It is good to prescribe medicine for the flu, right?

Question:
Based on the current influenza and H1N1 hysteria there will be a large number of prescriptions filled for oseltamivir in the coming weeks. This is part of some information that was emailed me from one of my attendings. I found it interesting.... What about some of the non-medical impacts of drugs?

Shikimic acid from the Chinese star anise is used as a base material for production of Tamiflu (oseltamivir). It is also used to flavor duck dishes in China. Star anise is harvested by local farmers between March and May, purified and the shikimic acid extracted at the start of a 10-stage manufacturing process which takes a year. The most dangerous part of the process involves the conversion of epoxide into azide in a reaction that produces highly explosive material. This is carried out by specialist companies that handle the material in small quantities to reduce the risk of explosion. Only star anise grown in the four provinces of China is suitable for manufacture into Tamiflu and 90 per cent of the harvest is already used by Roche.

The Cost of Responsibility

I am in such a strange state of mind. I find myself missing many people and events in my life and yet I also find myself becoming more reclusive in the times I have away from the hospital. I occasionally find opportunities to spend time outside the hospital with other residents or sometimes new people I have just met in hopes of building a personal life in this new city to balance my work life. All it requires of me is the enthusiasm to leave my house and interact with these new people in a simple, social situation yet I struggle to find that enthusiasm and it is getting harder. I don't care to tell my story or ask other people theirs. I spend my entire day asking other people their stories and then being empathetic with their feelings. When I make plans, even when it is something casual and social, it often feels like another deadline, another responsibility - another item on my overburdened schedule that must be met. It is this very viewpoint that is the biggest sign that my life is so out of balance and the biggest hurdle in my ability to regain some balance in my life. I see that.

Most people think of me as an extrovert rather than an introvert. I try to be gregarious and social when in the hospital, friendly and conversational. When I am with my patients I am often, not always, truly emotionally available. I reflexively empathize with their pains and struggles. I share their emotions compassionately and they can sense that. I try to allow them to express some of their fear and pain and frustration with me as a sounding board and then I try to direct their emotional energy toward something constructive. I try to lighten the mood of those around me when I can with a joke or a quick response. I even write a blog for the world to see. By all outside viewpoints I am rather outgoing, but outgoing is not extroversion in my book. When I tell people I am more of an introvert they usually laugh. It is true though. I once heard the definition of extroversion as the state of being where a person needs to be social, interactive and with other people in order to "recharge" and introverts are those that recharge alone, isolating themselves and "their inner world" to gather their thoughts and feelings. Extroverts absorb energy from everything around them to recharge. Introverts drain their batteries to give back to all that is around them, then they recede from the world to fill them up again. I can't think of a more socially and emotionally demanding role in society than an emergency physician and I am starting to see the toll it takes on me and my life. Perhaps it is because even though I am an introvert I still crave meaningful, personal and close interactions with people. I simple cannot stand flimsy, fake and superficial interactions. They drain me and tire me and I find them totally without value so I strive to make most interactions real interactions. I would rather go deep than wide in this respect. Emergency Medicine is a field that requires both though.

I usually have about 5-6 patients I am seeing at any given time in the ED and usually 2-3 of them are "sick". This is actually a very low number, by the time I am 3rd year resident we are expected to know and be following up to 10-20 patients at a time and half of those could be "sick"! When we say "sick" in the Emergency Department it means something different that general colloquial use. For us "sick" means acutely ill with potential life threatening implications requiring a high level of medical care. A badly beat up person after a car accident that is bleeding from their scalp and limbs is often not "sick" unless there is an artery or head bleed involved. Alternatively, an older person with a cough, fever and dehydration may not seem as dramatic since there is no bleeding, but they often have the potential to suddenly "decompensate" and require intubation and ICU care, so they often qualify as "sick". I balance the complainer in the ED that requires emotional validation for their suffering after a sprained ankle with the stoic WWII veteran that may have perforated a bowel and is becoming septic but even then still won't complain much. The diversity if wide, but what is required of me is deep, either emotionally or medically. Trying to stay present and offer care for this huge spectrum is challenging. I usually have a stack of charts which adds to the burden. I must document things correctly for the sake of the patient and the attending that must come after me to review them. I also have the personalities of about 4-5 nurses, several consultants one or two attendings and about 2-3 other residents to contend with - all different and all requiring a fast adaptation of speech, approach and mannerism. In short, I feel responsible for about a thousand things per shift, not just the patients or medical decisions but for the thousand interactions I have every minute of my 13 hour shift.

