Friday, January 31, 2020

Trump in the Hospital

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The Winner Is Kahnfections, 3321 20th St.

I completed my thesis toward the end of 2019 and sent it in. In due time, I got feedback on needed revisions, and sent those in earlier this week. The next day, I got an email from our thesis mentor saying that my paper had been accepted, and so I am done with all of the requirements for my two-year chaplaincy program in Santa Fe except for a 15-minute presentation, which will be the telling of a couple of stories from my thesis, and the graduation ceremony. Flatteringly, our mentor asked if she could share my paper with the palliative care fellow at her hospital; she said it did a “really good job” of explaining the theological foundations of my chaplaincy.

The next task is to put together my actual application for board certification, which, like everything else pertaining to professional chaplaincy, is not a trivial matter. I had the vague idea that it was due in July, which meant that after July, I can sit around on my butt reading when I’m not at work—finally! This whole process began in January of 2016. I checked on that due date yesterday evening and discovered that the due date is July 8, but applicants are strongly encouraged to send everything in as far in advance as possible, to have time to remedy anything that is amiss. I have assigned myself a due date of April 23, which is even better. After April 23, I can sit around on my butt reading when I’m not at work.

Yesterday, I took my thesis and portfolio—a collection of every paper I wrote during the program—to a nearby copy shop and had them spiral bound, and today I mailed them off to school, to be handed back to me at graduation.

At County Hospital, I found there had been a cataclysm in the area of personnel and I was suddenly at loose ends. I went back to the chaplain office to brush my teeth—I had celebrated mailing in my thesis by conducting a croissant taste test while en route to the hospital—and while I was sitting there talking with another chaplain, our priest came in and told me that the person who was the priest at my paying job for six or seven years died unexpectedly yesterday.

He was there when I did my summer unit of Clinical Pastoral Education, and still there when I was hired as a staff chaplain a year later. Several months into 2019, the church leadership called him home to Uganda, where he became the dean of a seminary. Perhaps in the past few weeks, he came here to fill in at a church in South San Francisco; this might also have been a vacation for him. (I’m a little miffed that he didn’t get in touch.) He went to visit the hospital—we have three—where his office was and where he was revered by the staff. Yesterday he was supposed to fly home to Uganda—but he never woke up. He was only 52. He had an emphatic personality. He made me smile.

I left County Hospital this morning after I found this out and went over to the hospital where our priest had spent the most time. I found my co-workers busily putting together a prayer service, which we conducted at noon, giving staff members a chance to start to grieve. I offered the closing prayer, and could hear people crying.

Art of Bugwalk from Long Ago

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Medical Mano a Mano

I continued agonizing about what to do, which greatly increased my sympathy for those trying to make decisions for their human loved ones. It’s hard! I felt that whatever I did would be wrong: Making Hammett undergo an unpleasant course of treatment would be wrong, but wouldn’t giving up too soon also be wrong?

But if both sides of something are wrong, then both must also be right: To choose not to do chemo would be to prioritize his happiness and comfort. To choose to do chemo would be to give him a chance of having a longer life.

The next day at County Hospital, I saw a man in the ICU whose elderly mother had been in an accident. He said, “I didn’t want her end to be like this.” I took him for a walk in the rooftop garden to discuss the surgery the patient’s doctors were planning to do. (Tsk!) The man said, “Would it be wrong to let her go?” I told him that he should feel empowered to decline any treatment for his mother he didn’t think made sense, and then I wondered if I was being too blunt. I couldn’t recall ever hearing any palliative care physician use those words.

I discussed it with Robert, and he said sometimes the chaplain’s role is to be blunt, so I guess that was OK. I asked him if it angers non-palliative care doctors when the palliative care team meets with a patient or family, and then the patient or family declines treatment the primary team was all set to go ahead with, or does that rarely happen because a doctor who believes in aggressive treatment simply won’t engage the palliative care team? Robert agreed that the latter is how it usually goes.

The patient cannot directly request a palliative care consultation. It has to come from a doctor. Usually, a doctor will relay a patient’s request to the palliative care team, but not always. If the patient of a doctor who believes in aggressive treatment requests a palliative care consultation and the doctor does pass on that request, then it can happen that a palliative care attending physician dukes it out with a non-palliative care attending physician. “Clash of egos” is the phrase I believe Robert used.

He said that in such a dispute, the primary team physician will typically point out that he is the one with the longer relationship with the patient and that not two days ago, the patient said she really wanted a fourth round of chemotherapy.

As for Hammett, trying to predict the future didn’t seem to be helping me to make a decision, so I thought about what values might apply, and concluded that any choice I made would be made out of love. Hammett himself was bulking up rather astonishingly, thanks to the prednisone. In two days, he went from 6.75 pounds to 7.5 pounds! He seems happy enough, but not quite like himself. Certain routines he has had for a long time have suddenly been abandoned, though he still does a lot of things he has always done. One new thing is that he has taken to clambering onto my lap, underneath the table, when I’m eating breakfast. It’s nice to have his warm little body there for a time.

Dr. Press had said that if we were going to try chemo, we should start ASAP, because once cancer starts to be resistant to prednisone, as it will soon enough, it also becomes more resistant to chemotherapy. Being urged to hurry up was a red flag. Katy Butler, in her wonderful book Knocking on Heaven’s Door: The Path to a Better Way of Death writes about the perils of Fast Medicine, where people feel hurried into decisions that turn out to have catastrophic consequences.

