Fail, fail, fail, fail, succeed

2 Strokes, A Respiratory Failure & A Suicidal Ideation

You’re the charge nurse in a busy NYC ER and it’s the middle of a business-as-usual busy day. In your main ED you’ve got 2 docs and a PA, 5 nurses, 2 ERTs and 46 patients. It’s 6:30 PM and there’s a shift change at 7.

You get a “notification” from EMS that a stroke in progress will arrive in 5 minutes. Just as you hang up the phone your walk-in triage nurse approaches you and says “I have an active stroke that just walked in.” Your mind is already figuring out where you’re going to put these critical patients and which doc and nurse will get them when your unit clerk calls out “EMS notification on the top line.” You think “WTF – is she talking about the stroke note?” Nope – there’s a respiratory distress coming in 5 minutes! Now your mind shifts gear and you realize the PA will have to take the respiratory distress and you’re quickly figuring out which patient to pull out of a room since you now have no beds. You also realize you have no one to triage since your internal triage has one stroke and you have your boss triaging the second stroke, so in the middle of this shit storm you’ll have to triage the respiratory distress…

Just as this is happening, your walk in triage approaches you with a “suicidal ideation” that is hearing voices and wants to kill himself. She calls security for a 1:1 and you think “Ok, that’s covered, I’ll deal with it once I make sure everything is under control with these other critical patients.” Since you have run out nurses you assign it to yourself.

Fifteen minutes later both strokes are at CT and have had a neurology consult, the respiratory distress is on BiPap, and security is calmly cataloging the SI’s belongings.

Not one person has complained, raised their voice, or even gotten excited. Everyone is taken care of quickly and I prepare to give report to the night charge nurse. I mentally take a moment to acknowledge this in my mind, and I think of how fucking cool my colleagues are and what a privilege it is to work with them.

I love my job.


I think we met at 14, it might have been sooner. But 14 was the year we connected deeply, however briefly it would last. Your brother had recently been killed and you were still grieving – we were kids, but old beyond our years. Suffering, pain, and neglect had been part of our lives for a long, long time. I remember laying on your bed, smoking cigarettes and listening to the Stones “Get Yer Ya-Ya’s Out.” I think we both felt kind of unlovable – but in our case it wasn’t teenage angst, it was just a painful reality. I remember feeling like we were deeply connected and it was intoxicating, but at the time all we knew was that it felt good to hold each other. We were damaged goods and we both knew it, searching for comfort and what we hoped was love without really understanding either one. Beautiful clueless kids with no one looking out for us, we were beginning the long road of discovering who we were. The world was unimaginably dark and beautiful at the same time. We weren’t together long, but at that age everything is profound.

Ten years later you left our hometown and came to live with me a thousand miles away. Holy fuck – you were even more gorgeous at 24 than at 14. But people are like that, they don’t really look their best, their sexiest, until they’ve lived a while. The second time didn’t last long either of course, and I honestly don’t remember how it ended. I just know we shared something beautiful for two brief interludes before our lives moved on.

Sometimes I still think about you – I wonder what you look like, and I really hope you are well. I remember you had some heart defect, WTF, for all I know you might be dead. Life is mysteriously beautiful and brutal and unfortunately none of us are getting out of here alive. I hope you found some peace.

I’d like to think we gave each other some comfort, however briefly, from this cold and often cruel world. Human connection is a beautiful and healing thing – I know I’m grateful for what you gave me.

So there’s that.

We Get To Choose Our Identity

I recently read an interview with Billy Bob Thornton where he was asked:

These days, do you think of yourself primarily as a musician or an actor?

To which he replied:

I just consider myself an artist. It’s all the same to me. It’s all just a different facet of whoever you are, creatively.

Note: Other people don’t get to pick a label that defines who you are.

You do.

Acknowledging Your Limitations

This is difficult for even the most self-aware among us – in part because it’s hard to see our limitations. But we all have them, and as painful as it is, it’s good for us to face them.

Understanding what they are not only helps us understand our weaknesses, it also helps us recognize our strengths. But first let’s unpack what a limitation is.

It seems to me that there are two kinds of limitations – the first is the kind you can’t change, the second is the kind you can. For example, there are intellectual and cognitive limitations for all of us beyond which we can’t go. It’s important to realize that, for the most part, this is something you can’t change.

Then there are limitations in your ability to do something or perform a task. Often, this is something you can change. Perhaps you have a language limitation – studying and practice can overcome this, at least to a point.