I want to be a thorough doctor. I want to be a friendly doctor. I want to a fun and relaxed resident. I want to be on equal footing with the attendings and the drug users so that we connect well and work together. I want to sound competent to the consultants. I want to be respectful of the nurses and the hard work they do. I try to adapt myself and my style, speaking and behaving, to the people I am around so that we all work comfortably and effectively together. To me that is part of the responsibility of medicine. To make people feel comfortable, safe and respected when they are in this difficult situation. I don't always succeed and honestly, as time goes by and I get busier and more is expected of me I fall short of it more and more. But I still feel the pressure to do well. The responsibility. First and foremost though, I must treat my patients quickly, accurately and effectively and I am still learning. When I have a shift where I don't connect with those around me, where my charting suffers, where I am not "on my game" I leave feeling disappointed in myself, the process, the hospital and the world around me. I am drained. I see that I am taking one a huge emotional burden every day and it takes everything that is "extroverted" out of me to do it. Responsibility for that which is outside of myself is the place I find myself in but one very much at odds with who I am in many ways...

The price of responsibility is high for an introvert such as myself and that is why I spend what little time I have outside the hospital isolated in general. It makes it harder and harder for me to balance my workload with a social life because the few hours I have off I need silence to be reclusive in so that I can recharge. By the time I have enough solitude to quiet my mind, fill my batteries and the desire to be social with humans outside medicine and the walls of the hospital returns I find I have to go back to work. I had the day off today and I slept 12 hours straight last night. Some nights I don't sleep well at all or when I do I dream only of more emergency patients, being within the hospital, solving problem after problem. I sense urgency in my dreams and I wake unrested. The exhaustion comes not from simply being awake, but from being responsible for so many people and events all the time. I know I am someone that has craved this responsibility. This is in part why I went to medical school, I wanted to be responsible for people, to have the knowledge and power to repair their injuries and illnesses. As I travel through residency though I see this knowledge is coming with greater and greater burdens. I can't detach myself from it. I can't do the work and simultaneously not care about the people which is what is required to unleash the weights from the role. It sounds more and more like an addiction actually. A compulsion. The deeper I get into medicine, the more I learn and the more I take on. The more responsibility I crave and strive for the greater the weight felt in my life and upon my being. It feels like it will crush me some days. I have seriously walked through the hospital late at night and seen the man emptying the trash cans, rolling his janitorial cart down a basement hallway dimly lit with fluorescent lights, and I have envied him and his lack of responsibility at work for anything greater than the trash cans. Keeping a hospital clean is such an important part of the whole process yet it is devoid of so much of the responsibility. Does he go home at night worrying that the door handle he forgot to clean might have transmitted an eventually deadly virus to someone unsuspecting? I am betting not. Yet we go home and wonder whether or not we should have ordered that one other lab test, or perhaps given more steroid or not given a steroid.

On the rare occasions I get a few days off I notice that I return to normal after a day or two of being home and alone. I then have the energy and enthusiasm to rejoin the outside world but I must first make time to "decompress" from the demands of residency. It is not that I don't desire more personal interactions with people and those around me, I do, but I don't have the emotional energy for it often. I am trying to find more and more ways to invest in myself simply so that I will feel whole enough again to participate in the world around me. This is all made more difficult by being in a new city without any close ties. In Seattle I had a small group of close friends, people I could share my inner world and thoughts with in such a way that it did not feel draining. When I had a few moments off I could both recharge and gain the perspective that being with other offers. But here I find that everyone is a stranger. Many friendly, quality people that would probably make great close friends given the time and effort to build those ties, but I can't find the time or energy to do so despite the need for those ties. I feel a bit trapped and I just wait and hope that when residency is over I can return to my life somehow. Then I will have a reduced work load, less learning and more emotional and mental space for my life and those close to me. I dream of working 1/2 time or perhaps 3/4 time so that I can better balance these demands with my other needs. . . away long enough to find the energy for my inner pursuits, my friends, perhaps love and hopefully time to rebuild closer ties to my family. All these things can enrich my life and they make it possible for me to have more to give to the people that need me in the Emergency Department. I know my life outside offers me the ability to be a better physician. It is a delicate balance that when done correctly enriches both aspects of my life. The personal can feed the professional and vice versa, but when slightly out of balance, such as my life is now, I feel that one destroys the other rather than enriches it. I really get the sense that this is not so hard for many other residents. I see residents that are married, dating, having children... rich lives outside the hospital so I wonder how they do it? Do they simply have more energy than I do? Less demands of themselves perhaps? Have the balanced the responsibilities in such a way that the whole generates more for them than the demands of the parts? Perhaps I will figure it out during this process, for learning that sort of balance and personal insight would truly be a great achievement.