The following day, I told my co-worker Nevada about my dilemma. She said, “I don’t know about chemo for an old cat. If he were young … .” In the end, something my mother said helped me make the decision, which was not to do chemotherapy. She pointed out that Hammett’s quality of life was not the only consideration—that mine also would be affected. She said that if Hammett were to undergo chemotherapy, I would be worried about it every single day. This is correct. I’d be worried about whether it was working and if he was unhappy. I’d be worried about this symptom and that symptom. I’d be worried about spending so much money. If the chemo didn’t work, I’d be worried about that (and I’d also feel guilty that I had made the end of his life miserable). If it did work, I’d be worried about it ceasing to work—which it is guaranteed to do, sooner or later. (My mother also pointed out that once upon a time, we didn’t have to make these kinds of decisions: If a cat got cancer, it died of cancer, and that was all there was to it.)

So Hammett continues on his prednisone and is still eating like a horse. His cat sitter said he might live years on prednisone. The internet says more like a couple of months, maybe six at the most.

Sunset over the Hospital

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That’s bright red blood per rectum.

A few days after my last post, I woke up to find a good amount of diarrhea produced by Hammett, including a bit of bright red blood. I carried him over to the vet in tears and was relieved when I saw his cat sitter standing out front on a break from work. She said that bright red blood is no big deal; dried brown blood would be the thing to worry about. I thanked her for talking me down, and she said, “You’re going to have to do that for yourself every day.”

Dr. Press agreed about the blood, saying it probably meant Hammett’s GI tract was inflamed. He prescribed antibiotics. (No blood seen since then, or diarrhea.) We had a discussion about chemotherapy and I decided to pay $300 for an oncology consultation. I asked if the cancer had likely metastasized already and Dr. Press said lymphoma is systemic (so, yes, by definition). I mentioned that Hammett’s bloodwork has consistently shown that his kidneys look great in the kidney failure sense and Dr. Press said that labwork cannot detect kidney problems until kidney function is 75 percent gone! This was news to me. Also, the methimazole he has been on for nearly five years for hyperthyroidism is an appetite suppressant. I never knew that, either.

Regarding chemotherapy, Dr. Press said the number-one objective would be for Hammett to thrive and feel great, so if he didn’t seem well after a treatment, that treatment would not be given again, or would be given differently. Dr. Press suggested that one approach would be for me to decide on my budget and we could offer treatment until that amount of money had been spent.

But it seems to me that if $10K might result in seven months of remission, spending one third of that might result in one third of seven months of remission, or even less, and then that would be spending what is still a decent chunk of money for not very much time at all. Also, I could easily see this being a slippery slope: If he seemed better after one month of chemo, I might well be tempted to pay for another, and then a third. Or if he didn’t seem better after a month, I might think that maybe a second month might do the trick.

And I also suspect that if Hammett did seem ill after a given day of treatment, I would be told that of course some fatigue is to be expected, or that I needed to give it a little more time for the chemo to kick in. That is, I think the thing about the number-one objective being for Hammett to feel great would prove to be ephemeral in practice. (That is, hogwash.)

But! What if he actually could have many months of comfortable remission? When I got the oncologist’s report, I saw that some cats actually live years after chemotherapy. I also saw that his suggested protocol was 22 weeks, not the 12-16 originally mentioned, meaning the whole thing would be closer to $15K.

Monday, January 20, 2020


Hammett guarding our new pressure cooker.

Furthermore, I am not sure it is proper to spend a small fortune to keep a terminally ill pet alive for several extra months when there are people sleeping on the sidewalk, even if it is the most precious cat ever, as this picture demonstrates. If there were the possibility of an actual cure, that might be different, but there is not.

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Chemotherapy for a Cat

Now we have arrived at the reason I just put up so many posts in a row: because I needed to say this, and didn’t want to say it and then veer months into the past in subsequent posts. I took Hammett to the vet a couple of weeks ago because he lost a quarter of a pound in one week. His weight had been hovering around seven pounds for a year or so; all of a sudden, he weighed six and three-quarters pounds. I also told Dr. Press that his hind end had looked a little wobbly a few times.

Dr. Press suggested that we do bloodwork and urinalysis, followed by an ultrasound if the first two tests didn’t find anything. The first two tests didn’t find anything. Dr. Press said his bloodwork, including in regard to his kidneys, looked great. I scheduled the ultrasound, and then almost decided to cancel it. Hammett seemed to have perked up, and veterinary bills often seem astoundingly large. But then I decided that it’s just one of the rituals of being a cat owner to periodically pay a small fortune to find out nothing is wrong.

I was standing outside The Butcher’s Son (an all-vegan deli in Berkeley) waiting for a friend from school to join me for lunch when I got a call saying Dr. Press would like to talk to me. I was expecting only a call saying when to pick Hammett up after his ultrasound, so this was worrisome. K. and I paced up and down University Ave. while I waited for Dr. Press to come on the line. When he did, he said that the ultrasound had found two abnormalities: both kidneys looked abnormal, and Hammett’s pancreas was inflamed. It was the day Hammett turned thirteen and three-quarters years old.

“I’m worried that this is lymphoma,” Dr. Press said.

K. and I had an absolutely scrumptious lunch, and an interesting conversation. I was able to put Hammett out of my mind after sharing with K. what Dr. Press had said, but after she and I parted later, I walked to BART in tears and wept pretty much all the way back to the city.

When I fetched Hammett, I was given a bottle of prednisone, which Dr. Press said to start right away. It was in liquid form, and was a nightmare to administer. Hammett, a sick little cat of six and three-quarters pounds, fought like a champion wrestler to avoid it, and after I got it into his mouth, he foamed at the mouth horribly.

