"Bugle Notes" - "The Man in the Red Sash"

July 2, 1973 a day etched forever in my mind. A day I remember as if it happened yesterday even though 47 years have passed! A day I thought would never come and then, when it did, would never end. It was the day I entered West Point as a 17-year-old kid with big dreams to “become an Airborne, Ranger, Infantryman and lead men in combat”! That was my goal in life at that time. My life changed the moment I reported to the “Man in the Red Sash”, a senior cadet responsible for the training of the 1400 New Cadets entering that day with me. Less than 700 of us graduated four years later on 8 June 1977.

That hot July day began my journey to becoming a man. The change began immediately. I reported to that senior cadet, who seem to me bigger than life, all-powerful, and all-knowing. In many ways he and the other First-class men (as seniors at West Point are called) were. After all, they had survived their first year and the subsequent two that followed. They had only one more year left and then they were free! I vividly remember thinking that my graduation would never come. Four years were an eternity to a 17-year-old who at that moment wasn’t sure he could make it through that day much less the two months of intense training to follow. Those two months were appropriately called “Beast Barracks” and I soon found out why.

“Beast Barracks” purpose was to begin the transformation from a civilian to a soldier as well as the inculcation of the customs and traditions of West Point. Talk about change! This was change with a capital “C”! It had another purpose as well, to identify and eliminate any New Cadet who did not have what it took to succeed at West Point and become an officer in the US Army. To succeed meant being mentally, emotionally, and physically tough enough to withstand the rigors of West Point. If one could not withstand these artificially imposed pressures, then how could you be expected to hold up under the most extreme of mental and physical duress - combat?

Those months epitomized change in every way possible. I endured sleep deprivation, food denial (a very common practice at that time), rigorous physical conditioning, hard military training, and verbal and emotional abuse from the seniors training us. In addition, I had to memorize massive amounts of “Plebe Knowledge” required of every New Cadet. This information was contained in a small book we all received that first day called “Bugle Notes”. I lost 12 pounds that summer and I didn’t have 12 pounds to lose!

During this time of dramatic change, I was learning much about me, about others, and about what it meant to be part of a team. Teamwork, unity, togetherness were drilled into us until they became a part of who we were. Expressions such as “cooperate and graduate”, “help your buddy”, “no one left behind”, and my class motto “Esprit de Corps” were ever present. No one successfully completes four years at West Point alone. If you do not learn how to work with others as a team, you will not make it through.

Those four years were hard work with very little play though when we played we played hard! Much sacrifice was required and when I graduated and drove through those gates that last time on June 8, 1977, I was not sure what I had been through had been worth the emotional, mental, and physical trials I faced. I actually flipped up my rear view mirror so I would not see even a glimpse of West Point behind me. Much change had occurred those four years and I was not convinced all of it was good. As the years passed, bad memories began to fade, and be replaced by better ones. Doors opened up for me that I am convinced would never have done so without my education and training there. I eventually realized those 4 years had been worth it.

Why do I tell you this story? Just as I went through changes that affected my life in ways I could never imagine, each of you has gone through times of change and continue to do so. Your own extensive medical training and life experiences have created these changes - for the good mainly but, at times, for the not so good. Each of you have become experts in change! No matter what the change, no matter what the challenges ahead, you keep moving forward because that is what you do - adapt and persevere! The ability to adapt and persevere have helped make who you are today. Is change easy? No, but it is critical if we are to fulfill our calling to help and serve others. Thank you for being that person. Thank you for the sacrifices you have made and continue to make so that our patients can receive the best care!

Andy Lamb, MD

"Bugle Notes" - "Wow!"

“Wow!” The child’s voice resonated from the furthest recess throughout the theater – a single word, yet heard by all. The orchestra had just finished a beautiful performance and before the audience could erupt into applause, the small voice, in all its innocence, expressed best what everyone felt – their souls had been touched. The Conductor heard it, too, moving him to tears. He expected an enthusiastic applause, maybe a standing ovation, or even a request for an encore but a heartfelt exclamation like this from a child, never! That one word, spoken spontaneously, reverently, is what all musicians live for – to have their music move someone so powerfully, so deeply, that their very soul cries out “Wow!”

He determined to find that voice, that singular person. He wanted to express his thankfulness for bringing him joy, a joy he had forgotten. After weeks of searching, he succeeded. It belonged to an eight year- old boy. This was not just any boy, though. He was severely autistic and, incredibly, non-verbal. His parents had never heard him utter a word until that moment! The Conductor was speechless, tears welling in his eyes once again, as the special uniqueness of that moment became more real. It confirmed for him that his work had meaning and purpose in a way he had not fully understood.

 I thought about my own “Wow!” moments - the births of my children; the multi-hued stripes of a sunset or sunrise over the ocean; majestic snow-peaked mountains; the dance of sunlight off a clear, tumbling mountain stream canopied by a brilliant tapestry of fall colors, the beauty of a rainbow trout. When was your last “Wow!” moment? The time you cried out in wonder and awe at something so beautiful, so moving you could not help it. The humanness that makes you the caring, compassionate person you are becomes more real, more personal in those most special of moments. When it happens, the inner child, long forgotten during the years of training, work, and life’s busyness, can come alive again. Take time to recognize those moments for what they are, a gift, an intimate reminder that there is so much more to life than medicine.

Andy Lamb, MD

"Bugle Notes" - "We Are Right Here With You"

My Daddy died peacefully on March 14, 2018 in his home of 46 years with his family around him. He was 87 years old. A 14 day vigil came to an end with his final breath and our tears that followed. My hero was gone. It’s strange to suddenly realize that with the death of both parents, you are now “next in line” for the inevitable.

The 14 days I was by his side proved to be more emotionally and physically exhausting than I could have imagined. Every day I was sure would be his last. We all stayed nearby lest we not be there when God brought him home. He died as he lived his life. He was a retired Infantry Lieutenant Colonel, having served 22 years in the Army. Prior to this he served 4 years as a Marine during the Korean War. He was the toughest man I knew. He completed the Army’s most demanding training and served two combat tours in Vietnam, earning numerous medals for valor in combat. This same toughness continued to the last. His once physically strong body wasted away to a mere shell. Yet, somehow (some reason?) he held on. My brothers and sister lovingly told him it was okay to let go and be with God and Mama just in case he needed that permission to leave us.   