But there’s a third perspective, which is this: sometimes falling short just means you have spread yourself too thin. Even though we might like to think we can be effective at whatever we get involved in, the reality is our time and energy are finite resources. You can’t excel without putting in the time and effort.

My point here is this: none of us are perfect and it’s good to understand our limitations so that we can maximize our contributions to life. Don’t beat yourself up – figure out what went wrong, fix it, learn and move on.

Les Paul

Fuck me – where do I even begin?

Maybe with an incomplete, ad hoc list of innovations? Before I get started, I’ve been listening to some of his old recordings from the late 1940’s to early 1950’s and they are just breathtaking in a way that, as a musician and producer, leave me feeling positively giddy. The impact this guy had on music is impossible to overstate – he was so ahead of his time, so vibrantly creative, that he literally changed global culture in ways that are still reverberating. Genius is an overused word, but I’m afraid it’s legitimately called for here. So let’s take a moment, shall we?

Without a doubt his biggest contribution to recorded music was the invention of multi-track recording. The really astonishing thing about this is that he didn’t initially implement his idea with tape machines, because, although early prototypes existed, Les didn’t yet have access to them. So what did he do? He figured out a way to pull it off with acetate discs! For a real mindfuck, check out his version “Lover” from 1948. If you listen to this, don’t be lulled by the first minute – at about 1:07 in the fireworks start! I cannot imagine what this must have sounded like to people at the time, it still sounds impressive.

Overdubbing onto discs of course meant he had to play each part as close to perfect as possible, because any mistake meant he would have go back and start the whole process over. He said it took over 500 discs to get it right. On this recording, he also innovated the concept of recording parts at half speed, so when he then played them back at full speed they were an octave higher, which he then doubled at full speed – so that these new parts now sounded like they were an octave down. Again, this was on discs with no synchronization! WTF!!

Before we get off multi-tracking, we have to jump ahead 3 years and listen to his 2nd biggest hit, “How High the Moon” with his wife Mary Ford. Now we have vocal overdubbing and copious use of delay and reverb – in 1951! This was done on tape, and you can hear how he has continued to develop and refine the concept. His use of “ear candy” would be further developed 35 years later by Trevor Horn as an effective arrangement technique – “Owner of a Lonely Heart” by Yes is a great example.

Of course he was a pioneer in his use of the electric guitar – when he was in high school he “experimented with using a phonograph needle wedged into the instrument as an electric pickup, attached to a wire plugged into a radio at the other end.” By 1933 he was playing electric guitar in big bands and on the radio, and in 1941 invented the prototype for what would become the Les Paul solid body guitar. These innovations were neither recognized as legitimate nor celebrated at the time, on the contrary he took a lot of heat for his ideas. He responded by not giving a fuck – he had shit to do! Let’s not forget Les was a ridiculous idiosyncratic virtuoso who influenced virtually every electric guitar player that followed him. It doesn’t take a lot of imagination to hear his influence on Jeff Beck…

I could go on an on about this guy, but let’s just end by saying I’m both awed and grateful for what he gave us. If any of this piques your interest, do yourself a favor and fall down the YouTube rabbit hole of Les Paul. Try to imagine the culture on which he was dropping these bombs and prepare to have some fun.

Life Is Easier If You Understand This

I read this line today that really resonated with me:

Nobody will ever see the importance the way you see it.”

If you’re the kind of person who feels passionately about the things you love, whether it’s film, music, fashion, writing, art, horticulture, B&D, physics, hunting, architecture, philanthropy, guns, ornithology, medicine, psychedelics or food – life will be much easier and less frustrating once you understand this.

When you are in the throes of being immersed in discovering something that is life changing, of course you want to share it with other people. Unfortunately, that is really the last thing you should do, because they won’t get it.

I’ve found that once you get into this stuff you’ll quickly discover a community (if not an entire subculture) who shares your obsession.

Just don’t expect your friends and family to be part of it.

You’ll save yourself a lot of frustration.

Wake In Fright

I love film, and have spent a lifetime watching (and re-watching) movies – the weirder and more obscure the better. As I get older, you might think it would become harder and harder to recreate the visceral excitement of discovering something new, of finding an uncategorizable masterpiece that stops you dead in your tracks and stays with you long after viewing it. If that is your thought you would fortunately be very, very wrong. Especially if you open yourself up to foreign films, because often they don’t fit into genres as we know them in the U.S.

