Even this late out into the game, I find myself still hoping for a reprieve from a life devoid of tender companionship, a life destined to loneliness and continued struggle.

I mean, c’mon, even Jesus Christ asked God to see if he could somehow defer crucifixion.

Despite what all the novels and movies say, the three magic words don’t do as much as you think they do. It’s the actions behind them that count.

And while I’m starting to recognize that I’m totally falling in love with her, I am frightened.

Frightened that I won’t do the right things, and that I’ll drive her away. Either I will go too quickly, or move too slowly. I’m frightened that, in the end, she’ll flee from me, and we won’t even be friends at that point.

Let me tell you, experience is a painful teacher.

But despie the current odds, I still hope. We’ll just have to see

That is most of it, being a physician—listening and seeing. The rest is technique.
—adapted from a quote by Schmendrick the Magician from The Last Unicorn, with apologies to Peter S Beagle.

I’ve continued plodding on in my re-read of Gödel, Escher, Bach° by Douglas Hofstatder (interspersed with *Little Dorrit by Charles Dickens, as well as The End of Time by Julian Barbour.

One of the things that struck me about Gödel’s Incompleteness Theorems is the resultant stratification of all human knowledge

1. true things that can be proven true
2. true things that can’t be proven true
3. false things that can be proven false
4. false things that can’t be proven false

One way to simplify this is (1) fact (2) instinct (3) lies (4) nonsense

Or perhaps (3) can be error, because it can happen unintentionally, too.

The point being, no matter how much any of these realms of knowledge expand, the basis of clinical medicine will always be the same: history-taking and physical-exam. The rough estimate is that at least 60% and up to 90% of the diagnosis can be derived from history alone. A good physical exam can probably narrow the gap by another 5-10%. Leaving lab tests and imaging to determine the last 5-10%.

So the skills to being a good clinician are exactly what Schmendrick says makes a good wizard. Being a good listener enables one to be a good history-taker. Always looking enables one to hone their physical exam skills. Everything else is mere technique, which can be easily overturned by adequately large clinical trials.

No, I haven’t watched it yet, so there aren’t any spoilers. I just read the review in the L.A. Times from yesterday, and it seems like it would be very much my movie, the way, I suppose, I got obsessed with “Beauty and the Beast”, even.

The sense of the protagonist’s shy, tentative optimism despite the overwhelming sense of loneliness, abandonment, and alienation that is already just palpable in the 5 min trailer is a little heartbreaking.

I can relate.

OK, I should’ve warned you, Kenneth Turan’s review of Wall-E does have a few details that could be construed as spoilers, although it doesn’t actually give any part of the plot away. The details make it sound almost like something that Douglas Adams would write.

Wall-E (which stands for Waste Allocator/Loader/Lifter - Earth Class, basically an autonomous, intelligent trash compactor) is the only sentience that seems to remain on Earth, excluding insects. He is tasked with the goal of reducing the amount of space all of the Earth’s garbage takes up.

Seemingly at odds with the typical Disney stereotype of “singing Zippy-dee-doo-dah out of your asshole”, “Wall-E” starts off with a rather dystopian vision of a planetary eco-catastrophe. The writers take our fears about rampant global capitalism and the inexorable expansion of the consumer culture, and they extrapolate them to their logical conclusion: the Earth basically becomes one large toxic landfill from which every human has fled, cavorting off into space polluting the rest of the universe too. The vision of lonely ruins of modern cities buried in garbage is extremely haunting, mostly because its probably going to be right.

And yet, despite this utterly hopeless desolation, you get the sense that Wall-E can’t help but harbor a spark of hope. As meager as his existence is, he finds small, meaningless joys in small, probably ultimately meaningless tasks. But none of this fulfills the need for companionship. For communion. For connection.

In a literal act of deus ex machina, EVE (which stands for Extraterrestrial Vegetation Evaluator) arrives on the planet, armed with a high-energy laser cannon. She is apparently the herald of the exiled, morbidly obese, wanton and gluttonous humans who have been living on interstellar cruise ships since the mass exodus—reminding me very much of the Golgafrincham B class as created by Douglas Adams in The Restaurant at the End of the Universe—an acerbic, sardonic send-up of humanity as a whole. Idiots, the lot of them. And that is where the mostly predictable plot begins.

Still, maybe that’s all there is to life. While I’ve had my moments of companionship, communion, and connection, they have, for the most part, been brief exercises, not going too deep, not getting too difficult. People slide in and out of life like set pieces. As long as you don’t ask too much, you’ll get by, but you won’t get much, either.

And it seems the moments that I’ve tried to bridge the gap, tried to reach out and go for something more meaningful have all been shot to shit somehow.

There’s no point in connecting closely, meaningfully, to anyone, because no one wants to be that close to me, and even if they did at the beginning, in the end, they leave as fast as they can physically go.

Times like these, I end up asking: why continue to burden the universe with my existence?

It would be one thing to be bitter and angry about all this, to learn all the wrong lessons. An eye for an eye, a tooth for a tooth. Get yours while the getting is good. Fuck everyone else. But all of that is pretty much just as meaningless as my one-dimensional existence of microscopic, ultimately meaningless, achievements. Why trade in one set of nonsense for a whole new set of nonsense, when the current set gets me nowhere just as well as the new set probably would?

So, instead, I’m just sad. And I wake up in the morning like everybody else, take a shower, get dressed, go to work. If I’m lucky, some of the meaningless little things I do will actually have measurable results, no matter how small.

Like I said, it’s not that there aren’t awesome people around me who are looking for deeper meaning in life. But they can usually find someone less mentally convoluted and more physically attractive than I am.

Bn likes to say that I’ve never (or at least, almost never) tried, and that’s why it hasn’t worked out for me all these years, and maybe it’s true. But each year I’m a little more tired. The gangrene affecting my soul advances just a little bit. Each advance, I feel less and less pain. Eventually I won’t be able to feel a damn thing at all, and then they can rip my soul out of me and I won’t even flinch.

Only hope can keep me together.
Love can mend your heart, but love can break your heart.
—”Message in a Bottle” by the Police

Then again, when we’re talking about someone who is just awesome in so many ways, even just being friends with her is probably more than I deserve.

Small victories. Little triumphs.

So I woke up at 2:30 am because of some excruciating left upper quadrant (LUQ) abdominal pain, with some referred pain to the neck. The abdominal pain was a burning, almost boring, continuous sensation. I wasn’t short of breath or diaphoretic, and this was pretty typical for the problems I’ve been having with my GI tract, which I’ve basically written off as either really bad GERD or quite possibly some peptic ulcer disease. I blithely entertain the notion that I’m having a heart attack, but since the only symptom is this quite caustic sensation in my belly, I don’t buy it. In any case, the neck pain goes away after some Tums and ranitidine (Zantac) 300 mg (4x the over-the-counter dose.) But the acid pain is still there, and I figure I may as well eat. And since I’m eating, maybe I should go to the grocery store.

I’m done with groceries by just after 6am, and while the pain has abated, it still quite annoyingly there. I end up buying some omeprazole (Prilosec), too, and gobble down 40 mg (2x the over-the-counter dose.) In about half-an-hour, the pain finally goes away to the point where I can get some sleep.

I end up having some really vivid and intense dreams. At first, it just starts out with me doing rounds with the new interns on internal medicine. It so happens I’m also taking call for the neuro service at the same time (which is completely nonsensical.) And my neuro attending is doing some really weird-ass research.

It turns out that, through sheer accident and some fucking around with the functional MRI scanner (fMRI), he has stumbled upon a region of the brain that lights up specifically when we’re trying to predict the future. (Would it make more sense to call it the Feynmann area or the Schroedinger area?) With a few other weird techniques including hypnosis and such, he has figured out how to get a snapshot of what this future prediction looks like, and essentially, the patient is able to make her imagined future environment persist, so that she can always go back to that timeline she predicted and make changes and do whatever. It’s like the ultimate immersive experience.

In slightly clearer language, basically the test subject is prompted to imagine something about the future, and then induced to dream. The test subject will then find themselves in a vivid dream set in the exact future that she imagined. Say that you make a prediction about Tokyo in 2038. Your brain does some calculation that includes the Feynman center, and spits out a likely scenario from which you can extrapolate whatever it was that someone wanted you to extrapolate. What my neuro attending’s contraption allows you to do is not only figure out the extrapolation, but actually make the Tokyo 2038 scenario you envisioned persist, so that you can return to it whenever you want and see whatever it is you want to see.

Now, since he hasn’t been doing this research long enough to figure out whether or not there’s anything to the futures his test subjects are predicting (no winning lottery numbers, sadly), all he’s really been doing is dutifully recording the extrapolations and scenarios. Well, it turns out that he figured that this would be really lucrative in the video game market, what with the extraordinarily fanciful futures that some of the test subjects have predicted.

As time goes on, he also figures out how to actually read the visual cortex and the images that flicker through it, and he can turn it into a computer model that can be manipulated and navigated in three dimensions. In this way, he becomes less dependent on the test subject’s recall, and it becomes easier to actually build a game this way.

Some of his results are particularly interesting, many of the test subjects evoking this world that feels like some weird melding of Japanese manga/anime tropes that are replete with mecha, cyberpunk dystopia, and interplanetary travel. One of the first games he manages to develop in this manner is a standard fighting game a la Street Fighter where you can choose to be various samurai from the Genji era, a few fight club participants from America in the late 1990s, or some kind of futuristic high-tech mercenary a la Boba Fett.

But a lot of the games are merely just background worlds. For example, there’s a future where the world has been totally wrecked by eco-disaster, and most of the world’s surface is covered by water (a la Waterworld.) But civilization hasn’t collapsed quite as much as in Kevin Costner’s movie. Naturally, the Japanese, being island dwellers who are used to extremely limited tracts of real estate, manage to survive quite skillfully, by building environments and habitats that are not only mobile, but can actually transform into mecha.

The also manage to either find a new fuel source other than hydrocarbons, figure out how to mine hydrocarbons from the Saturnine moon Titan, or actually discover an anti-gravitational force. Because, in addition to the mecha/habitats that roam the oceans of Earth, some people have actually taken to living on air-borne arcologies.

The world I enter is extremely dystopian. I have images of Depression Era 1940s, coupled with images from the [Spanish Inquisition]. Conservative Christianity holds sway over the entire Western World and the Reformation never happened. Islam enjoys the same niche compatibility that Judaism has, and the real ideological enemy becomes the East. The See of Rome intends to convert the believers of Hinduism and Buddhism to the Way, the Truth, and the Light.

So I find myself at a construction site which kind of reminds me of Mission Valley but in reality has no similarity to it at all. In fact, the mall reminds me almost of a favela. But some construction workers are building another parking complex, and some bizarre accident happens so that a really young black guy with cornrows wearing a wife-beater falls five stories and gets improbably impaled on a steel spike. Somehow, he manages to still have a pulse, although part of the steel spike has apparently penetrated into his brain, and he really isn’t saying much. Some of us assert that the guy wouldn’t’ve wanted to live brain-injured, and we try to cajole the on-site physician to at least give the guy some morphine until EMS arrives. However, because the Church has his fingers on everything, the on-site cleric puts the kibosh on that, saying that that would be euthanasia. I end up registering my disgust and try to get off the work site, knowing full well that I make myself an excellent target for the now 1.75 century old Inquisition.

The attending neurologist’s prodigy, however, is a 15 year old Hapa kid who is half-Japanese, half-French. His name is Shinji Yakamura, and from his labor alone, they have been able to sell two blockbuster games to Sony, Nintendo, and Microsoft, basically securing funding for further research.

Another alternative future is something of a transportation dystopia. The world has apparently been, quite literally, paved over. We don’t notice the environmental catastrophe that ensues mainly because most of our environment is almost completely artificial. Roads and freeways run in and out of the Grand Canyon. Rivers are wantonly redirected to make road-building easier. Everyone drives their hydrogen-fueled cars with retrofuturistic features like the fiberglass hatch and afterburners.

Even the air-borne environments which I mentioned previously have roads going to and coming from them, so much so that most maps have to be rendered holographically, because it is nearly impossible to draw a usable map in only two dimensions.

I would love these vivid dreams if not for the fact that they leave me completely exhausted.

This song, which recaptured my imagination a few months back, popped back into my head today.