                                                                                 

What do you say or do during these times? We did all we could to keep him comfortable and Hospice was a God-send. I found myself standing at the head of his bed, stroking his bald head, and saying “We are right here with you, Daddy.” I said this over and over. I wanted to be sure he knew he was not alone. The words came so naturally, without even thinking. As I continued to say these words, it hit me that these exact words, “We are right here with you” were the new brand statement for the hospital system where I worked. Now I understand their true impact. They came from a place deep inside me. They will forevermore carry a deeper, more personal meaning. They no longer are simply well- meaning words to be read or spoken. They are now very personal to me, and because they are, they have become very real to me.

As you care for your patients, I hope these words also become personal to you and subsequently the impact you have on their lives even greater. May they always be a reminder of the difference you make in the lives of those you serve. Thank you for being right there with them when they need you the most.

Andy Lamb, MD

"Bugle Notes" - Stories from My Father

I am sitting in a hospital room in Birmingham, Alabama. My 87 year old father lies in a Hill-Rom bed, frail, thin, and weak. This once physically strong and imposing man is a shell of who he was, of who he will always be in my mind - a larger than life Airborne, Ranger Infantry officer. A man who served two combat tours in Vietnam - my hero. I, too, wanted to be like him. That is why I chose to go to West Point. My father is the single most influential person in my life.

The “naturalness” of his dying is slowly progressing. I understand this. It is very hard to watch and I can do nothing about it. He cannot walk. He cannot even stand alone with a 4-point walker. He can no longer do the 100 push-ups and 100 bar dips that was his daily norm to the age of 80. The façade of immortality is gone. My heart breaks and I grieve.

He grieves as well. The realization that he may never walk again nor return to his home, work on his beloved cars, or build another remote control plane, begins to set in. What can you say and do in times like this? As the only doctor in the family, they look to me for answers to questions and help with decisions. At times, I feel resentful as I want to be his son not his doctor but most of the time I am grateful I can help.

Out of this comes an unexpected blessing - an opportunity to have a special one-on-one time with him. We talk about anything and everything! I learned things about him I never knew. He spoke of the hardships growing up in the Great Depression; of, as a five-year-old, walking 5 miles to the nearby airport to watch the biplanes take off and land. Occasionally he would be paid five cents to sweep the hangar floors. With that he would buy a Coke and “nurse” it throughout the day. If he was really lucky, he could get a Moon Pie with it! He talked how his mother would make fruitcakes in September, wrap them in cheesecloth, and keep them on top of the ice box until Christmas. To this day, he loves fruitcake! What surprised me most was how close I came to losing my father in combat during his two tours in Vietnam. God’s protection was readily apparent. I sat there amazed, humbled, and thankful.

Sadly, it often takes an unpleasant event to bring people together so these stories can be shared. As physicians, patients will reach out to us in their time of grief, pain, or fear. They, too, need someone to hear their stories. We become that someone and in doing so we acknowledge their humanity. We ultimately become their storytellers and they become a part of who we are as a person, as a human being, who one day will face our own mortality and need someone to listen to our stories.

Andy Lamb, MD

"Bugle Notes" - Fahad, My Friend

  

 I received a phone call last night. Not just any phone call but from Nepal, a place dear to my heart. A place I love – the beautiful and humble people, the exotic culture, the simplicity of life, and the mountains! I don’t mean just any mountains but THE MOUNTAINS, the mountains of all mountains, the Himalayans, with Everest towering above them all! Now, Nepal is fighting for its very existence in the aftermath of a catastrophic earthquake. Does catastrophic even come close to describe the situation that currently exists? I do not have the gift of metaphor to create in one’s mind what is now the rubble that is Kathmandu or the hundreds of once picturesque mountain villages now buried beneath “mountains” of boulders, dirt - homes shattered, buried; homes in which they were born, raised families and then eventually would die, but not on that fateful day! How many more “thousands” of men, women, children, entire families, are yet to be accounted for and the worst feared scenario becoming a reality!

I have led many medical missions to Nepal. I have walked the tiny, narrow streets of Kathmandu filled with throngs of people on foot, bike or motorcycle. Only the tiniest cars can pass through them. All around and above you are indescribable tangle mazes of electrical wiring of every description running from one building to another! Many buildings look as if they could collapse at any time. Yet, you walk shoulder to shoulder with this mass of humanity, feeling trapped, confined and wondering “what if…?” The “what if” happened. I can see, smell, taste, touch and hear all that is Kathmandu! What a place! The most exotic city in the world as far as I am concerned but now….

The phone call! It was from Fahad, whom I have known since my first mission to Nepal in 2009. I have grown to love him deeply since that time. He was one of 3 young Nepali physicians, fresh out of their first post-medical school training year who volunteered to serve with us. Two were Hindi and one Muslim, Fahad. They knew we were a Christian organization yet they still wanted to help us however they could. I welcomed them with open arms as did the entire team and in the ensuing week we grew to love them deeply, but especially Fahad.

 We worked hard every day seeing over 4000 patients in a little less than 5 days! We were a small team as well with only 12 Americans, 4 of who were medical providers and then the 3 Nepali physicians. Seven health care providers, 4000 + patients and so much need! Every morning we would arrive at our makeshift clinic, a tiny one room church whose pastor we were there to support, to find “the line” as we called it. A line of 500, 600 or more people most of whom had either walked all night, rode by donkey or came in an oxcart filled with hay traveling hours or even days to see the “American Doctors” who could fix anything, at least they believed so. Few had ever seen a physician in their lifetime. If you get sick there, one of three things happen – you get well on your own, you recover but with residual often very debilitating complications that you lived with for the rest of your life, or you died. The nearest “hospital” was hours away and unless you had money you don’t get seen. Sadly, this has been my experience in nearly every country in which I have served. We were overwhelmed by the physical, emotional and spiritual needs. Our hearts were broken, tears were shed, prayers lifted up, and hope given. The needs of the world became truly personal to me that day!

Fahad, my friend, was right there beside me, lovingly caring for his people. Fahad came from a more privileged background. He had never been to this part of his country, the poorest region in one of the poorest countries in the world. He had seen poverty and need before but never like this. How many of us have? But he worked in the ever present oppressive heat with the sights, sounds, smells, sickness all around us and it became personal to him as well.