When I was a kid, my father managed a movie theater in a small town in the south. There were three local theaters, and he had a “family guest pass,” which was a little card with an official signature that allowed immediate family members to see movies for free in any of these establishments. As soon as I was old enough to ride my bike to them I would literally go see everything. Good or bad, it didn’t matter what they were about, I was just fascinated. They transported me to another world.

Which brings me to “Wake In Fright,” a 1971 masterpiece from Australia that I watched for the first time a few days ago and has stayed with me ever since. It’s very difficult to summarize exactly what kind of movie this is, which is a high compliment in itself. Directed by Ted Kotcheff for a budget of $800,000, it made the rounds of film festivals and then disappeared for 40 years, but not before making an indelible impression on a young Martin Scorsese at Cannes, who had this to say about it:

Wake in Fright is a deeply — and I mean deeply — unsettling and disturbing movie. I saw it when it premiered at Cannes in 1971, and it left me speechless. Visually, dramatically, atmospherically and psychologically, it’s beautifully calibrated and it gets under your skin one encounter at a time, right along with the protagonist played by Gary Bond. I’m excited that Wake in Fright has been preserved and restored and that it is finally getting the exposure it deserves.”

I came across it on Shudder, thought it looked interesting, saw it had a 100% rating on Rotten Tomatoes, and immediately watched it. I’ve been thinking about it ever since – it’s that good. Very deep and layered, it’s really a study of who we are as humans, and to say the result is disturbing might be an understatement. It is not a horror film, at least not in the traditional sense of the genre. It’s a very dark look at human nature, but done with such brutal honesty that you are left a bit shaken. At the same time you can’t help but feel awed that anyone could actually pull this off. It’s an absolutely stunning piece of art, the kind of thing I live for because once you’ve experienced it you’re not quite the same person – you’ve grown a bit in the process of watching and thinking about it. At the same time I would caution you to watch it at your peril.

It’s truthful in an uncomfortably frightening way.

Choices Part 2

I’m not engaging in hyperbole when I say that even the tiniest, most seemingly insignificant choices we make in our lives change the fabric of the universe. If we were aware of this concept as we moved through each day we would be absolutely paralyzed, constantly questioning and analyzing our every decision. Fortunately, life doesn’t allow us to do this. Instead, most of our our days are filled reacting to our environment. Life doesn’t stop so you can have time to think about things – it just throws shit at you whether you are ready for it or not. Much of the trajectory of our lives is determined by how we react to this deluge.

But it is instructive to sometimes stop and think about how we are spending our precious time and energy, and what we hope to accomplish. These are the choices we have some control over. Now we are talking about acting rather than reacting. Acting implies thought and planning…

I recently heard the musician Greogory Scott talking on his podcast and he said something that really struck me. I’ll paraphrase:

If you just show up with intent and pay attention, life will show you what to do next.”

Clinical Note Part 1, Addendum

In Clinical Note Part 1, I wrote: “Being mentally ill and being an asshole are two different things.

I made this statement in response to repeatedly witnessing toxically abusive, completely unnecessary behavior in the ER. I feel compelled to note at the onset of this post that I am extremely sensitive to the needs of the mentally ill, and I try to be a strong advocate for this poorly served patient population. Having said that, there are things that are simply unacceptable regardless of the patient’s state of mental health.

Warning – in a blog filled with graphic profanity, I am about to use language I would never engage in to illustrate my point. Don’t read further if you are easily offended

It is never acceptable to call your doctor, nurse, or other healthcare professional a cunt, faggot, or nigger. You may be an unmedicated paranoid schizophrenic, but there is a limit to what these good people should be expected to endure in the interest of caring for you.

Your personality disorder does not give you a license to hit, threaten, or intimidate your doctor, nurse, or other healthcare professional when they are trying to help you.

Being bipolar does not excuse spitting at or urinating on your doctor, nurse, or other healthcare professional.

Your drug use or current state of detox does not give you the right to shit on the floor or throw your feces in the direction of your doctor, nurse, or other healthcare professional.

Engaging in any of these behaviors will result in summoning security, and in my ER, I will not hesitate to do so if your conduct endangers the health and safety of either yourself, your providers, or other patients and their families.

I have an extremely thick skin and a huge reservoir of compassion, but I have to look at the big picture. My goal is to care for you and everyone else in my ER, but I do not expect my colleagues to have the same degree of tolerance I do. Your “acting out” is preventing you from getting the care you need and traumatizing the people who are attempting to do so.

