to lie down and again when he got up. He could barely walk, but spent too much time pacing restlessly.

So today we took him to the vet, who offered to try a glucosamine and prednisone, the latter requiring 4-5 days off aspirin – and since for a year, missing aspirin caused him pain and because his back and hips were pretty much wrecked on the inside, we said no. So the vet gave him a sedative and within 1-2 minutes he was resting for the first time in days. He was lying on Leslie’s feet and I was sitting on the floor. Oh, what a relief to see him relax. Buddy licked my hand twice. About 10 minutes after the first shot, the vet came in and gave him an IV and he died so quietly.

Buddy died with his balls on and his dignity intact. He was a magnificent dog and he had a great life.

En la clinica

(For travel in Asia, go to 11/2008-1/2009)

Random thoughts in this last week of May, 2009. There were three Burmese (Karen) patients in the clinic today. Diagnoses included depression x 2, anxiety, insomnia, hypertension x 2, diabetes, nodules of unknown etiology, and so on. Two of the patients came in with our outreach worker and one with a woman involved in several Baptist-sponsored orphanages in Burma and on the border. So when Diana, the Grace pastor came down to the clinic for her weekly prayer with patients and staff in the waiting room, we all gathered (since swine flu, no longer holding hands) and Diana began her prayer (translated by Nora), with, “Dear God, our father and mother …” and meanwhile several of the Cristianas were muttering accompanying prayers and babies fussing and a toddler trying to get her mother’s attention, “Ma! Ma!” And there we all were, Mexican, Salvadoran, Karen, Mexican-American, Anglo – hearing and praying a prayer for healing, understanding, acceptance, and gratitude.

Photo above is borrowed from the Smithsonian Magazine article on Amerasians (June 2009). The older man at the table is Thao D (Uncle Thao), who came out of prison dedicated to liberating all people, including Amerasians. Uncle Thao is a Great Man, a manifestation of the beauty we all can be. See the upside down photo of the pretty girl with the checked dress on? I knew her too. Photo below: Pat B and one of her patients in the pharmacy. What a life we lead!

Later I wondered what people thought about the prayer to “God, our father and mother…”

I was saying to one Karen person, that when we were in Burma we were treated with kindness and that the country was beautiful. I didn’t say (and should have) that overall, it seems to me that people in & from Burma have a gravitas, a sense of dignity and substance. Back in the 1970s someone said, like royalty in tatters.

As part of her masters in social work, Erika R spent more than a semester in the Agape Clinic examining mental health disparities among Hispanics. Her most startling finding was that the main barrier to mental health services was that people were unaware of a mental health concern (72%).

(The following are conclusions drawn by me.) In other words, most patients who receive mental health care at Agape did not realize or acknowledge that they had a problem; they thought being depressed was just the way life goes. During the course of care for chronic or acute physical illnesses, patients are often asked questions like, “On most days are you mostly happy or mostly sad?” A positive response elicits further assessment questions and sometimes leads to the conclusion that the patient is experiencing depression and/or an anxiety disorder. Treatment is offered and provided when appropriate – in many cases, including further evaluation and treatment through Dr. K. Photo: in exam room 1.

Memorial Day 2009

I got the below email yesterday. My response follows. Photo taken at Con Thien, by someone else.

Charles,
I'd like to express my appreciation for your articles and photographs. They first caught my attention last year when I tried to find info on some of the guys from Santa Barbara County, especially Jerry Georges. I went to jr. and senior high school with Jerry. I wonder if you would like to see a couple of pages about Jerry from our 1964 yearbook? He was student body president that year.

On my tour I passed very close to your area on my way to Vandegrift and other places up north. I was with an engineer battalion in III Corps.

Let me know and I will be glad to email the yearbook pages. I think you will find them interesting, especially in light of the kind comments you made about Jerry.
Randy

Randy,
Thank you – yes, I’d like to see those pages about Jerry. Don’t know if you came across what I said about an older friend of mine bringing his close friend to our Bible study group a couple of years ago. The friend was from Santa Barbara and as it turned out, was a leader in (I think I have the organization name right) Young Life. Jerry was involved in that organization and my friend’s friend remembered Jerry with great warmth and respect. In my experience, Jerry was a good guy; I’ve come to realize that had he lived, he probably would have been a great man. What a loss. And here we are on Memorial Day.
Charles

"I'll go"

(For travel in Asia, go to 11/2008-1/2009)

Last week I spoke at the main service at my church. The idea was that I would speak to the help given our clinic (Agape Clinic) by the First Presbyterian Foundation. During the service I sat next to Dan F, my spiritual teacher for these past 15 or so years and that was a great honor for me. Here is what I prepared for the talk and pretty much what I said:

A front page feature article in the Morning News today is titled, “Facing an Ailing System – North Texans figure out ways to cope as they find limited remedies for affordable care.”