Love of mine some day you will die
but I’ll be close behind.
I’ll follow you into the dark.

No blinding light or tunnels to gates of white,
just our hands clasped so tight
waiting for the hint of a spark.
If heaven and hell decide
that they both are satisfied.
Illuminate the NOs on their vacancy signs.

If there’s no one beside you
when your soul embarks,
then I’ll follow you into the dark.

In Catholic school, as vicious as Roman rule,
I got my knuckles brusied by a lady in black.
And I held my tongue as she told me
“Son, fear is the heart of love”
so I never went back

If heaven and hell decide
that they both are satisfied,
Illuminate the NOs on their vacancy signs.

If there’s no one beside you
when your soul embarks,
then I’ll follow you into the dark

You and me have seen everything to see
from Bangkok to Calgary
and the soles of your shoes are all worn down.
The time for sleep is now,
It’s nothing to cry about
‘cause we’ll hold each other soon.
The blackest of rooms

If heaven and hell decide
that they both are satisfied
Illuminate the NOs on their vacancy signs

If there’s no one beside you
When your soul embarks
then I’ll follow you into the dark.
Then I’ll follow you into the dark

—”I Will Follow You Into the Dark” by Death Cab for Cutie

The YouTube star Kina Grannis and her sisters sing a cover of this song.

At first, it makes me think of the legend of Orpheus and Eurydice, with Orpheus heading out for Hades in order to bring his beloved back.

But I met one of my patients again whose wife had been diagnosed with Alzheimer’s disease 8-9 years ago, and they had moved into an Independent Living facility. He has a lot of medical problems and is in fact on oxygen for his ephysema and has been somewhat saddened by the fact that he can’t really take care of her. He and his daughters have decided that it would probably best to house her in the dementia unit.

But I think of his devotion to her. She will always be his one and only, even though the disease has been stripping her of what makes her her.

And I got pretty damn teary eyed. “For better and for worse, they told me,” he said matter-of-fact. “She would do the same, maybe more, if it were the other way around.”

And, even though I know I may never find an answer to this question: how do I find a love like that?

I woke up with this song in my head

Transport, motorways and tramlines,
starting and then stopping,
taking off and landing,
the emptiest of feelings,
disappointed people, clinging on to bottles,
and when it comes it’s so, so, disappointing.

Let down and hanging around,
crushed like a bug in the ground.
Let down and hanging around.

Shell smashed, juices flowing
wings twitch, legs are going,
don’t get sentimental, it always ends up drivel.
One day, I’m gonna grow wings,
a chemical reaction,
hysterical and useless,
hysterical and

let down and hanging around,
crushed like a bug in the ground.
Let down and hanging around.

Let down,
Let down,
Let down.

You know, you know where you are with,
you know where you are with,
floor collapsing, falling, bouncing back,
and one day, I’m gonna grow wings,
a chemical reaction, [you know where you are,]
hysterical and useless [you know where you are,]
hysterical and [you know where you are,]

let down and hanging around,
crushed like a bug in the ground.
Let down and hanging around.

—”Let Down” by Radiohead

Man, I really hate how my mood is totally pegged to the weather. Gray sky dawning means a touch of melancholia.

and one day, I’m gonna grow wings

It is weird to observe new beginnings without actually being part of it. Like when A+E first got together, for example.

But today the new interns started, and the heady mix of excitement and apprehension was intoxicating. I wish them all well. The next three (or so) years are going to be an adventure.

For a while, I felt like I was soaring, blown upwards by paroxysmal blasts of wind, wanting to do impossible things, forever chasing sunlight. But weariness creeps in bit by bit. In a lot of ways, I know that Bn is right, that my life is still ahead of me, that it’s too early to settle down and take root.

Even though the past four, eight, twelve years are finally catching up to me, and I look at the cold hard road behind me, and I realize that there’s no going back at all.

A part of me yearns achingly to claim this place for my own, to make that decision that this is enough.

That I am home.

A part of me recognizes that no place will ever be home, so long as my heart is sundered into sharp, jagged fragments. Just as I belong to no land, to no country, so too can no place lay claim over me. My soul lies fallow. What’s left of my heart is cold and still.

Maybe our hearts always know our destinies. As much as I’ve clawed, kicked, and railed against Fate, it has moved on inexorably, leaving me floundering in its wake, gasping for air and only swallowing sea water.

It’s been a long, long time since I remember knowing what I wanted. It may still be a long, long time to go.

It’s never gonna be that simple.

OK. I’m too exhausted to make up a video. I know it’s crappy, and I must warn you, there’s a possibility your tympanic membranes will rupture, and you might be enraged and/or disgusted by dropped notes, off notes, and screwed up timing, but I just had to post it.

But, yeah, this song has been making my heart want to burst this past week or so. I realize that, one way or another, whichever way the cookie crumbles (and I’m not holding my breath), I’m finished. One way or another, there will be no point in looking any further.

Non certior ubi omnes illi inceperunt. Fuisset ubi ea et meus laboramus pariter, ante omnes res quid ea subire. Pro nonscitarum rationalibus, ea meum accrediderat.

Importans est quid te subdare, scio quid eam mittendam ab caelo esse.

Ea mirabilis persona est. Ea curans, lenis, cogitabunda est. In unum verbum, ea verenda est.

Et dehinc ea paene moritur, et adhoc non subdo quid posse perdida.

Et dehinc aliqua, pro quippiam rationalis, ea meum vocaverat, in incapentio ver.

Cotidie ea meum diem illuminat. Solummodo quid meum scire quid eam existat magna felicitas pro meo est.

Aliquis similis meus fortem cum alicujus similibus ea non habeo. Non scio cur somnio.

Adquo possum amare, credo qui meum amare eae. Ea meum lucem solis fiat, meum lucem guidentem. Adqui si partem eae vivae non habeo post omnibus rebus, commutatus est pro major, et scintilla eae ignis semper vivebit in mea corde.

My dad relates this anecdote to me:

Doctor: What is this stuff in your ear? It looks like a melted glycerin suppository!

Patient: Damn. No wonder I still haven’t been able to poop. At least now I know where my hearing aid probably is.

I keep thinking about the cruel arbitrariness of the back story—how a beautiful fairy shows up dressed as a hag, and the prince is disgusted and throws her out. OK, so judging people by their appearances is not a good thing, but to use it as a pretense for turning a guy into a hideous monster makes me want to kick the fairy’s ass.

I’m thinking that what really happened was that the Beast caused his own curse. I can see it now. The fairy is someone he had fallen in love with, but because he never really loved himself, he has no way of winning her heart, and he slowly turns into the beast he imagined himself to be. Because shit like that tends to happen around fairies, you know? Latent death-wishes have a way of becoming reality sometimes.

The fairy—who just doesn’t see the Beast in that way, because, well, he’s kind of shallow and harbors way too much self-loathing, you know?—can’t do anything to undo the curse, except she realizes and tells him that he’s got to love himself before he can love anyone else.

Because just being friends with someone whom you’re hopelessly in love with is way too painful, the Beast and the fairy end up parting ways, and there he is, brooding in his castle, sadder than ever because there’s no way anyone is going to love him the way he is.

Of course, as the kingdom decays and because they didn’t have the Internet or Snopes in those days, everyone thinks the fairy actually cursed him, and uses the story as a way to scare the crap out of their kids.

Talk about pseudo-autobiographical. Sheesh.

I know you. If I leave you to your own devices, you’ll pick the path of least resistance. You’ll stay in San Diego because it’s the easy thing to do. Or you’ll go to L.A. because your parents are there and you have a fool-proof backup plan. But I think it’s time you took an active part in your fate and not just let chance decide where you go. —Bn. circuitously alluding to the fact that I haven’t dated anyone for a long while now.

It’s terrible, really. Times like these, when it’s sunny and calm and blissful and quiet, is when I worry the most.

I think about all those times that I’ve felt the cold presence of Death draw near. It’s never my death that I’ve feared, although I’m scared of that the way anyone is scared of jumping out of a plane at 30,000 feet, or jumping off of an 500 foot cliff. But that’s just visceral fear—the autonomous nervous system taking control, cutting off your cortex so that you don’t die from thinking too much.

No, what my encounters and near-encounters with death have taught me is the meaning of the word dread. Brooding dread. The kind of thing that keeps you up in the middle of the night, gnawing on the ends of supposition and running through worst-case scenarios, and having to wonder if, when you got up the next morning, you’d be able to bear it.

I’ve talked about the time my dad had his big MI, coming upon three years ago, now. If I didn’t know it before, I understood it then what it means to be outside of the loop. No one ever talked to me, showed me any test results. No one tried to reassure me or lay it all out on the table. It was just silence filled with my fretful worries, some legitimate, some completely out of my ass. I didn’t help that I lived 150 miles away, and that I was still trying to work and commute back-and-forth. I remember trying to take Step 3 of the USMLE during this time period, and I’m surprised I passed.

While the hours fled, measured by the inhuman beeping of the cardiorespiratory monitor and of the pulse ox, me and my mom were working on pure speculation, trying to piece together the fractured fragments of the so-called practice of medicine while my dad suffered in his bed in the ICU, barely awake. In this profession, they call that “circling the drain.” I’ve seen that look at least a thousand times now, and I think I’ve only seen anyone come out of it twice in the last six years.

Even now, whenever I drive past that hospital, or that train station, I still remember that day in late June. The heat made the streets seem to waver, and I felt like I was floating along in some kind of surreal nightmare.

Walking from the Chinatown Gold Line station to the doors of that hospital. Those were the loneliest, most onerous two blocks of my life, and will probably be the benchmark by which I measure all my future suffering.

Death smacked me straight in the face one random January morning in 2007. You see, phone calls before 5 am are almost never good. No one wins the lottery or gets engaged before 5 am. Sure, someone could have had a baby, but you usually know this in advance. You usually have some sort of warning So when I got that pre-5 am phone call straight out of the blue, I remember shivering. Hesitating about calling back.

Overcoming my dread, I call my cousin J. He tells me that his sister D is in the hospital. She’s intubated and sedated. (Reminding me of all those dreary progress notes I’ve written while rotating through the unit, trying not to kill anyone faster than they were already going.) What are you supposed to say, then? Not knowing anything about anything, just knowing that someone you knew and loved was dying, and quite possibly dead. Soul evacuated. I’m not here. This isn’t happening.

The last thing I ever said to her was that we should all hang out more.

I still get the shivers when I drive past the parking lot where we last parted.

Every day that passes, I feel like I’m just waiting. Whenever I see my dad slumped over on the sofa, having fallen asleep while watching TV, breathing quietly, I end up think about the fact that all our days are numbered. I know that we’ve got to make the most of every moment we’re given with each other, but at the same time, we’ve got to live in the present, with plans for the future. It doesn’t make any sense, really. I try not to think about any of this, but the longer I hold it in abeyance, the more likely it’s going to wake me up in the middle of the night, leaving me drenched in sweat, with my heart racing.

If I use all my strength up to swim away from shore, what are the odds that I’ll actually make it back? If I spend all that time now, what happens to later? Does it matter?

Eventually I end up quantifying how much anyone has ever loved me, which is an awful, ugly exercise. It’s like a Goldilocks and a three bears situation. I know for a cold, hard fact that my mom loves me. I know this more than I know that the stars that glimmer in the midnight sky are balls of hydrogen and helium gas. But there’s probably such a think as too much. I’ve lived under her shadow for too long, letting her shield me from the real world, and now that I know that it’s all been a big mistake, a massive clusterfuck of epic proportions, it’s too late. I’m a mama’s boy. There’s nothing to be done.

Now my dad. My dad is not a virtuous man. Last weekend on Father’s Day, my sister gently chided him for all the things he did when we were all younger, and really, for all the things he didn’t do. My dad is a passionate man, but he doesn’t know how to express it. I’ve learned a lot about distance from him. About keeping your cards close to your chest. About never giving away a tell. In cards, in mahjongg, in basketball. The problem is, you can’t just hide things from your opponent. You end up hiding things from your teammates, too. You have to hope that they know you enough to still trust that the things that need to get done, actually get done.

My dad has committed his share of betrayals. Sometimes he simply wasn’t there when we needed him. But I guess the thing that evens it all out is that, in the end, he stuck around. As paltry, as pathetic as that is, I suppose it makes a difference.