I will never forget that moment. We finally saw the last of nearly 800 patients that first day and we were exhausted, we were beyond exhausted. It was the exhaustion after the worst of the worst call days except more so. Fahad came up to me and he was crying. He said these words that I will always remember, words that bonded us together as brothers forever despite the completely different worlds from which we came:

“Dr. Andy, I have never seen people like you. All my life I have been taught to work and study hard, prepare myself for the future, and take care of all my needs. I was taught that I must do these things first if I am to become a respected physician and have a good life. Today, as I watched you work, I have learned how wrong I have been. I have watched the love this team has shown every patient. I have seen the compassion and caring flowing from your hearts and most of all, I have seen how you put the needs of others before your needs. I understand now that I, too, must do the same. I must put the needs of others before my needs. I am to serve others first, their needs always before mine.”

I was speechless! In one day, he learned a life lesson that most people never learn – we are to put the needs of others before our needs. I told him that God had given him a changed heart and great wisdom. I told him that he was right. It is in the serving of others, in the placing of others before ourselves that we become a complete physician, not just the façade of one. 

Fahad is safe but my heart breaks as I listen to him speak of the death and suffering he is facing every day. The grief, the sadness, the fear, and, yes, the anger at it all, coming through. Though his family is safe, it was days before he heard from his best friend, Ambesh, who had also served with Fahad and me that first mission. Ambesh was alive but had lost his sister, her husband and their young daughter. Fahad was devastated. He wept as he told me this. He had not talked to Ambesh yet because he could not make himself call him. He was afraid. What would he say? What if he became “mute” and could not say anything at all. What could I say in a time like this? I wanted to hold him and cry with him but I couldn’t, thousands of miles separated us. Of course, I told him I loved him, I would be praying for him, and I was here for him. But those words seemed empty in comparison to the reality he was facing.

I said these words to him:

“Fahad, in times like this who can know what to say? Sometimes, most times, there is no need to say anything. Just be there with him when you can and hold him, and cry with him. As Christians, we believe Jesus, at such times as this, “is the tears of God for us”. These are times you can be the same, the tears of God for those you love and are hurting. No one can imagine what Ambesh is going through unless they too have experienced the pain, the heartbreak, the despair he and thousands throughout Nepal are living through now. That is why there are no words sufficient to say. That’s when just letting him know you love him and are there for him is enough. You need to call him, Fahad. He needs to hear your voice, to know that he is not alone in this because he feels alone right now. Just tell him your heart is breaking for him; that you love him (and I added, it is okay for a man to say that!); and you are there for him.”

He said he would call him and thanked me.

Yesterday, he sent me a picture. Beneath the picture he had written,” Wanted to share this. It’s beyond me to describe. I can only wipe my tears.” The picture was that of a young Nepali mother, dead, lying on her back. Her son, probably 6 months old, was alive lying naked on top of her suckling at her breast.

I cried, how could you not? I answered back, “My eyes and heart cry for you, my brother. I am so sorry, so sad. As hard as this is to see, this needs to be seen. The world needs to know the pain and suffering that is now Nepal. BUT…Nepal will rise up from the ashes and your generation will lead it. Please keep sharing your heart with me.”

 As my wife and I climbed into bed, we thanked God for our many blessings, as we always do. Then it hit me, do I really appreciate, do I really recognize how blessed I am or do I simply go through the motions of living life with all its busyness and as an afterthought each night simply repeat without comprehending the words, “Thank you God for all our blessings”? I am certain tonight will be different. May this day and every day be different as well for each of you. May your blessings be truly heart felt. Please keep Nepal in your prayers and thoughts. If you knew the people like I know Fahad, your heart would be broken, too.

Andy Lamb, MD

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 [LDA1]

"Bugle Notes" - "Breathless Expectation"

I read something recently in which the expression “breathless expectation” was used. It describes how a person should feel about not knowing what tomorrow may bring. This caused me to think about the last time I experienced what could only be described as a time of “breathless expectation”.

The memories began flooding back! “Breathless expectation” could easily describe the interminable wait until my next baseball game in my playing days but especially Little League! It was pure torture! I would have my uniform on and glove ready to play hours before game time! Christmas! My older brother and I absolutely could not sleep Christmas Eve our excitement and anticipation was so great! Then there were the almost yearly “new kid in school” routine that I experienced as an “Army Brat”. The expectation the night before was probably best described as anxious excitement yet the unknown was still there. It was not fun being the new kid.

As time went by, these experiences became more significant. The day before I entered West Point at the age of 17 is etched in my memory as if it happened yesterday! I thought I knew what to expect that first day but I quickly found out I had no clue. It was immeasurably more difficult than I ever imagined. Four years later, after much blood, sweat, and tears, graduation day came and the expectation of that day truly took my breath away. Two weeks later came the marriage to my wife, Cathy, of now 40 years! This was followed by my first assignment in the Army in Germany, then my acceptance to medical school, first child born, graduation, starting residency, completing residency. The most vivid memory, though, was the night before I deployed with the 101^st Air Assault Division to Saudi Arabia for the First Gulf War. It was and remains the worst day of my life, leaving Cathy and my 3 young sons not knowing what was going to happen or when and even if I would return. That night before I left, Cathy and I laid in bed holding each other and crying. It was painful.

What were the times in your life that you would describe as “breathless expectation”? A more pointed question, though, would be, “When was the last time you felt this in medicine?” I would bet that early in your careers this experience was not uncommon – first day of medical school, first patient interview, first blood draw, IV, case presentation, start of residency, beginning clinical practice. Do any physicians, or for that matter, any health care provider, experience this anymore once the “newness” of medicine wears off and the daily grind of medicine begins?

Wouldn’t it be great to experience that feeling again? To have so much excitement about what tomorrow will bring that we are breathless with expectation – we can’t wait for the next day to come! Many would say that’s no longer possible in today’s chaotic, unpredictable, volume driven culture that is health care. The optimistic side of me disagrees. I believe you can have those moments but only if you will take the time to step back, reflect, and remember why you chose medicine, why what you do is  important, and that you make a difference in the lives of people every day. The sacred relationship between physician and patient is the catalyst to again have those times of “breathless expectation” that once kept us awake at night with excitement and anticipation.

You are appreciated and valued more than you know.

Andy Lamb, MD

Bugle Notes" - The Smile

I was leading a medical team in Moldova, the poorest country in Europe. We were serving in a village of around 5000 with its dirt roads, small stone houses, and indoor plumbing was a “city” thing. The clinic we ran had just finished for the day. My interpreter and I had seen at least 50 patients and we were exhausted. That’s when I first saw him. He was standing at the door to the clinic. A gangly teenager dressed in a white shirt and black pants. The look on his face, the way he stood with shoulders slumped, arms at his side, eyes downcast, however, all cried out “Help me”!