This blog is one small way that I can maintain some of my personal time. It is not an act of extroversion but an act of escape from extroversion. I can delve into my inner world, investigate my thoughts, feelings and observations in peace and quiet without the demands of the world around me. I write this mostly for myself, but by placing out into the world it also satisfies some aspect of my need to stay connected with the world outside myself. I do not believe you can remain healthy at either end of the extreme. Totally introverted or totally extroverted. I strove for ambiversion I think. The center. It may not be an actual place or destination, but an idea that continually pulls us back from the extremes. I am spending a lot of time in the extremes these days and it is a learning process. I am more aware each day of the weight that my new responsibilities as a physician place upon me and I hope that I can find the ways to balance it. I think being a physician gives you great insight into what being human is, but it certainly comes at a cost. You see a lot of ugliness but you can also see the beauty in it. How to find a way to balance this knowledge & responsibility while remaining whole outside the hospital is hard. It is probably my greatest personal challenge throughout this residency and one I hope I can achieve.

What Not To Write and the Space To Do It In

I just deleted a rather long post. When I have little time to write and even less time to become inspired about writing in general it seems foolish to erase 30 minutes worth of writing. But I don't want this to become a droll blog where I complain about things I am frustrated with. I think there is some good stuff to relate regarding the struggles, but I don't want this to be all struggles. The crux of what I was hoping to write about was the lack of words in my life right now. The lack of my own creative self in many ways. The general lack of inspiration and art in my life due to the overwhelming amount of learning and working that is occurring. My small amounts of free time are focused mainly on eating, sleeping or the maintenance of the minimal aspects of personal life and it has made me think about how I work as a human and what the true price of this training is for me.

Creativity for me is something that occurs within a larger space devoid of other activities. I can't "make time" to play the cello. I must have time . . . and then the cello playing occurs within it - or not. The same with writing and cooking and all things creative. I am not the "perspiration" sort of individual that produces creative works through sustained labor. I am the "inspiration" sort of person that needs space and beauty around me and then mysteriously I find myself moved, almost forced, to accomplish some creative task whether it be writing, building, playing my cello or simply sculpting a garden out of dirt. When this happens I can work all night, play music for hours or simply converse with a close friends about things spiritual and philosophical without exhaustion. What I am mourning right now is the profound lack of that empty space with which arise the opportunities of for my own self expression. The lack of that space is starting to take some of the color out of the day it feels like.

My mind tends to be very busy and almost reactionary. I am ADD and all stimulation, no matter how small, sets my mind into some intricate pattern of observation, analysis and prediction so that I can form an action. It is part of why I loved physics and why I love Emergency Medicine. It is only when I find myself in the profound lack of human stimulation that thoughts and events arise spontaneously for me that are not the sum of some mental equation. These thoughts are the expressions of who I am. This is why I am an introvert in much of my off-time. Most folks don't believe me because I am very social and enjoy interacting with people but I find it exhausting. These conversations & interactions for me are like gymnastics, fun and stimulating but draining in many ways because they set my brain into action automatically, muscle memory. This is why I prefer backpacking alone or sitting in the silence of the forest as my way of recharging. Throughout my twenties I took road trips in my Subaru, alone, for a month at a time every summer. I never went to distant cities or to visit friends, I sought out the loneliest, most empty and beautiful places I could find and I was my own best company! It was in this time I talked to myself, made music, played my cello or simply sat writing stories into my journals. It was when I was away from all the stimulation and expectations of others that I felt I knew who I was and what I wanted to say or be.