We went through the same ordeal the following morning, the following night, and the morning after that, while we waited for the results of a needle aspiration of his kidneys. By then, I was ready to euthanize that very day, before I had to put Hammett through taking prednisone again. The bottle said it had to be given every 12 hours, and the person at the front desk at the vet had said those instructions had to be followed precisely.

Dr. Press called that day to say that Hammett does indeed have renal lymphoma. I had been thinking that if it turned out Hammett had cancer, no way was I going to agree to chemotherapy for him, but that is precisely what Dr. Press suggested. He said only 10% of cats get sick from the chemo, and that it has an 80% chance of affording a remission of 10-12 months. Hammett would need to spend one day a week at the vet’s for three or four months, at a cost of $600-700 per treatment: $10,000 total, give or take.

Dr. Press said the prednisone does shrink tumors, but only for “several weeks.” He said that chemo would not be an option unless Hammett responds well to the prednisone. I said that if he did respond well to the prednisone but I was unable to spend $10,000 on cat chemotherapy, would he support Hammett’s being euthanized in that case? He said that he would, and that we could also discuss some cheaper options.

As for the prednisone, he said it comes in pill form, and that the doses do not have to be 12 hours apart. He said you can give them one hour apart if you feel like it. I went and picked up the pills, which are very easy to give Hammett using a pill shooter.

At the moment, he is doing fine in that he is eating, pooping and peeing, and seems reasonably content. He’d lost even more weight when I weighed him yesterday.

I have shed many tears since the day of the ultrasound, and even had moments of suffocating panic, for instance, when I picture the spot by the wall where Hammett likes to lie on a sunny day. It is a beautiful sunny day, but he isn’t there, because he is dead. The sweetest, most placid and most precious cat on earth has gone. I am trying to balance the natural and real experience of anticipatory grief with not terrifying myself with excursions into the imaginary future. It will be a future version of Bugwalk who sees that spot with no cat in it. It’s not happening right now.

I have mulled over the chemotherapy option. If I had to, I could come up with that money; I would be spending money I had planned to save. I love the thought of having ten or 12 more months with Hammett. Saying no to the possibility feels like I’m doing something bad to him, but that is not true. There will never be a moment when he thinks, “I’m angry that she deprived me of what could have been ten great months!” It’s all the same to him whether he has a peaceful death ten minutes from now or a year from now. He will not be able to judge the difference between those; he won’t be here to do it.

What he can tell the difference between is whether he’s snoozing peacefully in his little bed by the radiator or being stuffed in his cat carrier and hauled over to the vet. Even if he was going for a weekly spa day, he would not enjoy having to leave his house. Also, I have a gut feeling that he would be in the 10% made ill by chemotherapy and/or the 20% who don’t end up in remission. He has had a number of health challenges throughout his life. I wish he were going to live to be 20, but it’s wonderful that he made it to be thirteen and three-quarters. My mother’s favorit
e cat of all time died at just seven or eight years old. Dr. Press commended me for having taken “meticulous” care of Hammett.
Hammett has cancer. He is going to die. I understand from the Internet that chemotherapy is much less awful for a cat than for a human, but I have decided to embrace the inevitable and focus exclusively on his quality of life. Once that is gone, I will have him euthanized. If possible, his last day will be a good one, or at least not totally terrible.

I named this post as I did this so others in the same boat might find it. I have read so many posts from people who are glad they chose chemotherapy for their cat that it made me worry that I am doing the wrong thing. But working in palliative care, reading book after book about it, and having just written a thesis about it have bolstered my feeling that it is OK to make a different choice, as has talking with trusted advisors, including Lisa C.; both of my parents; Hammett’s cat sitter, who is a vet tech; and, somewhat weirdly, the manager of my apartment building. There has been some strain between us since the flood in May, but after I texted her about Hammett, she immediately sent a warm and loving response, with many heart emojis, and told me to follow my heart when it comes to choosing care for Hammett.

I have found out what his own vet charges for euthanasia and cremation, and have also spoken with an emergency animal hospital that is always open, and with a vet that does house calls. (The latter said that if you arrange for euthanasia at home but change your mind by the time the vet arrives, they just charge for a consultation and go away again. I thought that was nice. That is precisely why Thelonious was euthanized at the emergency animal hospital: I couldn’t bear the idea of waiting for someone to come over to kill my cat. My mother kindly said, “You don’t have to do that. If it would be easier to take her somewhere, then it is fine to do that.” Tom came with me.)

I can clearly remember the day I adopted Hammett. I remember the first night he was here, looking fearfully over his shoulder at Tom, and crawling up into my armpit after I went to bed.

Here’s the first line of the medical log I have kept for him all his life:

Adopted on 10/14/06. :-)

How quickly it has gone.

Breakfast of Bugwalk

I've been trying to think of a name for this salad I have nearly every morning and haven't come up with anything that seems quite right, but here's what it looks like. There are two cups of tea because I used to finish my first cup of tea and wish I had another, so now I just make two to begin with.

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Triple F Breakfast

I went to visit my parents, and sister, and Amy and Ginny, for Thanksgiving, which was great, as always.

Early in December, a young woman who had been sitting for hours with her father in the ICU left the room while a brief procedure was performed. While she was in the cafeteria, she heard a Code Blue called for her father’s room and went to ask the front desk, “What does that mean?”

The answer was, “Go back to his room.” By the time the daughter got back to the ICU, her father was gone. We sat together, mostly in silence. After awhile, the daughter asked, “What do people usually do?” She meant, what do people usually do right after their parent dies?

I said that, in my observation, they do pretty much what she was doing: sit there and let feelings and thoughts rise to the surface. “You’re doing it right,” I assured her.