I found myself irritated that he had “suddenly” showed up. I told my interpreter to tell him to come back tomorrow morning. Her eyes locked on mine and she said, “We have to see him! He needs our help, don’t you see that?” She was right. We were there to love and serve any way we could. I motioned him in and he slowly walked toward us, head down. He made me think of the village dogs that roamed the streets -neglected, beaten, starving, their tails between their legs. What was his story?

 In my many years of leading medical missions, I have learned that the emotional needs of those we serve are often as great as the physical. This is especially true in Moldova, a country without hope after centuries of oppression, wars, and nearly 100 years of Soviet rule. A corrupt government, crumbling economy, and high unemployment forced many a mother, father or both, to leave their children with friends or family for work in a neighboring country. It was the only way they could survive. A Moldovan pastor once told me, “The world has either never heard of Moldova or it doesn’t care.”

Through my interpreter, I asked if he was having any physical problems. He shook his head no, his eyes fixed on his hands. I then asked how things were at home. He began to cry. His father was an alcoholic, as were most men in the village. When drunk, he became violent and beat his mother and him. He had heard from others, who had been to our clinic, that “the Americans” were kind, compassionate, and spoke of a loving God. He had no place else to go, so he came to us.

 I reached my hands out to him. He gripped them tightly as my interpreter spoke of God’s love with a compassion and caring he had never experienced. His entire demeanor began to change. He listened intently, eyes now focused on us. We told him about the Moldovan pastor who had invited us to serve in the village and asked if he would be willing to meet him. He immediately nodded yes. We stood up, and wrapping my arms around him, I prayed for him. He thanked us and turned to leave. When he reached the door, he turned and looked at us. I hardly recognized him as the same person who had appeared so suddenly less than an hour before. Then he smiled. Not a faint smile, a big smile! He waved one last time and left.

I will never forget “the smile”. It is a reminder of the difference a person can make in the lives of others. May each of you have your own “reminder” of the difference you make in the lives of those you serve. This is where the human side of medicine happens and the joy that comes with it. We are better people and physicians for having experienced it.

Thank you for who you are and what you do.

Andy Lamb, MD

"Bugle Notes" - Every Patient, Every Time

She began telling me the same “sob story” but this time I looked at her and coldly said, “Mrs._____, you are going home. I don’t care what you have to say, you are leaving today. I need the bed for someone else.” She began crying. I walked out without saying another word and wrote the discharge order. The Intern with me said the words that I will always remember, “Man, what you just did was cruel.” I looked at him and said, “I don’t care. I’m tired, we need the bed, and she is going home.” The hard reality is that at that moment, I did not care. 

It was the second year of my Internal Medicine training at one of the Army’s busiest hospitals. I was finishing 15 months of inpatient work - no days off, no limitations on the hours worked. The patient had metastatic breast cancer. She had been ready to go home for at least a couple of days but kept begging me tearfully not to send her home saying she was not ready. By that time, I was completely exhausted emotionally, mentally, and physically. Always, like a black cloud hanging over me, the never- ending pressure to discharge patients so more could be admitted. There were always more patients.

We all know what it’s like to be pushed to our emotional and physical limits with long hours, never ending sick patients, and the ensuing stress of being responsible for their care, ultimately their life. I vividly remember those days and reaching the point of no longer seeing patients as people in need of care but rather “more work”, another case of CHF, stroke,  pneumonia, sepsis….you can fill in the blank. The patient simply became a faceless name on the door, another diagnosis taking up more of my precious time.

 This can happen to any of us if we do not guard ourselves against it. We need to remind ourselves of why we went into medicine. We need to see each patient as a person in need of help - vulnerable and frightened by the unknown, having to trust us for their care. It is easy in the busyness of our work to forget this, to forget that they are someone’s loved one, deeply cared for and loved. It’s easy to forget, that no matter their condition, they are still deserving of our best effort and most compassionate care; to be treated with kindness, respect, and dignity - every patient, every time!

As always, thank you for all you do every day for those who place their trust in you.

Andy Lamb, MD

"Bugle Notes" - "Speedy"

 I was 17 and a senior on the football team. It was the third game of the season. “Speedy” was our star halfback. The place Alabama, the year 1972, and Speedy was black. Our high school was well integrated for the time because of its proximity to a military post. The majority of the schools against which we competed, though, were still largely segregated. Skin color defined who you were and racism, in all its ugliness, came to play on the football field that night. Hate letters, filled with racial slurs, threats of injury, and even death, had arrived at our school the week prior. They warned us not to bring our “n-----s”, in particular, Speedy.

It was early in the third quarter. We were winning and Speedy was having a great game. Despite the threats, thus far, it was simply a hard fought football game. Then it happened. I played defense so I was standing on the sidelines when Speedy came running by for a 20 - yard gain. 5 yards past me, he was knocked out of bounds. As he rolled on his back, play called dead, another opposing player dived head first, spearing Speedy’s helmet with his. Speedy did not get up. The coaches rushed over and, after a few minutes, he was taken away by ambulance. We lost the game.

We did not hear anything further until the following morning. The coaches called our homes. Speedy was dead! Disbelief and shock set in. Anger, soon followed. The threats had become more than words. As a team, we watched the game film and “the hit”- rewinding, replaying, reliving that tragic moment. We all felt it was intentional, that Speedy had been targeted. We wanted something done. We wanted justice. We wanted revenge. Nothing ever happened, though, not even a penalty for the late hit. In the world that was Alabama, it was simply an unfortunate accident, a part of the game. I cried, we all cried, and our lives were changed forever.

Why write this story when it has nothing to do with medicine? I write it so you may have a better understanding of who I am as a person, as a leader, someone who hates prejudice and injustice. I write it so those too young to have known that period of history, may have a better understanding of how far we have come, yet how far we still have to go. I write because life is precious and there is no guarantee of tomorrow. I write because Speedy’s story still needs to be known.

Andy Lamb, MD

For those interested, this story was published in the October 14, 2013 issue of Sports Illustrated. It can be accessed by going to SI.COM/speedy, and scrolling down to the link “The Ghost of Speedy Cannon”. You can watch the hit on a segment of the 8mm game film.