The only two people in my life who probably give a shit about my sorry ass are my siblings. For better or for worse, we’ve travelled down a common path for decades. We’ve had our share of fights. A lot of them physical and violent, to tell the truth.

My brother is a lot more like my dad than I am, although we have the same penchant for distance. The only thing is that we’ve been through a lot together, and that’s probably all we can hope for. I honestly wouldn’t be surprised if my brother ended up getting married without telling me, or moving across the continent. It’s just the way we are. We’re brothers, and that’s probably as far as I’ve ever thought about it, for better or for worse. I don’t expect him to look up to me like I’m some kind of saint.

My sister. Well, that’s complicated. We’ve had an embattled relationship from the start, I think, striving for attention and control. Anything that my sister knows about politics, organizing, and sheer manipulation can probably be traced to the lessons of her youth from our sibling rivalries. Even today, we have long drawn out arguments that lead to shoving and hitting. I haven’t talked to her in three months now. I just don’t have anything to say that wouldn’t be patronizing. I’m not going to apologize. Even if I am wrong. If she needs me, she knows where to find me, and that’s that.

So much for living in the present, huh? Those are the four people I love the most on this green Earth, and it’s ridiculously complicated, and not a little painful. But I remember that quote about trying to stop a war being like trying to stop a glacier. I just ain’t gonna happen.

Oh, I’ve got friends who keep tabs on me from time to time. Mostly to make sure I haven’t imploded. I owe them far more than I’ve ever given them, if I’ve even given them anything worthwhile. And then there are those episodes that I like to think of as lost chances rather than abject failures. But we’ll never know now, will we? Somehow I stumbled upon some pictures I took with Chrsc., remembering that she’s getting married in about a year.

On bright days like this, the sunlight suffuses everything with a haze that gets embedded in my memories. These bright photons will fade with time, leaving impressionistic etchings on the walls of my mind. All I’ll remember is that it was bright and sunny.

Only the loneliness, the emptiness is real. It’s the only thing I seem to be able to touch, hard and sharp like forged steel.

Where do I go from here? That seems to be the eternal question. After all this time, I no longer want to know the answer. Times like this, all I want is some reassurance that I won’t have to suffer too much before the end.

The Dragonfly Initiative suddenly took me back to those halcyon days of yore, when I could just sit for hours studying things that I find are of little-to-no clinical relevance. Chronic renal failure? Obsolete. It’s Chronic Kidney Disease. Congestive Heart Failure? Obsolete. It’s just Heart Failure, or Decompensated Heart Failure, now. There is no such thing as Non-Insulin-Dependent Diabetes Mellitus, either. It’s either DM type I or type II. Beta-blockers are standard of care in Decompensated Heart Failure. Digoxin is almost useless, except as a way to achieve rate-control in atrial fibrillation. The difference between Q-wave Myocardial Infarctions and non-Q-wave Myocardial Infarctions are academic and don’t make a difference in terms of treatment. What we care about are ST-elevations: STEMIs vs NSTEMIs/unstable angina. And it’s all called Acute Coronary Syndrome now.

Hell, I’ve had to unlearn things I’ve learned during residency already! Erythropoietin can cause serious problems. COX-2 inhibitors are a marketing ploy more likely to cause Acute Coronary Syndrome. LDL is not the end-all, be-all of risk stratification for Coronary Artery Disease. No one I know has actually ever seen warfarin cause a thromboembolism, and it’s standard-of-care to just start it without bridging as long as you know they don’t have a hypercoagulable condition and aren’t a super-high stroke risk.

I’m trying to think of a situation where medical student syndrome became an issue.

All I recall a couple of cases that my friends and family tried to get me to diagnose over the phone, knowing full well that I was just a mere medical student, and that diagnosis without actually seeing the patient is fraught with massive amounts of danger.

1:

My sister develops severe right lower quadrant pain randomly in the middle of the night. She’s puking her guts out, and one of her roommates tries to describe everything to me over the phone. She also has a fever. I’m thinking that it’s probably appendicitis. She ends up in the emergency room, and the urinalysis is consistent with kidney stones.

2:

My friend A calls me up and reports that she gets right upper quadrant pain about 30 minutes after eating meals, and that she ends up feeling bloated and nauseated. A diagnosis of gallstones flits through my mind, but it doesn’t make any sense. The mnemonic for gallstones is 40 years old, female, fat. A is (or was at the time) in her mid 20s and barely weighs 100 lbs. Gastroesophageal reflux disease (GERD) also floats through my brain. But why now?

Then I remember the old dictum: every female of child-bearing age is pregnant until proven otherwise.

I ask her when her last period was, and it’s like three months ago, and I’m like, “What?”

A laughs and tells me she and E are expecting. Now that was a forehead slapping moment that I won’t ever forget.

3:

My dad starts having bright, red blood in his stool and my mom is a little agitated by this. My dad, who is excessively fatalistic, doesn’t seem to care. He says it’s his hemorrhoids. My mom retorts: Didn’t you have surgery done on them? My dad laughs mirthlessly. We both know that surgery for hemorrhoids is no magic bullet. He eventually gets a colonoscopy, and, what do you know? It’s his hemorrhoids. At least he won’t have to have that done for another 10 years.

I’m glad I wasn’t in medicine yet when I had my chronic cough. I mean, this was really a chronic cough. It lasted from September to March. Non-productive. Non-bloody. No shortness of breath. Just this irritating cough that wouldn’t go away. I don’t really think anything of it at the time, but my mom freaks out and demands that I get a chest x-ray, which, predictably, comes back negative. And yet, for some reason, I don’t get a TB skin test done.

In retrospect, it turns out that it was probably a combination of a post-viral cough and my latent asthma. This is when I realized that there is no such thing as outgrowing asthma, and I’m going to have bronchospastic airways until the day I die.

Oh, now I remember. I got my testicles checked because I have this lump that turns out to be probably a spermatocele. At least, the urologist didn’t seem concerned.

I got my salivary glands checked out by two ENTs because I kept having (and keep having) face pain. One of the ENTs diagnosed me with sialolithiasis and extracted two stones from my Wharton’s duct. That’s probably what it is, and I’m not sure if I should get anything else done about it. The idea of injecting iodinated dye into the ducts to do a sialogram sounds unpleasant, and knowing my atopic history, I may even run the risk of having a contrast reaction, but I should probably get this taken care of while I have insurance.

Lastly, I remember getting motion sickness and feeling nauseated for days and days, to the point where I was basically just going to sleep after coming home from my rotation. I even saw a neurologist, and they found my exam completely normal, and chalked it up to some form of viral labyrinthitis that should wear off in another week or so. In retrospect, I realize that this was probably venlafaxine withdrawal. Damn that drug.

It’s funny how I feel reassured when the so-called experts can’t figure out what’s going on. Unfortunately, this also means that they can’t figure out how to make me feel better. I’m wondering if I should just get empiric treatment with parenteral penicillin, in case this really is an smoldering case of actinomycosis that’s causing sialolithiasis, although this seems pretty damn unlikely. Although it could explain some of the night sweats. (And, no, my last PPD was still negative, and while I may have converted sometime this year, the night sweats would pre-date the point of conversion. And my last CBC was perfectly normal, so I seriously doubt this is leukemia or lymphoma. But, you know what? You never know. How reassuring is that?)

Bayes Theorem is a powerful, yet oft-misunderstood, tool in medicine. Physicians are probably slightly better than average people at estimating probability, but we’re terrible at adjusting these probabilities in light of data accumulated from clinical diagnostic testing. So, despite the fact that very few people, even when considering people with hypercoagulable states, even when considering people with cancer, develop pulmonary embolisms, anyone with chest pain and shortness of breath that can’t be ascribed to Acute Coronary Syndrome, has a pulmonary embolism, no matter what the tests say. D-dimer negative? I don’t care. Get a CT angiogram of the lungs. CT negative? I think it’s wrong. Get a ventilation/perfusion scan with xenon and technetium-tagged macroalbumin. V/Q scan negative? Who cares. Let’s just anticoagulate the guy. This kind of flawed thinking goes on everyday, at the tune of hundreds of thousands of dollars. I think if they just taught Bayes Theorem for an entire year, we might get better at this prognosticating racket. But maybe not.

Wow. Just, wow. Good thing I’m a little drunk.

I suppose it was fitting that today Bn exhorted me to go the Bay Area once I’ve served my sentence completed my residency down here in S.D. While ostentatiously there are several reasons why I would want to stay here, there really was only one, and as of 7:59 pm, I’ve come to realize once again that such reasons are always perilous.

There is a part of me that is gnawing upon itself in agony, wondering why I keep getting trapped in these temporal loops of complete, utter despair. There is another part of me that is perversely rejoicing, because it saw this coming from miles away, like an ICBM arcing towards its target with the utmost accuracy.

My mom grilled me again this past weekend about whether or not I have a girlfriend. I hate that question. I hate it a lot. Enough to make me not want to come home very often. But it must be endured. As I’ve mentioned a multitude of times, my mom really wants grandkids. I don’t know why she keeps bugging me about them. My brother and my sister are both in long-term relationships. Let them take care of that filial duty.

Mχ asked me if I was going to bring anyone to Mχs and L’s baby shower. (That kid is going to be super-lucky to have them as parents, I swear.) When I told him no, he used the term “terminal bachelorhood” and I had to laugh out loud. It’s odd, that. That where I am now is where I’m going to be when I die.

Part of it is that I’m on a geriatrics rotation right now, and prior to that, I was on an elective ICU rotation. Either way you slice it, the people I’ve been interacting with are all pretty much on death’s doorstep. So certain songs have taken on some rather dark, deep, depressing, and morbid interpretations.

That there.
That’s not me.
…
In a little while
I’ll be gone.
The moments already passed
Yeah, it’s gone
and I’m not here.
This isn’t happening
I’m not here.
I’m not here.
—”How to Disappear Completely” by Radiohead

I thought of some really morbid, macabre imagery to go along with this song. I imagine someone in the ICU, intubated and on a ventilator, with multiple lines going in and out of him. Someone like the soldier in white from Catch-22, almost entirely covered by bandages, so much so that you can’t even tell if there’s anyone in there.

That there.
That’s not me.

The main drive of the short narrative is the decision to withdraw care. So they go through the process of terminal extubation.

In a little while
I’ll be gone.
The moments already passed
Yeah, it’s gone

As the patient goes into agonal respirations, scenes from his life/my life are interspersed. Going out with his girlfriend. Talking to his parents and siblings. Living life, being happy and healthy.

The other song I think about is “What Sarah Said” by Death Cab for Cutie (who is apparently currently having a concert at the Greek Theater in Berkeley.)

Christian Sinclair, M.D. deconstructs the song expertly, bringing to mind exactly all the things that I think of whenever I hear this song, and I seriously always cry at least silent tears whenever I hear this song, and if I’m in a really bad or vulnerable mood, it will leave me bawling.

But I sort of have a different take on the instruments in the final passage, relegating them strictly to ICU noises, and leaving the emotional aspect more muted

• single guitar strum: inhalation/forced ventilator breath
• cymbals: oximeter alarm > agonal respirations
• organ: cardiac monitoring > asystole alarm
• continuous guitar strumming: tachyarrhythmia/vtach/vfib alarm
• snare drum: CPR/stop watch/clock ticking > death march rhythm > S1, 4/6 harsh sounding systolic murmur then S2
• bass drum: heart beat (on auscultation)
• descending piano: ventilator alarm (circuit disconnected)
• ascending piano: blood pressure alarm (A-line pressure tracing non-pulsatile)
• random instruments: all the alarms going off dyssynchronously
• doorbell: the elevator as they wheel the body away to the morgue

The cymbals are the first thing you hear, as your patient desats. The slowest rhythm is the single guitar strum, signifying a ventilator breath. The snare drum keeps time as code blue is called, but it also has the flavor of a march. It also happens to sound like critical aortic stenosis. The insistent continuous guitar strum reminds me of a tachyarrhythmia alarm, with the heart rate racing into the 200s, and then 300s-400s in v. flutter. The organ keeps the actual rhythm of cardiac electrical activity, which doesn’t match the bass drum because despite the flurry of electric impulses, the heart really isn’t pumping very effectively. As the code blue progresses, you start hearing the descending piano melody, as ventilation becomes compromised. One of the last thing you hear is the ascending piano melody as blood pressure tanks precipitously and irrevocably. Eventually, all you hear is the organ, now playing whole notes, reminding me of the asystole alarm. The cymbals start fading out, too, and they start sounding like unassisted breaths, or ineffective ventilator breaths. And then silence, and a quiet cacophony (is that even possible?) of dyssynchronous instruments as you take all the monitors off the body, letting the alarms go off willy-nilly.