I considered that she might actually be in shock and thought of a breathing technique useful in such a situation, but then considered how I would feel if someone in my family had just died and someone came in and told me how to breathe, so I did it myself and it was indeed calming. (Box breath: inhale for a count of four, hold for a count of four, exhale for a count of four, hold for a count of four.)

After a while, the daughter said, “Odd that someone has closed his eyes for him when he could do that all by himself yesterday. Odd that the doctors are in the hallway discussing the patient next door, when this has happened in here. How do they do that every day? Yesterday they were outside this room, discussing my father.”

I asked something I don’t think I’ve asked before in these words: “What did he love?” Rather than the more clinical, “What did he enjoy?” His daughter told me what he loved, and I put all of it in my chart note.

Later I visited a fellow with serious illness and onerous treatment, and asked him the same thing: “What do you love?” He looked blank for a second and then his face lit up: “Two things: Music. And food.”

He asked about the End of Life Options Act. “Is that suicide? Like, what would the Catholics say?”

Catholics are now OK with it, which he seemed relieved to hear, having been Catholic in his youth. But later I remembered something I was taught at County Hospital about not answering that question in a way that gives someone permission to commit suicide (not that the EOLOA is synonymous with suicide). I think that was in the context of mental illness, but it would probably be better to say—not “What do you think about whether this would be suicide?”, which would be kind of obvious and kind of lame, but to try to understand what is hard about the life the person is living.

At County Hospital, I visited a quite old and quite miserable man for whom nothing was going right. He said that he was unable to tell his relatives how lousy he feels. He said they make it clear they don’t want to hear it. When I left, he said, “It’s been so wonderful to meet you. What will I do when you’re gone?”

Late in December, I went to Berkeley to have lunch with Lisa M. at a wonderful Mexican place. 

On Christmas Eve, Tom and I drove in his co-worker’s car to Sacramento for a splendid Christmas Eve with his family, including another of Eva and Sarah’s amazing feasts. Tom’s mother, Ann, very generously put Tom and me up in a hotel right across from her place that night. She got us a suite so that we could have separate rooms! The next day, we had Christmas dinner at the place where Ann lives, and spent several hours just hanging out. We had to do this in the lobby, because Ann got new carpet not long ago and three seconds after I went into her apartment, I felt I might keel over. Thank goodness I had this experience before they put new carpeting in my apartment (because of the flood last May). I told the building owner I would love it if they could install something not toxic, and she said that should not be a problem.

My friend Lesley and I got season tickets to Berkeley Rep and went for the first time at the end of December. We had lunch at Au Coquelet beforehand, and saw Becky Nurse of Salem.

I told my father on the phone about my salmon salad, which involved, at the time, canned salmon from Vital Choice, black pepper, toasted sesame oil, hot oil, mayonnaise, minced fresh ginger, pressed fresh garlic, and a chopped pickle.

“Can you even taste the fish?”, asked Dad. Then he told me about his Triple F Breakfast: fish, fiber and fruit. This is half-and-half canned mackerel and salmon, oat bran, and blueberries.

“How does that taste?”

“I’ve gotten used to it.” It must be enjoyable, because the final sentence of the official recipe, provided later via email, reads, “Mix with teaspoon and enjoy.”

Here’s the exact recipe, in case you’re ready to enjoy radiant good health:

Add to bowl and set aside:
   heaping 1/3 cup frozen herbicide-free Canadian wild blueberries

Add to 1-quart saucepan:
   1/4 cup    organic oat bran
   2-1/2 oz   mixed Alaska sockeye salmon / Pacific jack mackerel
   2/3 cup    warm tap water

Place saucepan on medium heat and stir occasionally. Remove from heat just before contents begin to stick to bottom of the saucepan. Pour and scrape saucepan contents onto the blueberries in the bowl. Mix with teaspoon and enjoy.

Bird Family Calendar

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(The title of this post is sometimes seen in a medical chart. It means acute renal failure in someone who already has chronic kidney disease.)

As I was walking to County Hospital one day in November, I heard the sounds of a speeding car and a siren. Then I saw a small black car race past, driving toward oncoming traffic. At the next corner, the driver tried to turn right in front of the car that was about to go through the intersection, and there was a loud crash. Two or three police cars roared up.

Considering that the next thing to happen might be the driver shooting at the police and maybe accidentally hitting a chaplain, I considered changing my route, but saw that at least one person was still walking toward the scene, so I did, too, and came upon a young black man lying spread-eagled in the street, surrounded by several police officers with their guns drawn: rifles (I guess) and handguns. Passersby were collecting on all four corners, many filming the action with their phones. We were instructed to remain on the sidewalk.

I realized I might be about to see the police kill someone in front of my eyes. There was a long breathless moment. The police told the suspect to rise to his knees and move slowly backward toward them. He complied, and they put handcuffs on him, and then put him back on his stomach. The officers did not seem angry or agitated, and their actions did not appear to me unduly rough, though later when I pictured myself walking backward on my knees in the street, I could well imagine that would be extremely painful.

One onlooker, another young black man, saw it differently. He began screaming, “Y’all don’t got to be so rough! This is another black man. You bitches are being rough, and you don’t got to be so rough.” As he stalked off, he added, “Yeah, I said it.”

One police officer stood with a rifle pointed at the trunk of the car until another officer popped the trunk lid and it could be seen that there was nothing of interest in the trunk. After that, we were allowed to cross the street and move along.

At County Hospital, I spoke with a man who had been told he had about two months to live. He said that, on the one hand, this news was shocking, after a lifetime of good health. On the other hand, he said he had had a feeling something like that was going to happen. When I asked what he planned to do with his remaining time, he said a lovely thing: “I’m going to let it turn into an epiphany. I’m going to let it surprise me.”