"Bugle Notes" - Sacrifice

                            “Those things which are precious are saved only by sacrifice.”

                                                                                       Private First Class David Kenyon Webster

                                                                                       One of the first recipients of the Purple Heart

The Purple Heart was created in 1782 by George Washington to recognize those soldiers killed or wounded in action or for suffering as a prisoner of war. It symbolizes the sacrifice made by countless men and women throughout our history. The above quote resonated closely with me as I thought about my own experiences in the First Gulf War and how terribly hard it was to leave my family, not knowing what would happen or when I would return home. The day I left Ft. Campbell, KY for Saudi Arabia was the hardest day of my life. I openly wept as I said good- bye to my wife and three sons, ages 8, 5, and 2.

Sacrifice can look differently to people. Olympic athletes sacrificially dedicate years preparing themselves to compete at the highest level. The sacrifices made by the “Greatest Generation” should humble us all. They survived the Great Depression only to fight a devastating war that took them far away, most for several years, while their families sacrificially held down the home front and waited anxiously. Close to 500,000 did not return.

My father served two combat tours in Vietnam while my mother did the best she could to raise my brothers, sister, and me. Every night, with TV trays in place, we watched the evening news hoping to get a glimpse of my father as days-old film footage of the escalating combat flashed before us. Every ring of the phone brought fear to my mother in a way I will never forget, though I was only 10 years old. A phone call, too often, brought the worst of news, the ultimate sacrifice given, again. My mother sacrificed the most.

Each of you know sacrifice intimately. Years of demanding study and more years of arduous training has made it all too familiar. You have sacrificed time, resources, marriage, and family to get where you are today. Thank you for the sacrifices you have made in the past and continue to make daily in the service of others. I thank you, our community thanks you, and most importantly, our patients thank you. Always remember that what you do is important; what you do makes a difference every day; and what you do is still a privilege. You are our “most precious” resource. Your sacrifices have been worth it!

Andy Lamb, MD

 

"Bugle Notes" - "A Good Death"

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 In today’s increasingly technological, data-driven, depersonalized world of healthcare, I wonder if the concept of “a good death” is even possible. The COVID -19 pandemic, in particular, has caused me to reflect on this. What does it look like? How do you define it? As I did, a patient came to mind. He was a retired minister in his 80’s. I had cared for his wife as well until she died a few years earlier. He missed her terribly and longed to be with her again. He had his own significant health problems - severe ischemic cardiomyopathy with a left ventricular ejection fraction of < 10% and a 10 cm abdominal aortic aneurysm! Either alone would kill him and he lived with the knowledge that he could die at any moment. Surgery was no longer an option. Despite this, he lived every day to its fullest and always filled with joy! We often talked about how his death would be. One thing was certain, he was at peace with it because he knew he would be with God and with his beloved wife!

I remember vividly getting the page from the ED as I was rounding early one morning – “Reverend ___­­­__ was just brought in by EMS. His AAA has ruptured but he is still alert and wants to see you.” I immediately went to the ED and found him lying in bed surprisingly alert and oriented. He never complained of pain. As I stood by his side, held his hand, and looked into his eyes, I saw a calmness, a peace I had never seen in another person.  He spoke of not being afraid. Instead, he said he was ready to see his God and his beloved wife. As his blood pressure continued to drop, he thanked me for my years of care and for my “listening heart”. Tearfully we prayed together and within minutes after finishing, he lost consciousness and died peacefully.

It was “a good death”. As I walked away, my mind trying to process what I had just experienced, I was reminded of how privileged I was to have been a part of this man’s life and now his death and only because of the “sacred relationship” between a physician (or other providers as well) and a patient. We are allowed to enter into the most sacred place of all – that time between life and death, when “breath becomes air” and nothing else matters. May times such as this remind you of the difference you make in the lives of your patients. Your work is hard but it is sacred.

Andy Lamb, MD

"Bugle Notes" - The Hug

The Cardiologist was called STAT to the ED for a 50 year old man with an acute STEMI. The man arrested 8 times in the ED, each time successfully resuscitated. He finally stabilized to where he could be moved to the cardiac cath lab. The cardiologist quickly met with the wife and told her the plans and that they would do everything possible to save her husband’s life. As he turned to leave, he was struck by the look in her eyes. It was the look of not just fear but worse, despair and the hopelessness that goes with it - she would not see her husband alive again is what he read in her eyes.

 The cath went well with stenting of the culprit lesion. 2 hours later this same man, who repeatedly evaded death only 3 hours before, was awake, sitting up and eating in the ICU, completely alert and oriented with no neurological deficits!

 When he saw her in the waiting room, her posture, her facial expressions, her overall demeanor, and, again, that look in her eyes – said, “He’s dead. My husband is dead!” She braced herself to hear the words that would forever change her life. Instead he gave her the news she least expected - he was going to make a complete recovery!

Then that singular, unexpected event happened. She ran toward him with arms wide open and threw her arms around his neck, sobbing with joy, and wouldn’t let go! She continued to hold on to him as she wept and wept. It was a beautiful moment frozen in time.  As she continued to hug him, the cardiologist remembered thinking this is why he went into medicine and that he is making a difference! He walked away with a sense of contentment he had not felt in…how long?

“The hug”, a common human gesture, can be life-restoring, soul healing when we find ourselves in “a valley of dry bones”, needing fresh air breathed into us. These moments don’t come often enough but when they do, they forever remain, never to be forgotten. When was the last time you experienced a moment like this? When it does happen, do you appreciate it for the gift it is, a moment of joy, however brief?

 There is still joy to be found in medicine. Look for it, embrace it, savor it because like “the hug”, it will give you a glimpse into what could be again – joy in medicine. You deserve that, you need to have that again!

 Thanks for being there!

Andy Lamb, MD

"Bugle Notes" - A Band of Brothers and Sisters

“We few, we happy few, we band of brothers;

For he today that sheds his blood with me

Shall be my brother; be he ne’ar so vile,

This day shall gentle his condition;

And gentlemen in England now a-bed

Shall think themselves accurs’d they were not here

And hold their manhoods cheap while any speaks

That fought with us upon

Saint Crispen’s Day.”

-        William Shakespear’s “HENRY V”

In Shakespear’s “HENRY V”, just before the Battle of Agincourt (1415), King Henry’s remaining army, weaken and nearly decimated by battle and dysentery, is trapped by an overwhelming French Army that has blocked the only escape route to England. The French knights were heavily armoured and highly skilled, the defeat of the English Army was theirs. It was at this lowest point that King Henry V gave a speech to the remaining men that is now ever known as the St. Crispen’s Day speech. The final lines have become better known as “The Band of Brothers” speech. King Henry’s V speech rallied the English Army to victory!