Sinclair interprets the last sound as a doorbell, which may signify the arrival of the elevator car that leads to the morgue, but to me, it sounds like an old-school end-of-tape signal, both on cassettes and video cassettes.

So who’s gonna watch you die?
—”What Sarah Said” by Death Cab for Cutie

So I gave up on my psychiatrist because she’s been pretty adamant about me making timely follow-up appointments. Unfortunately, part of my problem is that my executive function is seriously fucked. I’m just not very good at making plans. Seriously. It must be at least a minor miracle that I’ve made it this far without ending up dead.

I don’t know whether to blame this on depression, or whether I really do have some type of brain injury.

The problem with not having a psychiatrist is that I can’t get my psychotropic medications. This, too, would be OK if venlafaxine didn’t have such awful withdrawal symptoms.

• neurological/psychiatric symptoms
  1. vertigo
  2. “brain zaps”
  3. akathisia
  4. excessive day-time sleepiness
  5. insomnia
  6. diaphoresis
• ENT symptoms
  1. facial discomfort/sinus pain
  2. constantly runny nose
• GI symptoms
  1. nausea
  2. bloating
  3. frequent bowel movements

Most of these can be dealt with perseverance. But the akathisia and the constant feeling of wanting to throw -up all the time made me want to throw myself off of a tall building. Add to this the brain-zaps, and it’s a wonder that more people don’t kill themselves while trying to get off this stinking drug.

The last time I decided to flush it out of my system was a couple of years ago. This was, in retrospect, probably a really bad idea. The work I was doing was kind of high-stress to a degree, and while I managed to cope, I could’ve worked on timing it a little better. I managed to do OK off of the meds for a couple of months. That’s when I realized I needed serious help.

But what I found that sort of worked were all the anti-cholinergic (really, anti-muscarinic) drugs that you can get over-the-counter. Things like diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton). Meclizine (Antivert) was useful, too. At the very least, all these drugs helped with the constant nausea and dizziness.

The problem was that these drugs also make you excessively somnolent. I mean, I really shouldn’t’ve been driving while taking this toxic cocktail of over-the-counter meds, much less working.

I’m thinking it all abated after a week of intense suffering.

This time, I just couldn’t take the brain zaps. For those who aren’t familiar, what this is is a sensation of some kind of force discharging through your cranium. It’s really hard to describe, actually. But I think some of it is the fact that your facial muscles contract suddenly and forcefully. Even the tensor tympani seems to contract, and this may account for most of the nausea and dizziness, now that I think of it. The zaps tend to occur when you’re moving your head. It’s like the worst case of motion-sickness you’ve ever encountered. I mean, I could do fine if I held my head rigidly, with neck flexed. But any slight deviation, and the zap would happen. It’s actually quite a miserable way to live. Maybe not the most miserable, but it’s pretty bad.

The idea is that this happens the most with venlafaxine because it’s such a short acting drug. Without the XR formulation, you’d have to take it three-times a day to maintain a steady state, for one thing. And even with the XR formulation, I’d get withdrawal symptoms if I went more than 24 hours out without taking my next dose. This makes taking overnight call slightly painful if you fail to plan ahead, like I tend to.

So I have some sertraline (Zoloft), fluoxetine (Prozac), and escitalopram (Lexapro) lying around from long-ago attempts at finding the right drug for me. It’s only a handful of pills, so I’ve had to use them exceedingly sparingly.

I’m coming down from venlafaxine XR 300 mg daily. The maximum dose recommended in the monogram is actually only 225 mg, but I’ve seen psychiatrists use this dose once in a while, particularly for resistant cases. If I had a way of partitioning the capsules, it might’ve been feasible to do an extended taper, but all I’ve got are 150 mg pills, and going from 150 to zero is god-awful. At first, I tried to subsist on my toxic cocktail of OTC anti-cholinergics, but that left me way too somnolent and I was basically in bed all day. So I tried the sertraline. It’s only 25 mg, so it barely has any effect on the withdrawal symptoms, and it, too, has a short half-life. When I realized this, I went with the fluoxetine.

The great thing about Prozac is that it stays forever in your system. It would probably be feasible to do every-other-day dosing once you’re on a maintenance regimen. Even at the base dose of 20 mg, it has managed to abolish most of the symptoms for the past 48 hours.

Except for the brain zaps. Damn them.

Lexapro has a much shorter half-life than Prozac, but it’s still longer than either Zoloft or Effexor, so I took 10 mg of that after the brain zaps started making me crazy. The dose I took yesterday is probably still sitting in my system, though. I had to take another dose of Prozac this morning. I’m trying to get to fluoxetine 20 mg every other day, with escitalopram or maybe even sertraline for breakthrough. I’m trying not to touch the venlafaxine ever again, but I may have to resort to opening up the XR capsules, crushing the spherules inside, and finding some gelatin caps to make my own 37.5 mg doses.

I think it’s been a week since I took any Effexor, though. Going cold-turkey, I think it took a total of two weeks to finally be rid of the withdrawal symptoms. With this taper I’m doing, it might take way longer than that. I’m hoping I have enough pills to survive before I start thinking about throwing myself off of a tall building again.

The interesting thing I learned about this escapade is that the antihistamines were actually attempts at making more selective anti-depressants. This was back in the day when all they had were the nasty tricyclic antidepressants (TCAs), which include amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil), and desipramine (Norpramin). So they came up with diphenhydramine and chlorpheniramine. Basically, Chlortrimeton and Benadryl are the scaffolding for all the SSRIs. The first SSRI was zimelidine, based on chlorpheniramine, which unfortunately caused Guillame-Barré syndrome and drug rash with eosinophilia and systemic symptoms (DRESS). The second SSRI, as I’m sure we all know, is fluoxetine, based on diphenhydramine. And the rest is history.

What would be neat is if I could find the affinity constants for diphenhydramine and chlorpheniramine for the serotonin receptors, but I’m sure all that stuff has been shredded by the drug companies who are more interested in you buying the latest and greatest drugs on the market. I’m also certain that the doses they’re recommending for allergy symptoms aren’t anywhere near the effective doses for serotonin reuptake inhibition. I also now understand why all the junkies want their Benadryl IV.

…some unhappy master whom unmerciful disaster
Followed fast and followed faster till his songs one burden bore—
Till the dirges of his hope that melancholy burden bore
Of “Never—nevermore.”’

—”The Raven” by Edgar Allan Poe

I may have missed my stop. Passed my exit.

My sense of timing really stinks.

I’m betting that if I fall, I’ll fall by myself, and find myself waking up at the bottom of an old, familiar ditch. Pit, more likely. Abyss, even.

So I won’t. Easier to struggle mightily against gravity than to climb out of that damned hole again. Easy to say at 11 am on a Saturday when no one is gnawing and rasping at your soul, but I’ll say it anyway.

When you’re tired of struggling, you’re tired of life.

Ursa Minor Beta is, some say, one of the most appalling places in the known Universe. Although it is excruciatingly rich, horrifyingly sunny and more full of wonderfully exciting people than a pomegranate is of pips, it can hardly be insignificant that when a recent edition of Playbeing magazine headlined an article with the words “When you are tired of Ursa Minor Beta you are tired of life,” the suicide rate there quadrupled overnight. —”The Restaurant at the End of the Universe” by Douglas Adams

Skipping merrily along the random fractured paths of the Internet, I somehow found my way from the sad fact that Cody’s Books on Telegraph and Dwight has closed (hat tip to Jamie Grove to the revelation that such a thing as a Twitter political debate exists, and that it sucked immensely (with commentary penned by the lovely Jennifer Van Grove) From there I discovered that there is now a patron saint to Twitter: tweetjeebus.

Somehow, this led me to some meme watching: check out I am aware of all Internet traditions (spawned by John Cole) and Nuking the Fridge (which I was led to by Jason Kottke)

Eventually, I found myself reading Edgar Allan Poe’s classic poem ”The Raven.”

Nevermore.

If there really is a balm from Gilead, I wonder if the active ingredient will be gileadensol, gileadensone, gileadensamine, or gileadensic acid?

And apparently, while nepenthe refers to (probably) opium (not surprising, coming from Edgar Allan Poe), a compound called nepenthol would probably have to be a barbiturate. Still, it would be nice to not be depressed, but have my memories intact.

man. so i’m reduced to this. blogging on my phone. no a/c. no writing utensil. brain barely functioning. maybe i should just go home.

Truth be told, I am hoping for something terrible yet wondrous. Awful, joyful things.

Come on, God. Make it all worthwhile.

One of the scribes came near and heard them disputing with one another, and seeing that he answered them well, he asked him, “Which commandment is the first of all?” Jesus answered, “The first is, ‘Hear, O Israel: the Lord our God, the Lord is one; you shall love the Lord your God with all your heart, and with all your soul, and with all your mind, and with all your strength.’ The second is this, ‘You shall love your neighbor as yourself.’ There is no other commandment greater than these.” — Mark 12:28-31, New Revised Standard Version

I have this belief that if God exists, she will always let stand anything that is rooted in the virtue of love. Love is the only thing that makes existence bearable, and to oppose love is to oppose God.

Internet traditions?!?! WTF?!?!

Yes, I believe that it is soft-minded to immediately call a woman a bitch. There are a lot more entertaining, and probably more accurate, insults out there. For starters, there is “shit eater.” That’s what neo-neocon is.

For another, it is grammatically incorrect to assign a gender-specific insult to someone who has no genitals.

We all want the good guys to win. Most major religions prophesy that Good™ will triumph in the end, even against overwhelming odds, even if it seems that most folks are playing for the dark side.

But you gotta remember, Good™ is always the side that wins. History (and prophecy) are always written by the winner. No one really knows jack shit about anything unless you were actually there, and then usually not even then.

And it’s in the best interest of the people you want to win to claim that they are actually going to win. Because until that prophecy comes true or is proven false, in some unspecified time in the murky future, there’s no way to tell ahead of time. How do you know that it’s actually going to come true? How do you know that they’re not just saying that to keep morale up?

How do we know that the Right People™ will actually win? How do we know that the prophecies aren’t all mixed around and screwed up? I think that the fact of the matter is that we don’t.

That’s why we call it faith. If we knew for sure, it wouldn’t be a matter of faith. It would be a matter of fact.

And unless you’re a hard core solipsist who doubts that anything actually exists, it’s redundant and unnecessary to believe in fact. It just is. Even if you disbelieve it, it won’t go away.

Now, I’ve been struggling with the whole “If God is good, why does he allow evil to happen?” question for several years now, and every so often, I come up with something that is temporarily satisfying. Nothing ever really sticks, though. It’s all nebulous and immaterial. It doesn’t predict anything. It’s ultimately a fairy tale that helps me sleep at night, that’s all.

So my current scenario is this: maybe God really does exist, is unquestionably good, and is omnipotent to boot. But he’s got a lot of bad guys going for him. They’ve got him in a stalemate in heaven. In the end, he could always win, by obliterating the universe and starting all over again, but he doesn’t want to do that. Because that means destroying us. And, in the greater scheme of things, us not existing is a far worse scenario than us existing, but suffering. But maybe, because of the stalemate in heaven, Good and Evil make a deal. No nuclear options. You don’t mess around with creation, and we don’t bomb it back to the Big Bang. That’s the deal that God and the bad guys make. So God is forced to do things on the down-low, behind Evil’s backs, in slow and subtle ways.

The problem is that, because God is Good™, she can’t just go around making promises to the Bad Guys and then breaking them. Even though she knows that they wouldn’t think twice about breaking promises they made to her. I mean, what’s the point of being Good™ if you do the same things that Evil™ does? That’s why there’s a war in the first place. (This is also the reason that the War on Terror™ is a pointless endeavor if we end up surrendering our civil liberties and commit war crimes. What’s the point of pretending that we’re the Good Guys if we end up doing the same things the Bad Guys do?)