Another patient that same day said something similar, about kind of knowing he was going to get bad news about his life expectancy. This patient planned to spend his remaining time making amends and trying to be stress free and happy.

Around that time, Carol-Joy came to town. We had a delicious lunch at Udupi Palace (vegetarian Indian food) and spent the afternoon playing cards while workers put up drywall in my apartment (because of the flood last May).

When I arrived at work one day, I shared news that I considered calamitous with two co-workers. One looked grave as I spoke; the other was smiling, which made me feel a bit aggrieved: why is this a time for smiling? I got to apply this lesson just two days later, when I visited a patient I’d seen several times, who had just learned she has only months to live. I realized that I was smiling pleasantly at her, and immediately stopped.

A young volunteer at County Hospital once said of a patient, “He’s a talker talker.” So is this patient. She can easily produce an hour and a half or two hours of seemingly uninterruptible discourse, but in a relaxed manner. It doesn’t make me feel tense to listen to her, but it is by no means a conversation in the conventional sense. This time, I deliberately interrupted her: “I’m sorry, I am interrupting you. This has nothing to do with what you’re saying. We don’t have to talk about this. I just wanted to ask you two questions that you can think about later: Who will you be able to discuss this with? And what do you want to do with your remaining time?”

She said something about a thing she would like to do while she’s still alive, and then she returned to her normal topic, which is the doings of her relatives. (On one occasion, one niece cussed at another. “She didn’t curse. She cussed. Cussing is different from cursing.”) Every 20 minutes or so, she briefly returned to the topic of what she would like to do in her remaining time, so I knew she was thinking about it.

Later, I interrupted with a third question: “Would you like to share what you have learned in life with your relatives, maybe by making a video or an audio recording, or writing it down?” She said she would be most likely to make an audio recording, and then changed the subject again.

This patient does not use humor as a defense mechanism, but she also rarely displays sorrow or any form of fear. I let my own feelings of sorrow arise as I listened to her, partly about what is happening to her, and partly just free-floating sorrow. She did become tearful once or twice, talking about relatives who are no longer living. I don’t know if that was because of the sadness I was consciously letting myself feel, but I have noticed that there does seem to be a correlation between my tuning into emotion when with a patient and the patient doing the same.

Lost World

In the days after the retreat, Lucy and I took a boat ride halfway around Manhattan and back, and we saw Ain’t Too Proud. We had dinner with her husband, Ricky, at the Westway Diner one evening, and at a deli near the theater district the next. I discovered that La Bergamote has fantastic croissants. I walked around and revisited many of the sites from the street retreat. I went to meditate one noontime at the Village Zendo, which was really lovely.

Several nice votes of confidence turned up early in October, when I was invited to interview for the first-ever paid chaplain position at County Hospital around the same time that I got a note from one of my former Clinical Pastoral Education supervisors saying I might be hearing from someone about another chaplain job here in San Francisco and that she had sung my praises. I was also contacted about co-facilitating a new Buddhist meditation group started by an organization that has volunteers walking around all night every night, in the worst neighborhoods in the city, to offer emotional and spiritual care, along with referrals. They offer phone counseling during the same hours. The Faithful Fools is hosting the new meditation group at its place in the Tenderloin. There are four of us helping to lead it. Each week one of us is the facilitator, and another is the door person.

The interview at County Hospital was a pleasure, because it was with Clementine and Helen. I didn’t get the job. It was a huge honor just to get to interview for it; it rightly went to the person who has been doing it on a volunteer basis for several years. I probably would not have been able to accept it if I had been offered it, anyway, because it wasn’t enough hours to replace my current job, but too many to do in addition to my current job. I am perfectly happy with my current job, so it all came out fine. I also talked to the person in regard to the other job, and it fell into the same category.

In mid-October (almost caught up!), I got an email from my father about “renovations” to my childhood house. The house was bought by friends of people who own the house next door. The latter have put such a huge addition onto their formerly charming home that you can probably see it from outer space. Alas, that is probably what is now going to happen to the house where I lived from ages seven to seventeen. Three sides of it have been torn off, and the stucco peeled off the front. The last time I saw it, when I was visiting for Thanksgiving and drove past, my mother’s white curtains still hung in the study.

Anyway, the day after I got that initial email about the renovations, the first word I heard when I turned on the radio the next day was “house.” Ann Patchett was on Forum talking about her new book, The Dutch House, saying that we all have a special house that we remember. Talk about felicitous timing. I called in and got to share on air my sorrow about my house. Ann Patchett kindly said something like, “You’ve called the right person!” She went on to say that life gives us continual practice in letting go, because it is one loss after the other.

Pictures taken recently of pictures taken long ago of my childhood backyard.

Lately The New York Times website has been making me log in every time I visit, a new thing after quite some time of being a digital subscriber. Someone in tech support there said to try using Chrome. Fairly often, The New York Times runs an article about how to protect one’s digital privacy. One way to do this is not to use Google for searching, but instead to use DuckDuckGo. Funny that I would have to use Google’s browser, Chrome, in order to  access The New York Times online so I can read their advice to avoid Google! Needless to say, I will not use Chrome. If their website absolutely won’t work with Firefox, then I will consider ceasing to subscribe. What will probably actually happen is that I’ll just have to log in again every single day, and be disgruntled. I can do that.

At work one Saturday near Halloween, I saw a whole bunch of little kids in the lobby wearing Halloween costumes. It was the annual NICU graduation party! These were all children who had been in the NICU at some point. Many were just babies. It would have been adorable enough just to see all the little faces, but to think that every single child had been gravely ill …

I have acquired a T-Fal pressure cooker, which I love very much. How amazing to have garbanzo beans cook to perfection while I’m having breakfast, and without having them boil over onto the stovetop.