You are a “band of brothers and sisters” just as much as those men were centuries ago. Like them, united, you face a formidable foe, one that appears overwhelming and where victory is uncertain. That foe is the on-going transformation of health care with all its associated change and uncertainty. There will be other foes as well, unknown now but sure to come.

The safety and well-being of our patients have never been more important or challenging than they are today. Patients are older, sicker, more complicated yet technology has advanced to the point that there is much more that can be done for them. The sacrifices required of you as well have never been greater - the long hours, night calls, emergency surgeries, the critically ill patient, the dying patient, the demanding families, the never- ending administrative/EMR expectations….It would be so easy to become overwhelmed and simply give up just as it would have been for those soldiers at Agincourt. Yet, you continue to make a difference in the lives of others; you are living a life that counts! Isn’t that how we all want to be remembered – that we lived just such a life, while too many others will “… think themselves “accurs’d“, that they cannot say the same?

Thank you as always for what you do!

Andy Lamb, MD

"Bugle Notes" - Despair

I know how hard healthcare providers, especially physicians, work; the challenges they face; the obstacles they must overcome; the demands and stresses they endure everyday as they do the work, the hard work of medicine. It is not getting easier; it is only getting harder; and health care providers are paying the price. We are tough, though, our training has made us this way. We think we can withstand any demand and do any job no matter how overwhelming it may feel. But in the recesses of our mind, we know it is not true and, for many reasons, we won’t admit it. For me, it was the fear of being seen as weak, not good enough, not having “what it takes”. I was taught I could do anything, endure anything through my efforts alone – or so I believed.

Have you ever felt pain? I mean real physical pain? Pain so unbearable it takes your breath away, you are afraid to move, and you can’t stop the tears from flowing. I have and the physical pain I experienced was the worst I had ever known. It gave me a better understanding and a deeper compassion for my patients who went through such pain. I could not imagine pain worse than what I had experienced. I was wrong.

There is a worse pain. Like me, others have experienced it. I know because I was at their side when they did. Too many are going through it right now and cannot endure it much longer. Like I was, they are on the precipice of a deep, dark pit called despair. Despair, with its’ brother hopelessness, is the worst pain of all. It is an emotional state that even now I find difficult to put into words. But I know it. I have felt it. I have lived it and it is bad. Despair, at its worse, must be experienced to fully understand what I am describing. I hope no one else experiences it but the reality is most will experience it at some time in their life.

Have you ever experienced pain so visceral that it was hard to breathe? Have you ever been so overwhelmed with grief or heartbreak that you cannot stop crying? Have you ever gone month after month with no joy, a complete loss of joy to the point that you have forgotten what it feels like to have it? You cannot imagine ever feeling it again. Have you ever gone night after night unable to sleep because your mind is racing, you cannot stop your thoughts, and you lay there praying for sleep but it doesn’t come? Have you ever felt completely hopeless to the point that you cannot imagine things ever getting better? Have you ever been in the bottom of a deep, dark pit and cannot climb out? Have you ever felt so alone that no matter how loud or how long you cried out no one heard you?

You can call it what you want to - depression, burnout, etc., yet these words do not do justice to the pain of despair. You cope the best you can, sometimes well, more often not so well. I know because I did the same. It was the hardest thing I’ve ever done. What saved me and brought me out of this pit of despair? First and foremost was my faith in God. A significant second, though, was when I finally opened up to a few friends, medical and non-medical, I knew I could trust, with whom I would be safe, and who would love and support me.

How wrong I was to try to do that alone because of pride, shame, embarrassment, or simply fear of being seen as weak! Trying to persevere through this alone won’t work. Eventually, your best coping skills, your strongest efforts, your best “mask” will fail and the pain of despair will overcome you. All those you love and care about will suffer with you. Fortunately, there are people who care, who will listen, whether professionally trained or simply, like me, who know what others are going through and are ready to help anyway they can. You cannot do it alone. Too much is at stake. Medicine is hard enough, life can be harder, without trying to do this alone. There is hope. Life can be good again and joy can even return! Despair does not have to overcome you. The pain can stop.

Andy Lamb, MD

"Bugle Notes" - Broken by a Smile

As I have led medical missions internationally, there often occurs an event that becomes etched in my mind and I cannot forget. This happened most recently in Mauritania, located in northwest Africa. We were there to support a nutrition center run by two Swiss missionaries in the capital city of Nouakchott. The center cared for severely malnourished children. It was heart breaking to see these children clinging for their lives.

Significant poverty, created by a “spider web” of causes, is common in this part of the world literally surrounded by the Sahara Desert. The beauty of the Sahara at sunrise was quite a contrast to the prevalent desperation and hopelessness that permeated everything. Yet, out of this came a reminder that something good, even beautiful can be found. That something was a smile, a smile from two children and it broke me.

Mauritania was my first time serving in an all Muslim country. I admit to having some trepidation but that quickly dissolved as I saw how appreciative, kind, and accepting the people were. The poverty, the need, the hardships they faced daily quickly became apparent as the days went by. The children though stole my heart. Despite the difficulties of their lives, they, like the countless children I have seen all over the world, were still happy. Life had not broken their spirits yet. Time would change that soon enough.

The two children, a brother and sister, came to the clinic with their mother. She was dressed in the traditional “Malafa” with only a small portion of her face showing. I was immediately struck by how thin and dirty they were. Neither child smiled or looked at me. They were too afraid and as I found out later, I was the first “white person” they had seen. I quickly began to do all I could to get them to relax. Simple “smiley face” stickers did it! I placed one on the back of each child’s hand and you would have thought I had given them their dream present! Their eyes opened wide and both broke into a big smile showing teeth in need of much repair but still joyous all the same. I had a picture taken with them to remember that moment, a moment when my heart was “broken by a smile”, in this case two smiles. Even in the face of great need, children can be happy.

I write this story to ask, ”When was the last time you allowed yourself  to be ‘broken by a smile” be it from a child, a grateful patient, or appreciative family member? When was the last time you let your guard down, put your busyness aside, and let a smile remind you of how fortunate you are to do what you do?” What you do only a few are privileged to do. We all need to be reminded for it is all too easy to forget in today's world of medicine. Let your heart be broken by a smile, you will be glad you did.