So God’s hands are tied by the fact that God must be virtuous.

And yet Evil can’t win, because if they try to wreck Creation, God will then no longer have any incentive not to nuke the universe and start over. And they’re not powerful enough to actually overcome God.

Again, it’s a stalemate.

So it occurs to me that that’s probably why God isn’t going around making sure that no one is suffering, and that everyone gets their heart’s desire. Because this is War, man. God’s got a lot of other problems to deal with right now, and your sad pathetic ass is the least of her worries.

Bad Things™ happen because the only alternative would be non-existence. It’s a tough call. Especially if I were constrained to always doing the Right Thing™.

It also occurred to me that my spiritual cosmology is riddled by Tolkienisms. My concept of the Eternal Struggle Between Good and Evil™ is basically cribbed off The Lord of the Rings. Evil, represented by Sauron, is nearly completely omnipotent, and holds sway over almost the entire world. He’s got control of Balrogs and Dragons and almost infinite armies of Orcs. If not for the fact that Good™ always wins, smart money should be on Sauron to win. The odds are overwhelming. Good, represented by Frodo Baggins, has no magical powers, is physically weak, is frequently frightened, is easily wounded and maimed, and in the end pretty much fails completely. It is only an act of Grace™ that saves the day.

I think that Phillip K Dick’s cosmology is similarly constructed. Evil (in the guise of Richard M Nixon George W Bush Ferris F Fremont and the military-industrial complex) pretty much rules the entire world, and only a few people actually remain free. Only the weak, the oppressed, the suffering remain in opposition to Global Capitalism Evil, and they are easily imprisoned, destroyed, and otherwise neutralized. And yet, somehow, Good manages to win out, just barely, and probably just temporarily.

But the Act of Grace™ is important. If Bilbo actually did kill Gollum way back when, then it would’ve been all over. Frodo’s failure would’ve been complete, and Evil would’ve triumphed. It wasn’t power or force that won the day. It was doing the Right Thing™ An act of mercy. An act of compassion. What the Bad Guys call “weakness.”

But if you don’t have mercy or compassion, then you’re playing for the other side.

Retrospect teaches us that doing the Right Thing™ doesn’t always mean that we’ll be rewarded. A lot of times, we actually get punished. Frodo ends up suffering because Bilbo did the Right Thing. Why is this? It’s because Evil is a lot more powerful than Good, and they hold a lot of the top positions. But overwhelming force doesn’t always win. (Just look at Iraq. And Vietnam before that.) So if we have faith, if we have hope, then we’ve got to do the Right Thing™, come hell or high water.

I guess that’s the way all our myths and legends are constructed. The Good Guys almost lose completely, and yet somehow in the end manage to pull it off against overwhelming odds. Maybe it’s because the world really *is* constructed this way.

No one ever won fame, fortune, power, or renown by doing the Right Thing. I’m of the opinion that most normal human beings are actually pretty good at understanding what the Right Thing is in the majority of situations. But most of us don’t do it because it almost never gets us to where we want to go.

So that’s where the battle lies. Think for yourself. Recognize that you really do know what you should do. And when you choose otherwise, remember that you did choose it. We always have a choice. The consequences may not be pleasant, but we always have a choice.

So it occurred to me that maybe that’s my only purpose on this Earth, to ease the suffering of at least a small handful of people. Nothing fancy, nothing glorious. While sucky, loneliness is only one of the multitude of varieties of suffering available on this planet, and it is certainly nowhere near the worst. I guess. That’s how I get myself through the day, at least.

It also occurred to me that there is only one way to relieve suffering, and that is by removing the thing that is causing suffering. So if I suffer because I do not get what I want, the relief comes not in getting what I want, but in removing my want in the first place. Or as has been stated more eloquently than this by wiser minds: all desire leads to suffering.

Even if it is the human condition to seek companionship. To share my hopes and my fears, my aspirations, my ambitions, my shame, my failures with another person who actually gives a shit. Even if this is the condition in which I have been created. If this want shall never be fulfilled, then the only way to stop suffering is stop wanting.

It’s so much easier to write it down than to actually live it.

An incredibly haunting piano and vocal re-interpretation of Radiohead, entitled “How to Disappear Completely”, found on Kid A

That there, that’s not me
I go, where I please
I walk through walls
I float down the Liffey

I’m not here
This isn’t happening
I’m not here
I’m not here

In a little while
I’ll be gone
The moment’s already passed
Yeah it’s gone

I’m not here
This isn’t happening
I’m not here
I’m not here

Strobe lights and blown speakers
Fireworks and hurricanes

I’m not here
This isn’t happening
I’m not here
I’m not here

Unsettling news that helps you to distance yourself from a destructive relationship. Painfully honest communication that needs to take place. Not letting yourself be dragged by your emotions into a negative situation. A trust or confidence betrayed in an attempt to help someone in need. The revelation of a painful truth.

And how many times do I need to face this truth, I wonder? I guess my heart will just have to re-learn how to be silent and still.

I just watched a sweet, low-key film called “Infinity” that stars Matthew Broderick as the renown physicist Richard Feynman and Patricia Arquette as his first wife Arline Greenbaum. Despite the fact that it covers the period of time when Feynman worked on the Manhattan Project, it is mostly really a love story.

It still trips me out that, despite the fact we (as in, Western civilization) had pretty much figured out modern physics (quantum mechanics and general relativity have not really been improved upon since), and had at last learned how to blow up the world, we still didn’t have penicillin in 1945, much less isoniazid.

The big reason why Feynman takes the position is so that he can keep his fianceé and later his wife Arline nearby. Arline happens to be dying of tuberculosis, which is supposed to better than dying of Hodgkin’s disease according to the movie, which I can’t really say, since I’ve never seen anyone dying of TB, but I’ve seen people dying of Hodgkin’s.

It also struck me that, while we can pretty much treat, or at least control, most cases of tuberculosis (the XDR cases the most obvious, most horrible of exceptions), our treatments for Hodgkin’s Disease aren’t quite as good. Although it’s way better than just waiting to die.

I think about a patient with relapsed Hodgkin disease who is three years younger than I am, who has a daughter, and who is pretty much dying.

But the quote that sort of caught my attention, in reference to the Bomb, (but which I don’t think Feynman ever really said) was this:

It brought to mind how terrible this thing was, that treated humans as matter.

I don’t remember the last time I wept tears of joy. Tonight—even though I have 16 days left—I felt that, at the last, it was truly, finally, over.

I gave up a long time ago on the likelihood that I would ever be recognized for anything. I have acquiesced to the fact that I will toil the rest of my life in anonymity. Whatever I accomplish throughout the rest of my life, I will be the sole witness to them. At best, they will be small victories. Minor triumphs.

But it hit me, in a wave of forlornness, that, no matter what else happens, no matter how insignificant I am in the scheme of things, I have been a part of this. I have been a part of this awesome group of extraordinary people who, by dint of who they are, are destined to change the world. You may never hear their names in the news. Their deeds may never be recorded in the history books. But know for a fact that your life is better simply because these people exist, because these people have dedicated their lives to the service of humanity. However peripheral I have been to their lives, I have been a part of this.

I will miss it terribly. I will miss all these wonderful people I have met. This is the last transition of my formal education. From here on out, the real world is gonna be coming at me at the speed of light, raw and unfiltered.

It occurred to me that no matter what, to be a part of her life, however minor and ephemeral that part may be, is already a lot. Her friendship is a great gift. For that, I am grateful. That I have shared a small slice of her glory, and of the adversity she has overcome, that she has shared a part of her life with me, is more than I probably deserve. I know that I will treasure it until my dying day, whatever else might happen.

And, as I have finally—after struggling all these years through nights of anguish, sorrow, and suffering—as I have finally come to understand, there is no next. There is only now. And I’ve got to live my life accordingly.

Carpe diem. And don’t let go until you’ve squeezed out everything you can.

What does it really mean to be done? I’ve got 17 days of formal education left. I’m trying to be as optimistic as I’ve ever been about the future, but I’m just not an optimistic type of guy. I don’t know. I’m more of a giddy cynic. A hopeful pessimist. The mantra of my profession seems to be “Hope for the best, but expect the worst.”

I can’t be too Eeyore-like about it, though. I mean, I know for a concrete fact that there are a lot of people who are far more miserable than I am. And I’m not even talking about people in places like Afghanistan and Burma. All I have to remember is that I don’t have metastatic cancer, I have lungs that actually work, I’m not short of breath all the time, I don’t have a breathing tube down my throat, and I have all my limbs. (Just to reference a few conditions I’ve run across of at work, of people who are clearly in worse shape than I am.)

But this whole despair thing can really get a guy down. As a morbid exercise, I decided to rank the ways I’m probably going to die. The way it currently stands is as follows:

1. suicide
2. high-speed motor vehicle accident
3. coronary artery disease/acute myocardial infarction
4. cerebrovascular disease/stroke

Seriously, though? I’m starting to worry about #1 a lot. Thankfully, the rapidly increasing price of gas is actually making the likelihood of #2 decrease. I can minimize #2 by minimizing the time I spend on the road. I mean, sure, I could always get hit by a bus, but I could also get hit by a hurtling meteorite, too. Life is uncertain, you know?

#3 and #4 are also minimizeable. If I actually ate right and exercised, I would probably survive at least 35-40 more years. But as I continue my sedentary lifestyle and refuse to do anything about it, #3 and #4 are going at it head-on, and are neck-and-neck.

But #1. I’ve got no way of knowing. Most days I’m OK. While certain things can be arduous, most days are purpose-filled and even possibly inspiring.

But then there are moments where I’m gripped with heavy, aching dread, and my mind is filled with the horror of years upon years of vapid, vacuous living, and the thought of living through them all is so onerous that suicide seems to be the only rational course of action.

Right now, I’ve got no incentive to make something better of myself. I’m not exactly sure what I’m waiting for. I’m starting to doubt if there might actually be something that would be able to stick its foot in my ass and make me get going. I like to wax poetic that if I found love, then there might be a reason. But that’s a pie-in-the-sky. Where I’m at right now, I’m pretty damn unloveable. While a lot of women are totally into “bad boy” personas, I really just suck in an irredeemable fashion. Nothing hot or sexy about it.

Certainly, a lot of this is rooted in some serious self-confidence issues. You would think that, by mere dint of getting to where I’ve gotten, I’d have some sort of modicum of self-pride. At least that’s how I imagine a rational person would behave.

But there’s been nothing. For some reason, despite the realization that life really hasn’t been all that horrible, I can’t seem to find a comforting memory that is unequivocally positive. Every triumph in my life seems to be interspersed with some sort of awful sacrifice. Every victory seems pyrrhic. Every moment of joy is tempered with sorrow.

See, what we have here is what psychiatrists like to call a “cognitive error.” The problem with depressed people is that they always tend to hang on to the very ideas that are driving them down their path of self-destruction.

If I could just realize—and actually accept—that my life doesn’t really suck at all, and that there have been some good times in my life that haven’t been tainted by the bad, then I might actually get somewhere.

I’ve read books. I’ve talked to mental health professionals. I’ve studied this disease from end-to-end, and while I understand the techniques, and know all the data, intellectually speaking, I just don’t feel it. I just can’t seem to navigate my way to self-healing, which is ultimately the thing that must happen. I can visit shrinks all I want, every day even, for the rest of my life. But I realize that they can only point me in the right direction. I’m the one who actually has to get there.

Until then, #1 is still going to be there. I’ve managed to stay ahead of the (generally favorable) odds so far. But that bullet is still in one of those chambers, and until I actually stop pulling that trigger all the time, one of these days I may just strike true, causing needless pain and sorrow to the few people who might actually care.

Ever since I’ve been caught up in my crisis of faith (fast approaching seven years now! Woot!) I’ve kind of abandoned spirituality. I mean, I feel like I’ve come to grips with the possibility that a hyperintelligent, disembodied entity (whom, for convenience, we could call God) may very well be trying extremely subtly to drive human history, but that’s as far as I’ve made it.

But it occurred to me that moments like these are exactly what prayer is for. Which is a complex topic that will probably have to wait for another post. (But for all you immature so-called Christians out there who use prayer to wish for material things, and to wish God’s violent intervention against your enemies, you can all suck ass and choke on dingleberries for all I care.)