Another thing lost, though not recently, is my great-grandmother. Here she is decades ago on Daytona Beach.

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On the day this photo was taken (from my kitchen window), namely September 10, 2017, it had rained or been overcast for so many days in a row that the sight of blue sky brought a burst of joy.

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You’ll See What You Do

In mid-September I flew to NYC and spent one night at Leo House. The next day, I had about four hours free between when I had to leave Leo House and when the retreat began, so I walked over to the Hudson River and made my way slowly, slowly south and then inland again.

Here is the paper I wrote about my retreat for school. I could have written fifty times this amount.

What I Thought Was Going to Happen
Several months before the retreat began—as one of the co-leaders observed, the retreat starts the moment you sign up—I listed my worries:
•    Having to pee outdoors. (I was not worried about having to poop outdoors, because I was planning to suffer a ruptured colon rather than do this.)
•    Having a rat walk on me during the night.
•    Having my suitcase not be wherever I had ended up leaving it when I returned to retrieve it.

I was also kind of worried about going four days without brushing my teeth or flossing, I expected to be in intractable physical pain after skipping my daily exercises, and I assumed that all items of clothing would be so filthy as to have to be thrown out, along with the blanket acquired for the retreat.

I had secretly planned to cheat and to bring plenty of handkerchiefs tucked here and there, and also the lip balm I use ten times a day, but in the end, I did not bring either. (Having received a diagnosis of arthritis in both knees a week earlier, I did bring a lacrosse ball, and that was invaluable for loosening up corporeal tight spots.)

The first night we slept on the sidewalk, I was at one end of a row of retreatants. It occurred to me that I was a bit vulnerable in this position: what if someone were to come along and kick me in the face? I wished I were one of the interior people, but it seemed that it would not be very gentlemanly to ask R. to take the outside position so that I would be less likely to be kicked in the face.

What Did Happen
None of the things I worried about happened. I was never kicked in the face. Thanks to the lawsuit against Starbucks, and thanks to the ubiquity of Starbucks and Whole Foods, I never had to pee outside. A rat did not walk on me during the night; I never saw a rat. (When I asked co-leader J. what I would do if this happened, he thought for a moment and said, “You’ll see what you do.”) One of the retreatants let us put our valuables, along with my suitcase, in her apartment overlooking Washington Square Park, where we met on the first day (six women and six men), and it was still there after the retreat!

I even got to brush my teeth, usually without toothpaste and never with flossing. Our first evening, we had dinner at the Bowery Mission, and when I asked the fellow at the front desk if he had a toothbrush, he gave me one. I would have gone right into the restroom to use it, but someone said that the restroom had been smeared with feces.

I had scheduled, for immediately after the retreat, a visit to my dentist, a massage, a visit to my chiropractor, and a facial. None of these was needed. I was not in pain, my pores were not cemented shut, my teeth were not coated with rock-hard scum, nothing was so filthy that it had to be thrown out (though I did give away the fleece blanket, because if I ever do this again, it will be in a sleeping bag).

Retreat Humor
Before one afternoon council, co-leader J. asked how long we should sit.

Bugwalk: 45 minutes.

R: 50!

J: Until the sun goes down.

Bugwalk: Until the sun comes up.

R: Full sesshin!

What I Learned / Associated Insights
When it comes to sleeping outside, the more cardboard, the better, and it’s best to overlap the pieces than simply to place them alongside each other, but be careful about where the overlaps are; that little ridge can produce a surprising amount of discomfort. Our first night outside, it seemed as if I changed position every three minutes, as any configuration immediately produced pain in one area or another.

A fleece blanket does nothing to keep out wind. On top of experiencing pain in one part of my body or another all night long, I was freezing cold and envied those who had thought to bring a sleeping bag, though I could also see that others were also feeling miserable; one yogi kept giving up on lying down at all and just sat up, with a barricade of cardboard arranged around her. The faint blue light signaling morning seemed years away, yet came surprisingly soon, and was very gratefully received. (“Thank God!”)

I did not ever notice the lack of lip balm, and the need for something to blow my nose on was easily met by taking some extra toilet paper each time I visited a bathroom; thus the pocket of my backpack ended up stuffed with wads of toilet paper, more than I needed.

The Bowery Mission forces you either to sit through a religious service before you eat, or to go to the back of the line. Either way, the whole thing takes the better part of two hours, so that by the time you’ve had breakfast, it’s time to start finding lunch, and by the time you’ve had lunch, it’s time to start finding dinner, and then it’s time to look for cardboard and a safe place to sleep. Given that it takes nearly the entire day just to eat and drink and eliminate what one has eaten and drunk, the gulf between getting the most basic needs met and, say, showing up clean and neatly attired for a job interview or training program interview seems dauntingly, heartbreakingly vast. (Also, where would you leave your stuff while you were doing this?)

People are incredibly kind. As we slept on the front steps of a church at 51st and Park Avenue one night—I actually got a pretty good night’s sleep there, under the glaring lights and amid the unbelievable racket, including protesters with megaphones assuring all within earshot that they love Sisi and love the Egyptian Army; the hotel for the United Nations General Assembly dignitaries was just a block away—three or four African American men appeared with large bags stuffed with all kinds of goodies. I’m crying as I recall them saying, as they left these dazzling gifts, “Be safe. Please be safe.” The reusable bags contained clean socks, deodorant, toothbrushes, toothpaste, a piece of paper listing places offering free meals, lots of food, tissues, fragrance-free wipes, hand sanitizer.