Unless you are having a complete psychotic break from reality, you still have the ability to understand your abusive behavior towards other humans. You have lived in a society around other people since you were born, and you understand, however vaguely, the consequences of your actions towards others.

The difference in the ER and the rest of the world for you is this: We deal with people exhibiting the most extreme behavior on a daily basis, and we know how to handle it, no matter how unpleasant it may be. We WILL care for you; we can just do it the easy way, or the hard way. It’s your choice.

The Double-Edged Sword

Although it’s debatable how many good qualities I have, I always felt I had at least one that was unquestionably positive. It turns out there’s a drawback to even that…

What am I talking about? Just this: I can keep my mouth shut. It doesn’t matter how irresistibly juicy the secret, if it is told to me in confidence, I will go to my grave without ever revealing it. This isn’t hard for me, it’s just how I’m wired – but it has a couple of unexpected consequences. The first is that I don’t gossip – OK, so far so good. I long ago realized if I couldn’t find something positive to say about someone else, it was better to simply keep my mouth shut – again, this all seems like it must be good, right?

One of the benefits of this behavior is that people tend to trust me. Having people’s trust turns out to be a very valuable commodity – it’s something that can’t be bought or coerced, it can only be given freely. It’s also something that must be built up and earned over time – we’re really talking about years here.

But the unexpected negative consequence is this: I’m often the last person to hear about what’s happening in the lives of the people I work with. Because I don’t gossip, no one talks to me about the current scuttlebutt, and that’s not always a good thing. For example, if someone is experiencing hardship or personal tragedy, I’m the last one to find out about it. Maybe I could have helped them in some way, or at least offered, but because I wasn’t in the loop I am powerless to help. In order to help you have to be aware there is a problem…

This is typical of how life works – even the things that seem to be completely benign and good can have unforeseen negative consequences. No big lesson or answers here, just an observation.

You just try to do your best, and understand that sometimes you’re going to fall short. It’s part of being human.

Nobody Knows Anything

I am listening to an old Marc Maron podcast with Anthony Bourdain from 2011 when he makes this statement:

I like doubt and I abhor certainty. Nobody knows anything, and I’m not even sure of that. And anybody who’s absolutely sure of something I’m very wary of…”

To which Maron replies “Even just confidence bothers me.”

Besides being darkly funny, there’s a lot of truth here. It’s uncomfortable, I know. We all want to feel like someone knows what the fuck is going on, but one of the dismaying things about living a long time is it becomes clearer and clearer that no one is at the helm of this ship.

It’s up to each one of us to live as righteously as possible, and we have to somehow figure this out for ourselves. I think a good place to start is to just treat each other with respect until proven otherwise, listen, and make every effort to do the right thing.

And try not to be an asshole.

Rest In Peace, Anthony Bourdain

You didn’t have to watch more than a couple of Anthony’s shows to understand that this was a man who was deeply in touch with the human spirit. His sense of compassion and empathy were palpable. He sought to connect with others on a deeply fundamental level, and, in his own way, seemed to be imploring all of us to do the same.

I loved watching him explore our world, and somehow he made me feel as if I too were part of his journey. He was irascible and profane, a man of the world who suffered no fools. He was rawly human and not afraid to show his vulnerability, as if to say “it’s Ok to be who you are.” By displaying his flawed humanity he made you feel less afraid to show yours. Because, of course, the reality is that we are all flawed.

I’d like to think he was a brave man who did his best to bring us closer together, whether he was aware of it or not. I’ll never know the circumstances that brought about his suicide, nor should I. Some parts of the human condition are privately unknowable.

I’m just grateful for his work. He touched me in a significant way, and I think the world was a better place with him in it. He encouraged real human connection, at a time in our culture where we seem to be in real danger of losing it. I respect the choices he made, and I feel empathy for his suffering.

Thank you my fellow traveler on the road to becoming fully human. As my old teacher used to say, “If you don’t get it right in this life, you’ll just have to come back and keep trying.” I hope you find peace in your journey.

Pay Attention To Your Internal Dialog

Humans are infinitely complex creatures, what you see is most definitely not what you get. The inner dialogue is known only to the one experiencing it and how much they choose to reveal is the choice of the individual. I am writing this in response to the recent suicide of Anthony Bourdain, who I would like to honor in another post – but there a few points I would like to address here first.