The unholy combination of Twitter, Google Reader, and raging insomnia brings me to this blog post about weighing the pain of loneliness vs the suffering of heartbreak. I kind of wonder if it just isn’t the distinction between chronic disease and acute disease. Isn’t loneliness just a more diffuse, protracted form of heartbreak? Loneliness is what heartbreak turns into, given enough time.

I feel like I’ve been in an emotionally stunted state for the last 15 years, actually.

There is nothing so horrendously futile as wanting to be in love and not even managing to get that right. We’re not even talking about reciprocation here. Much less revelation. The issue is that even the unrequited variety has been near damn impossible to sustain. Every time, the idea that it’s probably just going to end in tears sends me catapulting back into a totally cocooned state.

My heart lies closed, and is as cold and silent as stone.

And yet, that which fails to bend will break. That which fails to yield will shatter.

Rigidity, and certainly frigidity, can actually be a rather tenuous and fragile state.

I found myself digging through scattered sheets of paper containing random things I scrawled from about 10 years ago, and I must admit, I was a lot more melodramatic back then.

But I guess that’s around when all this started. This mind-crushing, agonizingly excruciating feeling of hopelessness. Of numbness. The only real difference is the intensity. It actually doesn’t actively hurt most of the time, although I’ve certainly gotten twinges now and again. But the pathophysiology certainly continues inexorably, and unabated.

I guess I never really appreciated how much of an emotional cripple I’ve become.

Well this is pleasant.

I found myself extremely exhausted when I got home around 7:30 pm and so basically just crashed out.

I woke up at 1:15 am choking on my own gastric secretions.

I hate GERD.

How did this make it past the cut?

The patient was noted to have a Glasgow Coma Score of 2.

The lowest GCS you can get is 3, for having no eye response, no verbal response, and no motor response. Meaning that a rock and the chair that I’m sitting on has a GCS of 3.

The current meme circulating on these internets is whether or not we should trust someone who can’t use a computer to lead the nation.

I have to confess, I’ve actually never really thought about it. I don’t hold it against anyone to not be familiar with the technology, but if you’re gonna be sitting behind the Shiny Red Button, you better be damn well-versed with technology, man!

Especially with technology that is now as essential as the telephone and the radio has been.

And this isn’t agist. My 72 year old uncle who happens to be an dyed-in-the-wool, Fox News-watching Republican knows how to use a computer, for God’s sake. As do both of my parents, who are in their 60s.

If you don’t know how to use a computer, you’ve got serious problems that should disqualify you from important positions.

I need to count the number of times I’ve used the phrase “Tomorrow is another day.” I keep hoping that each day will bring some magic change inside me, that somehow I’ll manage to snap out of it, and somehow all the things broken inside my soul will have mended themselves.

Physiologically, this makes no sense. If you break a bone and fail to set it, it’s not going to miraculously reknit itself. Scar tissue weakens the structure of organs, and while most people are focused on the scar tissue that forms on their skin, applying various products of dubious efficacy to get rid of them, there’s really nothing you can do about scars in your heart, your liver, your lungs, your brain.

In the end, all modern medicine can do is delay the inevitable. And if you keep poisoning yourself with alcohol, nicotine, and/or McDonald’s, no amount of medicine can protect you from their effects.

We have not yet gotten to the point where we can perform some kind of imaging study of the brain to confirm psychiatric diagnoses. While we can see scars in the brain, we can’t see scars in the psyche. And even if we could, could we really do anything about it?

Are there simply wounds that won’t heal? Or at least injuries that are irreversible? Sometimes the best you can hope for is that the bleeding stops, maybe.

I’m a spiritual amputee, perhaps. Maybe it’s time to accept the fact that some modicum of normalcy is basically impossible for me at this point, and that I just need to get through this life accepting my significant emotional limitations.

Hope has never regenerated a limb. It’s probably even too much to ask that hope regenerate parts of my soul that have disintegrated over the last decade and a half.

Turn me over, I’m done on this side.

Random links: Famous last words

Coherence is probably a little too much to ask at this hour, after this much to drink. Today I have come to another bitter revelation, and I have a good idea of what my trajectory is going to be.

As I walked down the hall between the ICU and the wards, I actually shivered a little, with the cold, hard realization that as each second passes, the probability that I’m going to find The One™ diminishes. The likelihood that I’m going to die on my own increases ever closer to complete certainty, and all I’m left with is this useless thought: this sucks.

There was some point in time that this all became irreversible. That I was actually never going to trust another person ever again, and that I would never be moved to actually pursue someone with all my heart, without preconditions, without fear, without expectation.

In the end, it’s all half-assed. Blundering, clumsy, idiotic, foolish bumbling. Senseless, ridiculous, and hopeless. The last, what, four months have passed without me learning a single goddamn thing, and I’m pretty much done. Sayonara. Arrivederci. Hasta la vista.

Maybe next lifetime.

Seriously, though. I stare numbly at the woman who OD’ed on God only really knows, and I can’t help but wonder, just how easy would it be? Everything at this stage in the game feels so fixed, so static, and no matter what sort of emotions rage inside me, nothing ever changes. I can’t even get myself to do anything about it. I’m a goddamn gimp.

How easy would it be to take the exit strategy?

But I recognize that there is always a third way out. Something that I haven’t thought of yet. Something so bizarre, arcane, convoluted, and perplexing, that you’ve got to ask yourself, is it really worth it?

Of course not, but it’s certainly better than the alternative.

Still, it’s like choosing to suffer for a long time, until the inevitable finally overtakes me, or suffering for a short time, with me taking an active role in ending that suffering.

hey pig
yeah you
hey pig piggy pig pig pig
all of my fears came true
black and blue and broken bones you left me here I’m all alone
my little piggy needed something new

nothing can stop me now I don’t care anymore
nothing can stop me now
I just don’t care

hey pig
nothing’s turning out the way I planned
hey pig there’s a lot of things I hoped you could help me understand
what am I supposed to do I lost my shit because of you

nothing can stop me now
I don’t care anymore
nothing can stop me now
I just don’t care
nothing can stop me now
you don’t need me anymore

—”Piggy” by Nine Inch Nails

I am stuck forever living that final moment of torment, never recovering from it. It is a cancer that has gnawed through my soul, a festering wound that will never, ever heal.

I can’t fucking win unless something inside of me somehow changes for the better. I don’t know how to do it on my own. I’m like a blind paraplegic crawling around in the dark, hoping for a fucking miracle.

I can’t save myself. The writing is on the wall. And if this cup will not pass, so be it.

I just crave sleep. I’m so fucking tired. The entire last decade and a half just decided to fall on top of me, and I can’t even crawl out of the debris. I’m just so fucking tired. All I want is to sleep, goddamn it!

It’s déjà vu all over again.

I felt like reposting this scene from Survivor by Chuck Palahniuk:

God forbid I should try and look good for [her]. The worst strategy I could pursue is self-improvement. It would be a big mistake to dress up, make my best effort, comb my hair, maybe even borrow some swell clothes from the man I work for, something all-cotton and pastel shirtwise, brush my teeth, put on what they call deodorant and walk into the Columbia Memorial Mausoleum for my big second date still looking ugly, but showing signs I really tried to look good.

So here I am. This is as good as it gets. Take it or leave it.

As if I don’t care what she thinks.

Looking good is not part of the big plan. My plan is to look like untapped potential. The look I’m going for is natural. Real. The look I’m after is, raw material. Not desperate and needy, but ripe with potential. Not hungry. Sure, I want to look like I’m worth the effort. Washed but not ironed. Clean but not polished. Confident but humble.

Honest is how I want to look. The truth doesn’t glitter and shine.

Here’s passive aggression in action.

Just when you think all is lost, sometimes you’re pleasantly surprised. After struggling futilely to find some kind of jerry-rigged solution, sometimes all you have to do is turn the power off, and then turn it on again, and miraculously, everything else takes care of itself.

If only the rest of life worked out this way.

I randomly went home on Sunday. I woke up around 6 am outside my own volition, without any alarms, and decided it would be a good idea to hop on a train and head up to L.A. I pretty much just ate something like six meals and watched cable TV with my dad. We watched a bunch of westerns.

But my mom casually mentions the fact that she notices that my dad seems to sleep a lot now during the day, and she wants to know if this is related to the fact that he has heart failure. Memories from intern year in the CCU flicker through my mind, and I think about all those poor souls with awful, awful cardiomyopathy, and dread sort of grips my chest. Like it or not, a lot of medicine is what we erroneously call gut instinct. More accurately, it is unconscious knowledge, the sort of pattern recognition capability the mind excels at, even when our consciousness fails to keep up.

My mom and I discuss the various things that have transpired over the past three months regarding my dad’s health. Apparently he really does have a left ventricular thrombus, but for some reason, his cardiologist is not treating him with low-molecular weight heparin. And the strangest thing is that my dad is not taking any sort of diuretic.

I am incredibly skeptical about the notion that he was never prescribed any Lasix. The idea that someone with an ejection fraction of 45% could escape the grasp of this drug seems absurd to me.

Then again, I know for a fact that my dad basically manages his own medications according to his own whims. He is, after all, a physician himself. So, for all I know, he probably takes Lasix whenever he feels like he’s getting bloated, or putting on weight too quickly, or whenever his legs swell up too much. He used to screw around with his long-acting nitrates and his anti-platelet medications, but stopped when he started getting chest pain too frequently for his own liking.

It is a known fact that physicians are the worst patients in the universe.

But watching my dad slumped over in the couch, snoring noisily at 1 pm worried me. The notion burrowed into my mind, and dug and dug, and it’s still digging, and I don’t want to take my thoughts to their logical conclusion.

Maybe it’s just his sleep apnea catching up to him, I tell my mom. And I know he stays up late watching TV. And in a short while, my dad wakes up, and he’s his normal self, quick-witted and temperamental as always. He takes me back to the train station, and I try not to think about the fact that none of us are getting any younger, and that damned stopwatch is always ticking, ticking, like an industrialized version of Poe’s tell-tale heart.

And I think about my silly desires. If I ever have kids, I want them to meet my dad. And that damned pendulum just keeps swinging and swinging, the grains of sand keep falling, and I’m not even sure I can get to that path from where I’m sitting, and maybe everything going through my brain is just futile.

I think to myself about the fact that there have only really been one or two things in my life that I’ve actually succeeded at, and I wonder if either I’m due for more, or if that’s really it, there ain’t no mo’, and it’s all down hill from here.

They say that you’re at your peak when you’re around 19. Physiologically, this makes sense. You’ll have just finished myelinating all your long tracts, and neural signals will be traveling the fastest that they ever will. Your lungs will have finally stopped developing, and your athletic ability will be at its optimal. Your long bones will have just fused and you’ll be as tall as you’ll ever be. I can still imagine what it must have felt like about a decade ago, when I thought I had everything I ever wanted.

But everything after that is a wearing and a grinding. The only thing that I’ve managed to improve, with a modicum of suffering, is the state of my brain, but at times like this, even that’s questionable. I have certainly not taken the best care of myself. But I figure I’ve got a ways to go. There are probably a lot more twists and turns to the future than even I can imagine.

And like always, all that I can really do is hope for the best, but expect the worst.

Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that. Hate multiplies hate, violence multiplies violence, and toughness multiplies toughness in a descending spiral of destruction…. The chain reaction of evil—hate begetting hate, wars producing more wars—must be broken, or we shall be plunged into the dark abyss of annihilation.
—Martin Luther King, Jr.

found on ayşe's tumblr

post

1. adj. post-call, referring to the time period when a physician is finished taking admissions or performing consults. This may refer both to time spent at work or time at home after a call period. Typically this is reserved for the time frame after working 24 hours in a row. Before work hour restrictions were in place, residents would typically stay at work for an additional 12 hours to ensure that all active issues were resolved, for a total of 36 hours in a row. In 2003, the ACGME mandated that the post-call period at work be limited to 6 hours maximum, for a total of 30 hours in a row. See also postal, going postal. 2. n. post-mortem examination, see also autopsy, necropsy.

Time is an illusion. Lunch time doubly so.
—Douglas Adams

The problem is that if you think too far ahead, everything always ends in disaster. This is the ugly reality.