Thank you as always for all you do,

Andy Lamb, MD

"Bugle Notes" - A Servant Heart

As I was preparing for my next medical mission, I began to think about the word “minister”. Obviously, from a religious standpoint, it has certain connotations one of which is “to serve”. When you are ministering to someone’s needs you are serving them.

This caused me to think of my dear friend in Nepal, Fahad. Fahad is a young Muslim physician with whom I had the privilege of serving and working during my first two medical missions to Nepal. I will never forget the first day we served together, working side-by-side. In the four and a half days of clinic we saw just over 4000 patients many with significant physical and medical needs. It was overwhelming with only 8 providers to see them!

The first day was particularly hard as we had not anticipated such large numbers of patients. The weather was also very hot and humid. At the end of the day we were all emotionally and physically exhausted. It was then that Fahad came to me with tears in his eyes and said these words that I will never forget, “Dr. Andy, I have never seen people like you. My entire life I have been told to take care of myself, work hard, and prepare myself so that I could be successful. Then, if I have time, I could help others. But today watching you and the team I am learning that I am to put others needs before my needs, to serve others first!” I was completely blown away by this. He learned a lesson in one day that many people never learn or come to understand.

 Servants have a servant-heart – a heart that is loving, obedient, and humble. People understand the concept of being loving and obedient but being humble, the act of showing humility, can be harder to grasp. Often humility is seen as being timid, or passive, or even weak. The reality is that humility is not that at all! In my office, I have framed on my wall a definition of humility that I came up with from different sources. I display it prominently so as to be a constant reminder of how I am being. It says:

“Humility is not timidity. It is not an attitude toward ourselves. Rather, it is an appreciation of other people. It is a respect for them as persons of worth, a recognition of their abilities, a willingness to receive from them what they have to offer.

We clothe ourselves with humility by helping others do what they are capable of doing and by recognizing their successes. We do so by listening rather than talking to them. We do so by supporting them rather than competing with them. We clothe ourselves with humility in other words, by putting others ahead of ourselves.”

Every day in the hospital and in your practices, when taking care of patients, healing them, comforting them, you are ministering to them. You are serving them. You are putting them first. You are a servant with a servant heart and I am most grateful for you!

Humbly,

Andy Lamb, MD

"Bugle Notes" - "Sacred Trust"

  

The words “sacred trust” evoke a response within me that I find difficult to put into words. Yet there is no doubt, and each of you know this, that a “sacred trust” does exist between a doctor and the patient. This sacred trust is the glue that holds a healing relationship together. It is the privilege given to us by patients and their families when they allow us to become intimately involved in their lives as a result of this unique relationship.

Patients at their most vulnerable, open themselves to us, disclose things to us in ways few other professions experience. They may tell us things they have shared with no one else. They will open themselves to invasive physical treatments because they trust, hope, and believe in us. Sacred trust is necessary for a true healing relationship to occur. Without trust there is no relationship. Without relationship there is no special bond that transcends all the forces driving healthcare transformation. Without this sacred trust the real art of medicine is lost and the joy that goes with it.

Many transformational forces are increasingly impacting healthcare today. What will become of this sacred trust? Will the future model for medicine be based solely on algorithms that provide a treatment plan drawing on the latest clinical evidence, gleaned from a massive database? This model requires no human interaction only analytics.  More and more it seems that this is the direction medicine is taking. However, such a model misses the critical human element of healing, caring, and compassion. It lacks intuition and judgment. It completely ignores the art that is medicine as well.

The practice of medicine is both art and science. This sacred trust must exist in a healing relationship as well as science. The transformative forces acting on healthcare must serve this relationship not diminish it. People want a human connection in their care. For this to occur, the framework for healthcare delivery must be created which would demonstrate how the transformative forces can enhance the healing relationship. This is the challenge to health care leaders today. This is the reason why we as physicians must reengage in all aspects of healthcare and lead the way through this transformation. 

How will this look? I don’t know. I am not sure anyone knows at this point. Changes are occurring at incredible speed and we must be ready to take on this challenge. However, foundational to all of this is maintaining that sacred trust. The relationships we develop with our patients, and the sacred trust that results, is why most of us went into medicine. Without this, it becomes only work, hard work with no joy. You do make a difference every day. This sacred trust is one reason why.

As always, thank you for the many sacrifices you have made and continue to make so that our patients get the best care possible in a loving and compassionate way.

Andy Lamb, MD 

"Bugle Notes" - Back Into the Mountains

She shook her head no, eyes brimming with tears, chin quivering with emotion. I told her, again, that without further care her son would never have use of his arm, and possibly would die. Her voice trembling, she told me her husband would beat her if she returned home without the boy. She placed her son on their horse, his newly bandaged arm in a make-shift sling. I gave her antibiotics and medicine for pain still pleading to let us take him to the nearest hospital. Shaking her head again, she turned and led the horse back into the mountains of central Honduras, the boy silent, staring back at me, the contrast between his tiny body and the horse striking.

Only an hour earlier, they had arrived at our clinic. She heard an American medical team had arrived for the week and she desperately wanted her son to be seen. The day before, while he was cutting bamboo with a machete, a miss  - swing cut into his left forearm arm. She bandaged it with cloth as best she could and made the several hour trip by horseback to see us. I was amazed how stoic he was at only 8 years of age, his toughness forged by the circumstances of his life. No tears, no sound, his ebony eyes watching my every move. I removed the blood-caked bandage revealing a gaping wound traversing his left forearm, exposed muscles appearing to be completely cut through. Remarkably, the main arteries were intact.

A nurse cleaned the wound and then I began to carefully explore the extent of damage. He needed urgent surgical attention to save his arm and possibly his life. The nearest hospital was several hours away. My host partner, Ricardo, began calling. In a matter of minutes, a physician was on the phone, a friend of Ricardo's. IV fluids and antibiotics were started, a sterile dressing carefully applied. In less than an hour, he was ready to go by car. I explained to the mother all we had done and the arrangements we had fortunately been able to make. Without our intervention, he would be refused care at any hospital because of her inability to pay. This is an all too common scenario in many countries - no money, no care. I was anticipating tears of joy and gratitude. Instead came the side-ways shake of her head and the flowing of tears.