I stayed on for several nights after the retreat, at Leo House, where I observed, on the one hand, the incredible luxury of having a clean bathroom and bed and upholstered chair indoors and all to myself. And I also noticed that in each moment, there was simply what was seen, what was smelled, what was physically felt, what was thought, etc. It was safer, cleaner and more comfortable. It was great, but it wasn’t sudden and permanent bliss; it was just what it was. It was also a little lonely, after several days of doing nearly everything in a group of 12. Suddenly I only had to count to one to account for the whole group.

I think B. deserves a section of his own. A person with 35 years of experience being homeless in Manhattan and elsewhere, he joined us during our opening circle and stayed for the whole retreat, crying out a loud “ooh-OOH!” to get our attention when needed. (A couple of others in the group took up the same practice.) He was an invaluable source of information about many things, including where and when to find cardboard and what to do with it the next day. His feet were visibly misshapen, and he told us that walking was painful for him. It was touching to me that he was desirous enough of our company that he was willing to walk miles and miles on those twisted-up feet, not without periodic complaints that we were walking too fast, and also, that we were not very good at choosing efficient routes. He also threatened / promised to leave us a time or two, but allowed himself to be dissuaded. (Co-leader J., kindly: “What do you need from us?”)

I perceived that B. was often in need of a listener. At almost every moment of making our way around Manhattan, B. was far in the rear with one other person, a kindly and patient listener; co-leader P. did this for hours. B.’s conversation did not end when silence began each evening, after the dedication of merit, either. Our first night outside, on top of being physically uncomfortable and also freezing, I was kept awake by B.’s 90-minute conversation with a friend of his who had happened along. I was furious the next morning, and had a word with him about it, which he received very gracefully. (However, a night or two later, he kept me up again, this time chatting with a person he later told us was Trump’s cousin’s chauffeur / bodyguard.)

Co-leader J., not having the luxury of an hour for a nightly dharma talk, did a fine job of guiding us via short bits of instruction here and there. On the morning of our second full day of retreat, he said the sense of not knowing might be wearing off a little bit and that we might need to make a conscious effort to cultivate this, for instance by not getting into long conversations with our fellow yogis about our non-retreat lives. He also said, “There’s no right and wrong decisions. It’s just coming and going. We learn from everything.” He described an exchange between a student and Bernie Glassman, who originated the Zen Peacemaker Order street retreats, about panhandling, where the student said something like, “I don’t want to panhandle! I’m not homeless. I feel weird taking money from people who think I’m homeless when I’m not.” To this, Bernie said something like, “Where is your home right now? Is it here? Are you one hundred percent positive you’ll see it again?”

The end of the retreat was extraordinarily emotional for me. At our final council, I cried as I shared that I was born wanting to know what was going to happen next: Where are we going? When are we going to come back? Who is going to be there? When I was a child, I believed that knowing meant I was loved and seen, but now I see that maybe it is just the opposite: maybe having to have a tight grasp on—what’s the word?—everything cuts off energy, love, relationships.

As several of us headed off to retrieve our stuff, I watched B. walk off into the park and began to cry again. I sobbed, in fact, and tears arose several more times in the course of the next hour or so and even in the coming days. B. was a huge presence in our group, vivid and real, at moments very helpful and at other moments definitely irritating. By the end of the retreat, he also had a pretty strong urine smell per a mishap outside the scope of this account. As he limped into the park, I realized that, in a way, I was watching him turn from somebody into nobody: to those now seeing him, he was just another old, evidently homeless black guy who smelled like pee. It was incredibly painful. (And it was also rather romantic and condescending on my part, as I realized later. In fact, the genuine toxicity of racism aside, B. and I are equally somebody and nobody—loved by some, disliked by others, not noticed one way or the other by most.)

Applications to Chaplaincy
Things are no less or more certain now that the retreat is over. It’s just that on retreat, I was more aware that I didn’t know what was going to happen, which made even rather ordinary things seem miraculous and surprising: I’m sitting right near a children’s playground! I didn’t know that was going to happen! It is a substantial gift to realize that I still don’t know what’s going to happen, now that I am back home, and never did, including with each patient I visit.

Exactly two weeks after our final night on the sidewalk, a homeless man just a 25-minute walk away was bludgeoned to death as he slept, along with three others in other locations in Chinatown; a fifth victim went to the hospital with critical injuries. Having slept so near that spot made this horrible act of cruelty even most disturbing. Possibly the victims were at the Bowery Mission for a meal when we were there for the same reason. Possibly we might even have recognized their faces.


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Exfoliation Countdown

One of the street retreat’s co-leaders—I’m talking here about the street retreat in New York City that I did in fact attend last September—said the retreat begins the moment we sign up for it (and someone else or other said it never ends, in that it reverberates forever). At the time I made these notes, I was thinking that at least the former was true, based on the fact that as soon as I decided to do the retreat, six months beforehand, I began worrying about where to leave my suitcase. (I now think the latter is probably true, as well, though it hasn’t quite been forever yet.)

At first I thought I would just fly to NYC overnight and then embark, exhausted, on the retreat, but then I decided that was stupid and that the best thing one can have prior to four lousy nights of sleep is a good night of sleep, so I booked a room at Leo House for the night before the retreat, plus the four nights after.

The obvious place to leave my suitcase between stays at Leo House was at Leo House, but they firmly declined this opportunity. I considered mailing the entire thing to myself at UPS, or sending myself a box with just the essentials, or just doing without. Some people do not have fresh clothes to change into. Some people do not have a toothbrush or floss. I could pretend to be one of them. (Even the most unfortunate indigent, of course, has several clean, folded handkerchiefs placed strategically about her person, as I planned to have.) But then Lucy, my NYC associate, said she had no intention of going to a Broadway show (after the retreat) with someone who appeared to be homeless, so then I considered leaving my suitcase at a place called Schwartz Travel in NYC.