The trick is to recognize the appropriate time frame and to not exceed the limitations of human perception.

The is far more difficult than you might imagine.

I think of poor Sidney Carton, and wonder if that’s the only possible path at this juncture. Self-sacrifice. Unrecognized martyrdom. Is this the far, far better thing that I must do? Death, so that others might be happy?

At least they’d fucking remember me. I guess.

Is sustainable happiness simply too much to ask for? Oh, I know that life is filled with pain and struggle. I know that I will suffer. Even if she loves me in return, it doesn’t mean that we won’t argue, fuss, or fight. That kind of harmony is impossible, and anyone who says otherwise is suspect.

But, to have fucked up days upon end, and yet know that you’ve got someone on your side, even if they disagree with you and think that you’re totally wrong, to know that she’s got your back. Is this just too much?

I’m not going to get anywhere in the state I’m in. Maybe I just have to call it a night, and pass out into the oblivion of sleep.

I am thinking that 26 years of formal education can really burn a guy out. I’m like beyond slap-happy. I’m this close to raving lunacy.

It occurred to me that I’m totally fried. Like beyond toasted. Charred. Carbon.

Realizing this was somewhat liberating. I shared my epiphany with my preceptor today. I promised that my mental faculties would probably return once I finally actually finished residency.

The remainder of the month is otherwise going to be an awful struggle.

Today was also the earliest I’ve gotten out of work this week. At 6:50 pm, I was cruising over the Coronado Bridge, and I decided that I ought to catch the sunset. Monday I think I may have just passed out. Tuesday, the sun was barely out, quickly extinguished by the marine layer as I gazed at the sea from Torrey Pines. Yesterday, the sun didn’t even come out once.

So, as per my routine, I camped out off of Sunset Cliffs. There was a layer of haze sitting on top of the ocean. I am thinking there is a slight possibility that I may have caught a green flash on film the CCD sensors of my digital camera, but I have yet to download the images to iPhoto. We shall see.

For some unaccountable reason, I felt joyful on the drive home. Maybe I just need something as simple as sunlight to make me happy. Then again, I’ve grown to associate sunsets and the sea with redacted, and every time I think of her, I find myself smiling a little.

The trick, however, is to stay firmly anchored in the here-and-now. It’s the hopes and aspirations that always manage to do me in. It isn’t fair for me to have any expectations whatsoever.

Friendship has been offered. This is already a lot. In of itself, it is already a very generous gift.

To use an idiom of our times, it is what it is.

The first order of business is to get my fragmented life into some semblance of order. I’ve lived in this hellpit for four years now and have never managed to arrange it into a livable configuration. I figure this weekend will probably be a good time to at least give it a shot.

Then there are the things I need to fulfill before the end of the year. These may be a little more difficult.

As always, it all about small, non-threatening things. No problem is so big that you can’t run away from it.

Given all that tripe, I did have a decent day today. I managed to get in an arterial line after three tries. The attending that I’m working with—who has a reputation for making interns cry—thinks that I’m probably no dumber than a box of rocks. (Which, believe me, is a complement.)

Small triumphs. Little victories.

One of these days, I might manage to get a little self-confidence. What is this world coming to?

8 Asians introduces me to the acronym SDU, which means single, desperate, and ugly. I find this acronym highly amusing since I find it so self-applicable.

I am also reminded of something that I think S (not S.!) told me once: desperate is *so* not sexy. Or maybe it was N. I sometimes get all these women who rejected me mixed up.

So I have, in fact, tried to cultivate the demeanor of someone who is not desperate. It’s been so long that I’ve almost forgotten that I’ve been consciously trying to do it.

But sometimes reality pimp-slaps you upside the head. I mean, doesn’t the fact that I’ve been single all this time undermine the notion that I’m not desperate?

I suppose I could just put a spin on it. I just haven’t met the right girl yet. Riiight. That’s the ticket. My standards are just too high. Yeah. Or I just haven’t been looking.

I mean, there *is* some truth to that last notion. I have been living a sort of twilight existence this last half decade or so. I work all the time. I deal with death and disease. That alone is enough to sort of anesthetize the soul, really.

And then bad shit happens. When my dad had his big fat LAD, I took it pretty badly. Mostly because I held it all in for quite a while. I actually stopped blogging for almost two months. But that shit got me thinking about mortality big time, and I don’t think I’ve ever really gotten over it. My dad is doing pretty well, but none of us are getting any younger. The fact that there aren’t any little kids at Christmas kind of gets me down. If I were ever to have kids, I’d want them to meet my dad and remember him. But only Atropos knows when those threads run out, really.

But that reflex to just shut down and burrow in gets me every time.

What really threw my mind for a curve ball was the fact that my cousin D died about a year and a half ago. She was just a little younger than me, 29 at the time. I had gone to her wedding just a few years before. We weren’t the closest of cousins, but we pretty much grew up together. I still remember those days when we were all little kids and we’d go out to Fallbrook to my aunt-and-uncle’s place and play badminton or something. Or when they’d come out to Harbor City or even to Eagle Rock. When I finally moved down to San Diego, I saw her a bit more. We had sushi about two months before she died. That was the last time I saw her. We made a deal to hang out more.

That’s probably the last time I couldn’t stop crying. Even though I tried to let it all out, and not hold anything back, it still ached as I wept, like something was yanking my insides out. I remember that awful clawing feeling at my chest as they lowered her casket into the ground, as I watched her brother, her mom, and her dad just bawling, just trying to hold each other up. Just thinking about it fucking kills me.

I walled-up pretty good that time, cocooned in my own ball of self-pity and dread.

I think about the people I’m taking care of lately. You would think, that after all this time, I would’ve gotten used to death. But maybe it’s just the reflex of the living, to fear death. There’s one poor woman whose lungs have just been obliterated by smoking, and now she’s on a ventilator. The chances of her getting off the ventilator are pretty much slim-to-none. It’s guaranteed to be slow, drawn-out, painfully protracted experience. Today, her brother saw her for the first time. The last he had heard was that she had gotten discharged and was actually doing better. Unfortunately, that lasted for all of twelve hours, and she ended up back with us. I had a hard time looking him in the eye, telling him what had been going on, and what we had been doing. That look of shock on his face kind of haunts me, to tell you the truth. You’d think I’d know how to deal with that by now. At least I don’t choke up any more and need someone to hold my hand and help me out.

Then there’s this other lady whose life has been seriously unnaturally prolonged. She showed up in 2006 with lung cancer that was already all over the place. Metastatic to the brain, the bones, the liver. When you’re at that stage, we usually measure life expectancy in weeks. Months if you’re extremely lucky.

But she persevered, and demanded everything that modern medicine could throw at her. And we probably crossed a line somewhere. That point when everything you’re doing can only hurt. Sure, you can intervene, but in the end, it doesn’t really mean a goddamned thing.

Somehow, she convinced a surgeon to open up her chest and lop off the part of her lung that was tattered and torn up by tumor. Never mind that the mets in her brain were getting bigger. She got hard-core quasi-experimental chemotherapy that left her weak as a kitten.

She got two extra years out of the bargain. Maybe it was worth it. But I don’t know. Ultimately, we’re just delaying the inevitable. She’s dying. Not in the existential way we’re all dying, but actively dying. The cancer has managed to chew it’s way through the part of the airway that the surgeons had to sew up after lopping off part of her lung. And she and her family aren’t even close to accepting the undeterrable fact that she just ain’t gonna make it. You always have the chance to die very badly—with ribs cracked apart, blood spewing from your mouth, shit and piss all over the place, and you struggling for air, or die well—peacefully, with dignity, and a chance for your loved ones to remember you at rest. I hope she makes the right choice. (Oh yes, there *is* a right choice.)

You would think, this far into things, I’d have gotten used to it.

Maybe, it’s because, ultimately, we’re all narcissistic, and I can’t stop thinking about that day when I finally come to a full, complete stop.

The color of the sky as far as I can see is coal grey
—”Like the Weather” by 10,000 Maniacs

The weather really does make me want to crawl back into bed and call it a day. I’ll try again tomorrow.

Instead, with a mania partly fueled by caffeine, but significantly driven by some kind of raging insanity, I feel compelled to wander back out into the tangled mass of chrome and light precipitation that creeps outside my door.

It’s no joke. No one in Southern California knows how to drive in the rain. It’s really pathetic. I don’t understand it.

But on my excruciatingly long, slow commute from work, I got to thinking about this whole timing thing.

I’ve never been very good with timing, as most people who’ve known me for the past decade or so know. And it’s not like I have a knack for very bad timing, either. I just can’t get things right. I’m in dyssynchrony with the universe or something.

But somewhat surprisingly, this situation (or perhaps, more accurately, this non-situation) that I find myself skirting around the edges of and refusing to write about is the fortuitous result of coincidence. Things couldn’t’ve transpired any earlier (what with redacted being in a relationship and all) but any later and I probably wouldn’t have all this time to ruminate, ponder, and over-analyze everything.

I discovered an amusing blog post by Kahlee about why ‘nice guys’ finish last, and yeah, it’s true, most guys who think they’re nice guys aren’t really nice guys. They’re just unattractive shlubs who expect a woman to just dig their emo-ness and whining, and who have serious co-dependency issues. Because, come on. The pendulum swings both ways (so to speak), and just like it’s feminist dogma that a woman doesn’t need a man to be complete (the whole “fish and bicycle” thing), it’s also true that a man doesn’t really need a woman so long as he’s got at least one hand, some type of lubricant, and free access to porn.

Or, to summarize the one enlightening epiphany I’ve had in the last 15 years or so: I am going to live the rest of my life alone and unloved, and when I die, no one is going to miss me until they notice that the work is starting to pile up and I haven’t been pulling my weight at the office. If I’m extremely lucky, death will be swift and painless.

Oh well. It’s only life, after all.

I did try the whole hedonism thing for a while. No one cares what you look like if you wave around a bunch of benjamins (I’m’a tell you what Wu told me: cash rules everything around me) and while it’s kind of depressing to only be able to have sex with skanky hos with chipped teeth who charge by the hour, in smoke-filled motel rooms with busted-ass beds, sometimes the porn just doesn’t cut it, and it’s nice to have a warm body underneath you or on top of you for all of those 30 seconds. And, in reality, once you realize that sex is relatively easy to obtain no matter what you look like, it really sort of loses its charm and novelty.

In all seriousness, though, it was really just booze and drugs, the latter only rarely, and never with the use of needles.

OK, OK, perhaps I over-exaggerate things for effect, but you get the picture. Even the messy, vomit-smelling oblivion of drunkenness never really did much except drain my wallet. It was a decent way to kill time in the Midwest during Winter (otherwise known as all the months between October and May) but you couldn’t do it every day of the week (although we damn well tried our best!)

I was fucking doomed from the start. I’ve always dug this quote from Louis-Ferdinand Céline (translated from French):

Even masturbation, at times like that, provides neither comfort nor entertainment. Then you’re really in despair.
—from Journey to the End of the Night

Even I am shocked by the idea that I’ve somehow survived 15 years of this sort of despair.

The other thing that Kahlee’s post makes me finally, finally understand is what N was trying to tell me all those years ago when she cheated on my sad, emo, co-dependent ass by fucking some dude she knew for all of fifteen minutes: lust wins. Unconditional love is all well and good, but if she doesn’t think you’re hot, it’s just not going to happen. And it’s true. Even the nicest girls who aren’t superficial still want the hot guy, provided that he is a decent human being.

That last part, of course, is the kicker, and the only way I have an in with women of significant attractiveness. Given enough exposure and enough alcohol, I think I can manage to worm my way into any woman’s heart, and as long as I can keep her away from hot guys who are nicer than I am, I just might have a chance. It is therefore in my best interests to go around promulgating the notion that all hot guys are assholes. This is, of course, not true. (Any statement that claims ‘all’, ‘none’, ‘always’, or ‘never’ is false. Gödel would be proud of that one.) But the same story happens over and over again, much to my amusement. If you fall for that hot guy, be prepared to get shafted! (OK, that was probably low-hanging fruit. I’ll aim higher next time.)