I know where these reactionary aspects of my personality came from and I know why they were once useful and how they can be used effectively and beneficially in my life now, but they need strict limits. I know that to maintain balance I must put brakes on the reflexive and machine like parts of who I am and maintain time for the other facets or I am afraid I will lose them. This is hard to do in residency as it demands, for the most part, the machine like parts of me and less so the human ones. I am frightened because I have never felt more distant from myself and my life as I do now. Part of this is the isolation of living in a new, unfamiliar place, but part of it is about who I am becoming. I am starting to not fully recognize parts of me that seemed so familiar only 10 years ago. Back then I was living in the mountains of New Mexico running a telescope, nearly isolated, at almost 10,000 feet. I had just left a short stint in philosophy trying to find something I was not only passionate about but good at as well. I remember sitting in front of a wood burning stove at night, in the winter, with snow all around. I was listening to the crack of antlers from the male bull elk as they would collide in contest over some female. There was the sound of the bugling elk, the crackle of the wood in my stove and perhaps the mist from the cup of tea I would be drinking. Nothing else. No street lights. No car noises. No human stimulation at all aside from my own breathing . . . and then I would pick up my cello or my journal and see what rose from within me.

Now I want to pick up my pen (or keyboard) but I don't know what to say. I don't feel inspired by anything. I am not unhappy, I am just less dimensional than I once was and I feel sort of flat. I want to be more than a functioning doctor in an emergency department. It is good, but it is only a single thing to own in your life. Medicine is a great gift and wonderful honor to be given the chance to help people that need you, but it is still only one thing and the world is a varied and beautiful place with so much that is important besides sodium levels and lactate. I am told this will pass, that this is part of my training and that it requires continued sacrifice, but that afterward I will have the means and the time to create the life I want. Not only will I have the means for my life outside medicine, but I will have the honor of being a physician and truly of service to those around me. I still believe it and I know that will be a good time, but it is not always easy watching so much of life passing by in the meantime.

It is fall time again, my absolute favorite time of year. I see the neighbor kids playing in the leaves when I bike home from the hospital. I see the sports games being played on school fields in the crisp autumn air. I see houses full of families being decorated for Halloween. It is a time very rich in my mind with the fabric of communities and life and I feel more separate from it all right now than ever. My schedule is filled with start times for shifts and end times and any time in between is filled with "I shoulds" regarding my residency reading, testing, self education and such. Meanwhile my cello sits in its case. My back yard garden is looking a bit neglected. My writing is mediocre and uninspired. My waistline is softer than it should be and my level of fitness lower. I have not been in the mountains in a long time. Books of literature & philosophy are not being read and when not being read the ideas that they would inspire are not being thought. I am tired and I simply want 8 hours of sleep and enough time in the morning for a cup of tea. My biggest hope when I go to bed is that my dreams won't again be about sick patients in the hospital that I am responsible for but instead I hope that they will be about the life I don't have time for while awake. A life of mountains, friends, music and . . . well, life.

and all I got was this lousy T-shirt...

I have had a few ideas rolling around my head to write about on the blog but I have had little time lately and I have felt half-delirious with the time I have had. I contracted some sort of viral illness almost 10 days ago and my head is still congested and my chest still hurts some from the bronchitis I developed. I had HOPED it was H1N1 flu so I could at least check that off my "viruses I am now immune to" list but no luck. Employee Health tested me, sent me home and later found it to be negative. So, I am now immune to some other ruthless virus of unknown origin but probably vulnerable to oncoming onslaught of H1N1 this winter.

Despite missing two shifts in the Pediatric ED to rest, recover and avoid infecting my compatriots I am not rested in the least. I have not been able to sleep more than 4 hours a day (since I am working nights) in the last week and it is starting to get to me I think. I did manage to scrounge together enough words to make a comment on a local news story today about the flood of psyciatric patients we are seeing in our ED, but that took what few functioning neurons I still have. It is a real disaster, our hallways are filled with patients on "psych hold" which is called "5150" here. This is all because the state and county are out of money and have closed up most of the major psych hospitals. As a matter of fact, Sacramento County is abandoning pretty much all patients in this county after withdrawing funding for ANY county patient being treated at UC Davis for any condition. This state is out of money and the Emergency Department is getting hammered as a result. for better or worse, the ER is the last place in society that can truly be called sanctuary and it is busting at the seams! So, when my head clears, when I get some rest and can write, I hope to delve into this a little.

I miss writing and really wish I had more time to both take some writing classes and pursue the many topics I care to write about. I only seem to get one or two posts out a month on this blog these days and only about half of those have anything worthwhile to say. Many, like this one, are just a forum for me to vent and chat and let my mind ramble about whatever I am thinking about. But, it seems many blogs suffer similar fates when residency starts. It is just so busy hard to find time for anything other than work, didactics and journal club! But I sense halth around the corner so I hope to have something to rant about soon!

Human Heal Thyself

"No one should die because they cannot afford health care; no one should go broke because they get sick. If you agree, please post this as your status for the rest of the day."