In the end, it was not settled until a week or so before the retreat began. One of the co-leaders said she knew someone in Manhattan who could keep our stuff. Right around then is when I was diagnosed with mild arthritis in both knees, on the same day that Hammett was diagnosed with a  heart murmur. However, I had been faithfully doing the exercises prescribed by my chiropractor, and my knees were detectably starting to feel better. (The key exercises are to stretch the IT bands and quads, using a lacrosse ball and a foam roller. This was excruciatingly painful at first, but after a couple of weeks or so, was less so, and in some spots it even began to feel painful in a pleasant sort of way.)

Right after my final shower before the retreat—five days prior—I had to force myself not to start counting the minutes until I could exfoliate again. The next day was my final shift at work. The morning after that, I was lying in bed semi-awake when the pager went off. Fortunately, I had been in bed for 12 hours and it was a bit less than an hour before the next chaplain was due to start. Since we have a one-hour response time outside of normal work hours, whatever it was was technically the next chaplain’s thing to respond to, but it turned out it was a dying baby, so I leaped out of bed and made it to the hospital 21 minutes after the pager had gone off.

This was my first time doing an emergency baptism since the miracle baby, and this time I went ahead and unabashedly prayed for a miracle. I don’t have to align with what seems biologically possible. The room was full of doctors and nurses who were working as hard as they could in that realm. I am the chaplain. I am in charge of invoking the sacred and the mysterious, and so I did. (Or if that is a bit too pompous, let’s say that the chaplain has the luxury of referring to these things.) The baby’s mother was weeping, and so was I, at the sight of the baby with her eyes closed, with a bit of blood around her mouth. She just looked so little and so vulnerable.

I went on to say, to God, that sometimes we get the exact opposite of what we want, and that if we get what we think we cannot stand, what we think will break us, we need God to remind us that this is not so. Our hearts are large enough to contain whatever we are given to bear. If the unthinkable happens, we can still feel, and we can still love. (I stole those last two phrases directly from one of my fellow students in my chaplaincy program in Santa Fe.) I finished with the Lord’s Prayer.

Cutest Cat Ever

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Visiting Scheherazade

One day at my paying job last August (yep), I had an unusual number of very long visits, including one early in the day that was 95 minutes long, and one at the end of the day that was 100 minutes long, which took me well past my normal stopping time. In both cases, I couldn’t figure out in the moment how to get out of the room; there was no obvious pausing point. I felt like I’d had two visits with Scheherazade. However, getting out of a room is something I can actually do, as long as I remember and am determined: “I’m sorry—I will have to go in about five minutes. Is there any last thing particularly on your mind?”

As I wrote my chart note for the last visit, I realized that my ex-boss would scold that it looked more like the note of a social worker, and I wondered if that had anything to do with how utterly exhausted I felt when I got home, plus that whole evening, and the whole next day.

I wondered if I should be trying to make my visits true pastoral conversations, or is it inevitable that many conversations will have nothing to do with the patient’s religion or spiritual practice? I believe the answer is yes: I should be mindful that I am a spiritual care clinician, and people are  going to talk about whatever they need to talk about. It is also very clear to me by now that if I’m going to find out what’s really going on with someone, patience is required. It can take an hour to find out what is really on someone’s mind on a given day.

Late in August, the group of people who are in the chaplaincy program in Santa Fe and who live in the Bay Area met for tea. Afterward, I attended a small and congenial vipassana meditation group in the Castro for the first time. I decided that I would attend regularly, but have not been back since.

My knees had been killing me since June, unprecedented both in duration and the intensity of the pain. About that dance party after the talent show at school: One knee was giving me particular trouble at that point. While dancing, I did not notice any pain, but the next day, I very nearly could not walk at all.

I saw the wonderful chiropractor again after I got home from Santa Fe, and continued to do what he said to do, and at this point, my knees are basically 99 percent fine, as long as I do my exercises every day. My mother, who has had two knee replacements, worried that it might be time to see an orthopedic surgeon, so I did. He said that my basic problem is that I’m aging. He also said that the amount of degeneration does not correlate with the experience of pain. Some people have horrible degeneration and little pain, while others have the opposite. As for my particular knees, he said he could do surgery, or inject steroids, or I could find a set of exercises that keep pain at bay and do them faithfully. Basically, he validated the approach of my chiropractor, and he agreed that when there is pain, it’s something to do with the kneecaps.

At my paying job, I was thrilled to see that a doctor had pasted a few sentences from one of my chart notes verbatim into her chart note. I ran and told my boss.

Once upon a time, if we called a priest to come during the night, we were required to be present to act as the priest’s host and chart what he did. This was under my former boss. Late in her tenure, she changed her mind and said we could just call the nurse to confirm that the priest had visited and make a note of it in the patient’s record. Our new boss has instructed us to go back to the original procedure, and I was getting ready to feel disgruntled about it when I remembered that it is absolutely moot. We used to be attached to a church that actually would send priests over at 3 a.m. to provide Anointing of the Sick (formerly known as Last Rites). Now that we have moved to the new hospital, we are attached to a church that won’t even answer the phone after 5 p.m.

Early in September, Tom and I went to see his mother, Ann, in Sacramento. It was a gorgeous day, and it was nice to be with Ann, as always. The following day, I went to see Carol-Joy in Novato, for lots of eating and card playing.