My downfall is probably the fact that I can’t stand anyone feeling sorry for me. I mean, if it means having sex with me, I can probably stand it for at least 30 seconds, maybe even a full minute. But eventually it does get on the nerves. There’s something abysmal about being treated like some retarded and crippled pet rabbit. Eventually, even the most empathetic woman gets sick of that kind of patheticness anyway, no matter how cute it seemed at the time.

I suppose one could look at things from an extremely optimistic standpoint: at least most of the women whom I fell for, and who had no interest in me in That Way™ were decent human beings who didn’t lead me on, and who let me know the score fairly early. What’s a little suicidal depression among friends, right?

I am afraid that this conversation will eventually come up with redacted, like it usually does whenever I fall for someone who is way out of my league (which is essentially every time) and then what? Back to my personal existential hell, I guess.

What prompted all this soul-searching? I suppose it’s the fact that redacted has hooked up with someone, and for some reason, I feel like this is it. She found her One™. Whatever chance I had (and I realize the idea of me having a chance with redacted is an incredible assumption) is long gone and completely evaporated. To quote the Comic Book Guy: Oh, I’ve wasted my life.

The other thing is that another of my friends whom I’ve known for the longest time told me a little while ago that she was going to get married next year, and I realize that I probably squandered my opportunities with her as well (that is, if there was even any opportunities, which is always the big “if”)

I have essentially run out of single female friends with whom I might’ve had remote, perhaps infinitesimal— yet nonetheless finite—chances of hooking up with.

Aim low, kids… So low no one will notice it when you fail.
—Marge Simpson

But, instead of aiming lower, I manage to fall for someone who is totally way out of my league. Extraordinarily beautiful. Wonderfully brilliant. Authentically caring. And magically creative. She could literally have any guy she wanted. There’s just no way in hell. I don’t know what the hell I’m thinking.

I am reminded by Br. that this is typical of my behavior. (Man, I really miss Br. and Bn. They always knew exactly when to kick me in the head so that I’d stop acting like a dumbass.) Go for something that you know you’re going to fail at spectacularly. Because it’s safe. If you know how it’s going to turn out, then you don’t have to deal with the messiness of uncertainty. If it doesn’t kill you, how bad could it be, right?

And I can tell you, I’m pretty damn good at failing miserably. It’s a wonder that I managed to survive life as long as I have.

Whoo. It was good to get that out of my system. I don’t know why I never learned to play this game the way it was supposed to be played. Maybe because I was never meant to be a player. Darwin decided early on that I shouldn’t be allowed to contribute to the gene pool, perhaps.

Man, my brain is currently occupying another dimension entirely.

There are so many things that I want to talk about. Things that would be imprudent to actually blog. Because Google doesn’t forget. And in the rare instances that it does, archive.org, certainly doesn’t.

Things that would make no difference to blog about, since (1) there’s a large, finite probability that I’m misreading events completely and (2) because what can I really resolve talking to the uncaring ether? Hmm? And (3) I’ve been through this several times before, and it seems to always turn out the same way.

That said, I’m banking on Heraclitus being right about the whole river thing. (Come on, seventh time is the charm, right?)

What I do know is that I can’t keep doing this whole internal mental roller-coaster thing, triggered by nonsensical stimuli. It’s a symptom of immaturity, I know. Clearly, I’m not ready.

It’s easy to believe in my unreadiness. I kind of think that I’ll never really be ready. But you gotta jump anyway. That is the nature of side-scrolling platform video games, after all. Oh, and life, too.

In any case, no one ever died from ending up in the Friend Zone™. At least, not directly, anyway, but we won’t go there. That’s what happy pills are for.

I do know that I had a really weird dream yesterday morning. It involved being bombarded by these weird fractal diagrams of circles interconnected with tubes, infinitesimally repeating over and over again. I tried to draw an example in one of my notebooks (which I’ll have to scan in at some point) but there’s no way I can actually remember the patterns. All I know was that there was some important information in there. Like a message from God, or something. Maybe I just missed my pink laser-ray moment.

That said, I think I have started to grow just a little, emotionally speaking. I have come to understand the whole “tomorrow is another day” philosophy from “Gone with the Wind.” I think it might’ve been Einstein who said something about repeating the same thing over and over again and expecting to get different results basically defining insanity. But I’ve come to realize that the converse is true as well. Particularly in our chaotic world where none of us really understand the initial conditions. Meaning that it isn’t reasonable to expect the exact same outcome with the same behavior if you have no idea what the initial conditions are like.

Oh, history does like to repeat itself, but the names and the countries always change. Even the earth, the sun, the universe ages. They ain’t getting any younger. And like the weather, the initial conditions will fluctuate. Some days it will be favorable. Other days, not so much. As Douglas Adams describes it, even a single stray photon can have some pretty remarkable consequences. So I think I’m on sound scientific ground here.

Lately I’ve begun to realize that there’s no physical law that says that today is going to be just as miserable as yesterday. If all you ever expect is disaster, that’s all you’re ever going to get. You’re better off just shrugging your shoulders, and blindly picking through the ruins of probability, hoping for the best, and expecting the worst all at the same time. Bayes Theorem is only useful when you actually have reproducible data, and most of life is pretty damn irreproducible.

In other words, you just never know.

At least that’s what I tell myself when my spirits start to flag.

But I would like to talk about these things with my friends whom I’ve done a very bad job of staying in touch with. I kind of know who is going to tell me what, but it’s still worth going through the exercise.

I also know that I’m kind of crazy, so I’m certainly not looking for a reassurance of sanity.

Oh, how vague, how wondrously vague I am sometimes.

Ever since I got addicted to Twitter, I guess I haven’t been blogging as often as I used to. There are just so many ways to express myself besides the long form of a blog post: Twitter, Facebook link posts, Google Reader shares with notes, del.icio.us. I am Web 2.0-ed out.

But I feel like there are all sorts of thoughts that I’ve just been letting go. Thoughts that don’t fit very well in that 140 character limit. And I think I’m starting to feel the effect of neglecting them.

To start: the worry and the dread are coming back again, despite maximal medication.

I am clearly doing something horrifically wrong with my life, and it’s probably going to kill me if I don’t fix it soon.

So what started out as a reasonably good weekend turned into a total nightmarish disaster, all on the account of such a small thing as a stupid car key, the story of which I’ll get to. Eventually.

On Saturday, I tried to run a bunch of errands. I ended up waking up several hours later than I had hoped to, but nonetheless managed to get a hair cut, get my car smog checked, and then grab breakfast. I’ve been hanging out a lot a Cafe Milano lately. Maybe camping would be a more accurate term. I haven’t decided yet whether it’s actually therapeutic, or whether I’m merely enabling my OCD potential. I have a feeling we’ll find out soon enough.

So S. crochets hats, which she says helps her relax and stop worrying. The repetition and the simplicity (I’ll take her word for it) are quite soothing. The end-products are quite useful, and she gives them out as gifts.

I have since discovered that mapmaking happens to be my simple, repetitive exercise that makes me stop worrying about the world. I realize I’ve been doing this since I was a little kid. (Have I been anxious since then?) But it hasn’t been until the last few months that I’ve been spending hours at a time drawing maps of imaginary places. Not quite as useful as a hat. Actually, most people who have seen them immediately think of that Russell Crowe movie “A Beautiful Mind”, which is not at all reassuring. When they finally lock me up in the psych ward neurobehavioral unit, I’m sure this is what I’ll be doing all day and all night. Although they probably won’t let me have sharp objects, so I’m not sure what I’ll do, but I digress.

We’re not even talking about maps about fantasy worlds (although I have made those as well.) What I’ve been drawing are road maps.

There is a soothing ritual to them. First I draw the coastline, then the rivers, then I approximate the hills and mountains. After that, I find a spot for a crossroads, draw the major highways, and then fill in from there. Some are more convincing than others. (I’ll have to upload them when I get more time.) None of them are probably places anyone would ever live.

So that’s what I’ve been doing at the cafes lately. Trying to get my mind off of issues that are increasingly more and more pressing.

After I finish yet another map, I decide that it’s time to get on with my errands. The next thing on my list was to get rid of the stupid PDA that my residency program lent to me, which I never used, because it was simply impractical. So I drove over to work, snuck into the chiefs’ office, and left it there.

To my horror and infinite regret, I discover that I no longer had my car key.

Now, I had been ignoring this issue for quite a while now. The corner of the key had cracked, meaning that the key would easily slip off the key chain. This had, in fact, happened several times over the past few weeks, and I kept swearing that I would find some Crazy Glue. It even happened that Saturday morning, when I gave the key to the mechanic who performed the smog check.

I retraced my steps carefully. No dice. I peered into my car from all humanly achievable angles, to no avail. I wasn’t about to call AAA to open up my car, only to discover that the key wasn’t even in there.

And the nearest copy of the key was 150 miles away, in L.A., at my parents’ house.

Meanwhile, I had to figure out a way to get out of Kearney Mesa.

One of the more infuriating things about San Diego is that there are several parts of town where the only traversable route is a freeway. Many sections of the city don’t have surface street alternates. It is literally the highway, or no way. When you’re in a car, this is merely irritating. When you’re on foot, this can mean walking several miles out of your way.

I managed to navigate my way to Fashion Valley. Turns out that this is only 3.9 miles, which according to Google Maps, should only take 12 minutes. Provided you have a conveyance powered by an internal combustion engine. With my out-of-shape sorry ass, it took nearly two hours.

I did contemplate trying to walk upriver towards Texas Street, but the 805 bridge loomed very, very, very far away, and I decided that the better part of valor would be to just take the trolley.

After clambering out of Rio Vista and onto Qualcomm Way, I started walking south. By the time I crossed the 8 and got to the bottom of that godforsaken hill, I realized that I was overmatched. I waited for the bus, which took me up that hellish incline, and deposited me within steps of my apartment.

Luckily, the street I live on is on a major bus route, so I wind and wend my way to Downtown. I overhear a girl having a conversation with the bus driver. Apparently she had flown out from Atlanta the day before, at the behest and accommodation of an unnamed party. Things didn’t turn out so well, and she was now trying to figure out how to get to the Greyhound depot to take a bus back to the ATL. So I guess that ought to put things into better perspective for me.

I arrive at Santa Fe Depot to discover that it is infested by high school kids all dressed up for prom. Apparently they were all taking the train up to Anaheim. (Grad night?) I find myself a seat and commence drawing yet another useless map. I finally make it to Union Station in L.A. around midnight.

My sister and her boyfriend pick me up, which is slightly awkward because me and my sister haven’t spoken to each other for nearly four months, ever since we got into a huge fight about one of the dogs. If you asked me to try to recall what exactly it was about, it would probably take me a while to remember. Like most of these violent, emnity-causing arguments, I’m sure it was for a completely stupid reason, but me and her are stubborn like that, and while I know life is too short to hold grudges, she really knows how to piss me off.

Be that as it may, I finally went to sleep around 1 am, although I woke at least twice in the middle of the night. I’ve been doing that a lot lately. It can’t be a good sign.

Turns out, my mom isn’t sure exactly which key is actually the key to my car, so I end up taking all of the likely candidates. There is other extended familial drama that I really don’t want to get into at the moment, but suffice to say, being at home does little to ease my disturbed little brain. My dad drops me off at Union Station at 5pm, 10 minutes before the Surfliner South is scheduled to leave, and I hustle to the track.

No seats. There are a bunch of us poor schmucks left standing around, gawking miserably. I find myself ensconced in the same car as a middle-aged, portly white guy and a youngish, college-student-looking Asian girl who are busy discussing Christian metaphysics, on the same order as how many angels could dance on the head of a pin. With the A/C in the train on full blast, it still feels like it’s 100 degrees in there. My only salvation is my iPod. Thank Jobs.

After Fullerton, I finally find a seat, although it’s a backward-facing one, which is not my favorite, since I’m prone to motion-sickness. Eventually, I slip into cool oblivion, and manage to stay asleep until after San Juan Capistrano, so that I’m treated to the shores of San Clemente, then watch the sun set over the sea as we pass the varied lagoons of San Diego County. It’s just past 8 pm when I get back to the Santa Fe Depot. I briefly contemplate the notion of taking public transport back to work to get my car, but wisely decide to take a cab instead.

Without further incident, I finally make it home.

You would think that I could relax, but for some reason, my brain is refusing to cooperate.

Why can’t anything be simple?