This statement has been cropping up as many people's status message on Facebook lately. A statement of unity among, from what I can tell, many of my friends that believe in equity and fairness in our society. Those people that do not feel it is right that some members of our community are suffering consequences as serious as bankruptcy and even death because they don't have enough money to get the health care they need, which just seems wrong. It seems just as wrong as people starving because they can't afford food or sleeping outdoors because they can't afford shelter or being shot during some other country's war. I would like to think I am among that group of people yet I have found it difficult to cut and paste that simple statement on my Facebook status window. I think this is because some part of me understands this little sentence seems somewhat inadequate and off the mark. It is an oversimplified view of a complex problem. I feel guilty for not posting it because I am afraid people will think I don't agree with it, yet I feel guilty posting it because this statement implies that fairness and equity exist in the world and they don't.

The concept of equity is a good one - one that we strive for and one that we should try to attain, but we never will . . . and that is okay. That is why we have emergency departments that accept patients regardless of their bank accounts, why we have food banks for those that can't afford to feed their families and why we have unemployment insurance for those that lose their jobs. I am proud to work in an emergency department. One of the most important educators in my medical school experience, Terry Mengert, had an excellent take of the ER in our society. "The Emergency Department is the one last place in our society that can truly be called sanctuary. In the ED we care for all those that request our care, regardless their ability to pay us, their religious beliefs, their gender issues, their crimes toward society or their personal demeanor towards us. Who else can say that?" What is wrong with the Facebook statement is not the intent to reinforce the need for equity in our society, it is the fact that is misses the forest for the trees.It should not cost $4800 to fix your daughter's broken arm, which was an accident on the playground, but it does. It does because now we have to pay for all the administrators, insurance billers, lawyers and support staff required after someone sued the hospital after not being able to resuscitate their 450lb loved one after diabetic & heart related physiological collapse. It does cost that much to pay for the care we gave that homeless patient in the ER with hypertensive encephalopathy because they never got the education, medication and simple medical care needed to avoid this disaster. It does cost that much because we had to have the latest 64-slice CT scanner now that the 32-slice is considered sub-optimal when the for-profit hospital next door has one. Just because we can cure one person of a disease when we allocate unbelievable amounts of money and resources trying to, it does not mean we can do it for all. Especially in an environment when we are creating more problems to fix than we have resources to do so.

We are creating a society that, more and more, is expanding the gap of inequity, promoting the habits and building a foundation for more need in the future. The haves and have-nots. The educated and ignorant. We don't fund early education for our children, we let corporate America market self-centered ideals and self defeating gratifications to increase their sales now despite the unhealthy lifestyle that comes of it later. We have abandoned the dedication to community and responsibility to ourselves that promotes self respect and respect of others. We have anonymized one another in order to pursue our selfish interests without having to accept the guilt that comes with trampling on those around us to climb higher. How do we abdicate ourselves of the feelings of self-disgust that should arise? I fear that we create funds and institutions to care for those that are marginalized by our values and then feel we have done the right thing by sewing up the wound that we ourselves created. We then ask payment for it anyway or are outraged when we can't afford to have our self-inflicted injuries repaired. I see this all the time when a neglected parent from a nursing home comes into the ED with bed sores and in poor health. They live alone in that place with staff paid to care for them so that the family can pursue their lives without the burden if this illness or the infirmity of old age. When the time comes and this elder is succumbing from the infections of neglect the family throws money at the system saying, "Do everything you can!" or the scream of how unfair the system is that they can't afford to have everything done. I worry that this is not always because they feel the pain of the imminent death of a family member but rather they feel the guilt of the years of neglect and now want us to delay death so that they can either rectify their behavior or simply avoid the reality that their parents are going to die alone and delirious from infection and they were not there. Death, disease and injustice are not going to go away and we can't expect them to and we can't pretend they don't exist for our own comfort. When we do, we lose something by not embracing the lessons and life they have to offer in return.

These are extreme examples and statements, I know, but I use them to illuminate a subtle but important difference in the need and utilization of the support systems in our country and our world. When we create a society that expects all seemingly unjust things in our world somehow rectified we are setting ourselves up for disappointment. We are also ignoring the fact that most of this injustice is OUR responsibility to avoid in the first place. Epidemic obesity, diabetes and the sequela can be avoided and we should not feel outraged when the health care system can't support the consequences of these diseases when we sold them the 64oz high fructose corn syrup soda and hamburgers in the first place. They ate them because they did not know any better, did not have the education to know how to make better choices or simply found the self-destructive comforts they offered the only solution to their emotional pain or simple hunger. We made vegetables and the environment to cook and eat them in impossibly expensive so that $2.99 grease meals is all they can afford. We package sugar and salt in such a manner that it offers nearly the addictive pleasure of heroin. We teach kids that drugs, guns and gangs are an easier way to make money and find a family & respect than their own communities through our TV and advertising.