There are legitimate reasons for taking one’s life, at least in the sense that the act of suicide has been thought out and processed thoroughly and rationally in response to whatever is causing the extreme distress. For example, my sister committed suicide after many years of untreated debilitating mental illness and poly substance abuse. She had attempted it multiple times before, and her life had been a nightmare of psychic pain and chaos for a long, long time. She chose to end her life, and ultimately I had to accept that this was her choice. I had tried to intervene a thousand times, but one of life’s brutal lessons I learned from her was that you can’t fix someone else, no matter how much you love them – the desire to get better has to come from deep within.

When a well loved public figure commits suicide, the rational human response is to wonder why? But why is unknowable except to the one making that decision. Perhaps they were recently diagnosed with an incurable disease, or had been fighting one privately for a prolonged period of time. Maybe that disease was mental illness…

And that brings me to the point of this post: Pay attention to your inner dialog. There is a well known and statistically successful treatment for clinical depression called Cognitive Behavioral Therapy (CBT) that essentially works by teaching the individual suffering from depression to monitor their thoughts and learn to to recognize their cognitive distortions. This requires a degree of self-awareness and the willingness to seek help.

If you are thinking about hurting yourself or ending your life, you owe it to yourself to think carefully about what you are doing and why. The choice is ultimately yours to make, and yes, you do have the right to end your life as you see fit. Just don’t do it as a spontaneous act.

When you are feeling this way, write down your thoughts and tell yourself you’ll wait until tomorrow to read them and decide whether to act on ending your life. And if you are so fucked up you are afraid you are going to kill yourself immediately without being in full control, call 911 and simply say “I’m afraid I’m going to kill myself.” EMS will pick you up and take you the closest ER, and as an ER nurse, I love it when someone does this, because they have asked for help. We have a protocol for protecting people who feel this way. It keeps them from immediately harming themselves and gets them evaluated by a psychiatrist.

There is no shame in having a mental illness, and there is no shame in wanting to hurt yourself. These things are just part of the human condition.

There is shame in not asking for help.

Show Some Kindness

A spontaneous moment of kindness could be a life-changing event for the one receiving it.

And you’ll feel better in the process.

Do it.

Every Day Is A Gift

A 40 year old colleague just had a stroke.

Seriously, I am really not kidding here. I constantly say this to myself – I repeat it several times each day, sometimes out loud, and sometimes only in my mind.

I repeat it enough so that it becomes ingrained in my psyche, over and over, day in and day out. I am deadly serious, and I suggest you do the same.

You just never know when it’s coming, but it’s somewhere out there, biding it’s time, waiting. And it will find you my friend, because there’s no where to hide.

All you can do is really try to make each moment count. Understand that tomorrow is not a given, and you’d better be fucking grateful for what you have right now, today.

It’s a gift with a time limit.

Make Your Own Religion

I was recently talking to my wife about my attempt to answer metaphysical questions about life and death as an atheist. I was specifically talking about the concept of reincarnation and how it might explain a lot, yet lamenting the fact that I am not a Buddhist, as if to say I couldn’t believe this even if I wanted to. With her usual clarity she simply said, “You can take bits from different religions and incorporate them into your own belief system,” as if this was the most obvious thing in the world, except, at least to me, it wasn’t.

It was one of those “Ah-ha!” moments where I immediately realized she was, of course, right. Mind you, I’m not really sure I want to incorporate specific aspects of different religions into my belief system, but it’s a novel idea, and really, why not? I am so used to rejecting all religious dogma that perhaps I was “throwing the baby out with the bath water.

This is one of the cool things about the human experience – you have the freedom to figure life out for yourself.

System Failure

This is an unfortunate perfect storm – I dropped and broke my iPhone for the third and final time, and I’m on vacation. So now I have a shit ton of spare time on my hands with no computer, no tablet, no iPhone and no TV. No books, no music, and unfortunately no blog.

My wife is letting me type this on her iPhone, but understandably she doesn’t want to give up her password. I don’t blame her, god knows what you’d find on mine.

So although I have a personal contract with myself to do this blog everyday, it would appear that Mr. Murphy has made his appearance. Whatever could go wrong did go wrong, but we can at least be grateful that no one got hurt.

So unless I can hijack my wife’s iPhone I’ll be back on Saturday when I get home. At least I can post something on my home computer until I replace mine.

Until then, protect yourself at all times, roll with the punches, and stay safe.

Vacation Mode

Due to multiple modalities of “relaxation” therapy, this blog has been temporarily suspended. Regular operations will resume tomorrow.

Thank you for your understanding.