The Texas Medical Association website reports 16% of people in America are uninsured and Texas is in (where else) last place with 25% of the population uninsured.

At Agape – with wonderful help from this church – we serve the uninsured, the working poor, the people who process the chicken we eat, who mow our lawns, who clean our offices and hospital rooms – we serve the people who cannot get Medicaid, who cannot access services at Parkland or Project Access or Homes or anywhere else.

We serve our patients and families and community with:

• Primary care for acute illness
• Specialty care, including psychiatry, dermatology, gynecology, pediatrics, asthma
• Spiritual care (with help from our wonderful new Grace pastor, Diana Holbert)
• Community education
• Follow-up for patients with chronic illness
• Health screening
• Service learning site students from Baylor, UTSW, UTA and others

We are unique among community-based clinics in that we do all the above AND we are a medical home for people with chronic illness – the Morning News article gives some insight into how hard that is to find.

The FPC Foundation invests in the Agape Promotoras de Salud – the lay health promoters, women from the community (clinic patients) who triage and teach our patients, who teach in the community, who assist doctors and nurses, who provide spiritual care, who are the connections among patients, clinic, and community. When the swine flu thing started nobody knew how it would go – a disaster or just another variation on influenza (pretty bad in itself!). I asked the promotoras if anyone would work the fever, cough and congestion hall with me and Irma said, “I’ll go.”

A moment ago I said, “with wonderful help from this church” – I was referring to monetary help. But I also mean other sorts of help – the support from the men in G5 Men’s Bible Study – and especially I meant the support, when I have nothing left to give, of a church where we’re taught that practicing mercy is a spiritual practice. And it’s not a theoretical teaching – it’s reality here, in the lives of teachers, at the Stewpot, in hospital visits, in support for incarcerated youth, in people’s homes when Cynthia brings communion to the sick and the dying. It’s a good church.

So, on a personal note, it’s good to have a church home and I thank you.

Oink!

(For travel in Asia, go to 11/2008-1/2009)

May 1st & 5th - Here we are in the time of swine flu, nobody knowing how it will play out and the way we’re addressing it at Agape is to triage patients at the door and send everyone with flu-like symptoms one way and everyone else through the waiting room and on into the clinic. Irma, Pat and I are seeing the patients in the fever, cough, etc. area. I’m thinking, well, here I am again.

But what prompts me to write (now that the swine flu crisis seems to have passed) is that I saw this photograph of a young woman named Thao (one of my favorite names) studying in her dorm room in medical school in Haiphong. Check out that desk, and the closet at the head of the bed, and how about the mattress (we're thinking the bottom bunk is the same). An Australian woman we know - Alison - created this extraordinary opportunity for Thao to go to medical school. Thao's family is very very poor (single mother, seriously ill, forages in trash to survive) and there is no chance she would have made it without Alison and you, Alison, are the salt of the earth.

As I think about being back in the mountains, looking at photos of the Beartooths and Wind Rivers, the swelling in my chest feels almost physical. What a great thing it is to contemplate the (likely) reality that I will again stand in the cold alpine wind in the high mountains, surrounded by raw and sublime beauty. What a thing to be here! Alone on a high mountain meadow in August; by icy tarn waters, looking up at the night sky with stars by the millions right here/now, sitting among a million tiny alpine flowers, scrambling across rocky domes, and here come the clouds and soon the snow – first flecks of sleet, more, now the snow – ahhh.

The things that helped me get going into the mountains again include:

• The Sierra Club took me on my 1st return trip – Big Bend for a wonderful time.
• The backpackers.com forum has been immensely helpful in giving me knowledge and inspiration. Hikerjer (words) and swimswithtrout (photos) show the true heart of the matter and I’m grateful to them.
• Always, of course, Leslie, my beautiful understanding and supportive wife (and partner in the back roads and alleys of Southeast Asia).

Clarification on no “I” “to be” – not here, of course; and it’s incomprehensible to think that this “I” would endure beyond death. I mean, what a disappointment to still be regular old me with my weaknesses and faults and lies hopefully (even if still just barely) outweighed by my strengths and goods and truths. AND an infinitely higher I (and of course, thou) seems certain.

When you find out who you are, beautiful beyond your dreams.