Yes, people should not die because they can't afford healthcare. They should live healthy lives filled with friends, education and community. They should help those around them to find similar lives of value and self-respect and THEN, when luck or the odds turns on one member of the community, the other members should come to their aid and help them back onto their feet. That is what a community originally meant and what we have lost in our overpopulated, anonymous and selfish megalopolis that we have grown into. Don't buy that new car - hire a skilled mechanic to fix and tune your old one and help them feed their family. Ride your bike to work or walk even. Spend that those extra hours you would work to make the money for that car payment in your garden with your children or on the sports field playing soccer with them. Spend time at home, with your friends and family, not at work trying to make "more". When you are feeling lonely and isolated in this anonymous world, go out into your community for a walk, talk to your neighbors, read a book or paint a picture. Respect yourself and want MORE from yourself when you look into the mirror, not more from the world around you. When it comes time to vote, spend money on your kids and pay for more teachers not more police to incarcerate the kids we have already failed. Teach your children your values or the values you aspire to through example, because they will learn them anyway if you don't. If you are at work and never home, if you are always unhappy despite your bigger house or car, if you medicate all painful things with alcohol, mindless entertainment or huge amounts of starchy salty food . . they will learn.

This is more of a topic than I can address here and I have more passion for it than I realize. I see that a large part of that passion comes from my own unhappiness with my choices. I am the most selfish person I know. I always have been. Medicine is a pipeline for me to care for others, to give rather than take and to fill that need, yet living life as a doctor and training in this field seems to foster the self-centered behaviors and ego which I struggle with. I was reminded of this recently when my grandmother passed away and I felt I did not have the time to travel to my mother's side and be present. My mother cared for my grandmother these last many years during her bout with Alzheimers. She did it at home by herself. I offered what I could on the phone, my medical knowledge and guidance. I helped educate her on hospice and the value of it at this time. It was something, but not the same as being there with her. My friends in Seattle just adopted a new baby boy. I have not had time to find them a present or travel there to see the new addition they have waited so long for. In residency your life is owned by the training and what little time you have left-over you become very stingy with, or at least I do. I see more and more in the world around me how this short-sighted and self-centered approach to life is creating so many of the problems that are breaking our back as a society.

It is unfortunate that bad things happen to good people and we as a community should be there to help them, but we can't fix every problem and some people will be left behind. The only reason it seem so much more a tragedy now is that it is often not fate or chance that's responsible for the majority of people bankrupted by healthcare or the innocent civilians killed in armed conflict. We are. We created the coronary artery disease that suddenly stopped a father's heart unexpectedly with our promotion and love of leisure over exercise and fatty foods over healthy agriculture. We created the need for oil and the armed conflicts that arise when the pressure to control it forces one group of people to dominate another. We created the disenfranchised gangster member that shoots a rival teenager with an AK-47 because that gang is the only family he has ever had or ever will.

We can't fix these problems with more money, more hospitals and more police. We shouldn't be led to believe that we can.

Thanks Grandma and Have a Good Trip!

Jean (Rixey) Miller (1923-2009) "Turkey Hunting in Montana, approx 1981" She and my grandfather, Bob Miller, helped raise me at times as I grew up and were responsible for introducing me to the outdoors, a favorite place now that I am older. She passed away today . . . in as good a way as anyone could ever hope for. Peaceful right up to the last breath. She and my grandfather had lived all around the world but they loved the outdoors and were the first to show me how important the mountains and lakes around us were and why they were so valuable. They could be in the most exotic places for years where grandfather was working but they loved getting back to the mountains of Montana whenever they could. They did not have a perfect life but they had a good one. The flaws at times were big, but just as big were the joyous moments shared with friends and family. They knew how to live and at the end she was peaceful and content surrounded by her family. My mom was wonderful these last years taking such good care of her every day. It allowed my grandmother to die at home, surrounded by her children, without pain. Can anyone hope for anything more?

Those camping trips growing up meant so much... thanks grandma! I carry those memories every time I am I am in the mountains!