I have led over 40 medical missions to countries in Central America, Eastern Europe, Central Asia, and northwest Africa, experiencing their unique beauty and the richness of their vastly different cultures. I have also seen the desperate poverty and ever-present hopelessness with which the people live. We are most fortunate to live where we do without the daily struggles to survive common to many in the world. The eyes of that little boy are always a reminder of that to me.

Andy Lamb, MD

"Bugle Notes" - "A Little Moment of Joy"

The cab driver pulled up to a small house, typical of the post – WWII era. He honked his horn and waited. He honked a second time but no one came. He contemplated leaving, as it was near the end of his shift, but decided to go knock on the door. Through the door, he heard a voice and something scrapping across the floor. The door slowly opened and a frail, elderly woman, with several suitcases at her side, stood before him. She appeared to be in her 90’s. There was a noticeable sadness about her.

She thanked him for coming as he helped her down the steps to the taxi. He asked where she wanted to go and she quietly responded, “To the Hospice Home”. She explained that her doctor had told her she had less than 6 months to live. She had no family left to care for her. Her husband had died a few years before. Suddenly she said, “Could you take me downtown?” Hesitantly, knowing it was out of the way, he agreed. He drove slowly through the town where she had lived her entire life. She was seeing it for the last time. Her eyes glistening, she reminisced of times long ago – the building where she had her first job, the park where her husband first kissed her, the matinee theater, dance hall, soda shop…her children. After 2 hours, they arrived at the Hospice Home. She asked how much she owed. With tears in his eyes, he turned off the meter and told her there was no charge. Helping her into a waiting wheelchair, she thanked him again and said, “You gave an old woman a little moment of joy”.

I read the above story on social media and was deeply moved. We often care for those nearing the end of their lives. It is so easy to see them as another old person with their myriad of physical problems, increasingly dependent upon others. We forget that once they were young, vibrant, strong, navigating life as best they could. They have their own stories if we would only take the time to ask – where did they grow up, what did they do for a living? Simple questions that could open unexpected windows allowing glimpses into their lives and hearts.

I always asked my older male patients whether they had served in the military. Many of my most memorable stories came from that question. History came to life – Pearl Harbor, Guadalcanal, Tarawa, Iwo Jima, Omaha Beach, the Battle of the Bulge, the 8^th Air Force over Germany, Chosin Reservoir, Ia Drang – bloody places, costly places, still very much alive in the recesses of their minds. I treasured these stories. In their telling, you could see a glimmer in their eyes, hear the pride in their voices, and, for a moment, see them as they once were - young, strong, their entire life ahead of them.

Each of us can give “a little moment of joy” to others. In doing so, we are reminded of the human side of medicine.  The rewards can be life-giving to you and to the person telling their stories. Stories are powerful. They need to be heard lest they be lost forever. Who will you bring “a little moment of joy” to today?

Andy Lamb, MD

"Bugle Notes" - On Death and Dying

 Death is inevitable. How we die, though, we can and should have more control over. We are most fortunate in this country to have Palliative Care and Hospice programs. These individuals are “angels on earth” as far as I am concerned. They enable our patients, friends, those dear to us to have that control while being cared for with compassion and dignity. I am so appreciative of the hard work they do. Yet, our healthcare system overall is not doing as well in this arena.  

In today’s aging, over medicalized, technological environment with increasingly challenging patient/family expectations, the concept of dying with dignity has become too uncommon. The highest expenditure of costs on patient care occur in the last two months of a person’s life and all too often for futile reasons. Atul Gwande’s book, “On Being Mortal”, provides great insight into the current state and the high costs, not only financially, but also emotionally on every person involved.

 In 30 years as an Internal Medicine Specialist, I cared for more dying patients than I can remember.  Some patient’s death, though, you never forget because of the circumstances surrounding it and the impact it had on you personally.

 I cared for her husband and her while in the Army years ago. She was dying of pulmonary fibrosis. She was a woman of strong faith with a loving, supportive family. Her desire was to die in her home, family surrounding her, with grace and dignity. I had developed a very close relationship with them both. They were wonderful people. They had become my friends.

One night, I received a phone call from her husband - she was near death and could I come by to see her? I drove to their house where I met him and the three daughters who had flown in from other states to be with their mother. By the time I arrived, she had died. I remember standing at the bedside with the family as the husband prayed. Afterwards he thanked me for the care I had provided her. 

That day was the birthday of the youngest daughter. They had plans to celebrate it with cake and champagne. Then a most remarkable thing happened. The daughter poured a glass for each of us and led us outside to the patio. The night was clear and the stars were shining. She lifted her glass to the night sky and thanked God for her mother’s life and the blessing she had been to her, the family, and so many others. We toasted her and then we celebrated her birthday, tears of sadness now mixed with tears of joy. Their mother, my patient, my friend, had her wish fulfilled.

Moments like this are a reminder of the privilege we have to be so intimately involved in the lives of our patients. It is a humbling experience during these sacred moments because of this privilege and the relationships that result from it. What you do so well every day in the care of others, is hard work, very hard work. It is important work. Thank you for caring, serving and loving so well.

Andy Lamb, MD

"Bugle Notes" - Your Greatest Gift

                                                          "Your Greatest Gift"

I stood inside the door of “una chosa”, Spanish for “a hut”- the walls bamboo and sunbaked mud; a broom-swept dirt floor; two open windows partially covered by tattered cloth; no running water, no electricity. The acrid smell of smoke from the wood fire in the open brick oven permeated the air. Then I saw her. Lying on a bed made of wood and rope was a young woman. To my astonishment, she had a gastric feeding tube and foley catheter. Her arms and legs atrophied, contracted, her breathing shallow and rapid. Rivulets of sweat traced down her face. The oppressive heat and humidity of Honduras in August punctuating the surreal scene in front of me.

Wendy, a third year medical student, and I were doing home visits as part of a medical team serving in El Triunfo, a village of 5000 people in southern Honduras. We traveled by truck, over rock strewn, dirt roads, crossing several small streams to a village of 50 families. We did not know what type patient we would be seeing. Most often, the home patients are elderly and bedridden by severe arthritis or an incapacitating stroke, but not this time.

 She was 21 and healthy until the year prior, when she collapsed, never to regain consciousness. She was carried in the back of a truck, over mountainous, rocky dirt roads to the hospital in Tegucigalpa, arriving 8 hours later. They received the news; nothing further could be done. Their hopes shattered, she returned home the same manner as she had arrived, now with her permanent feeding tube and foley catheter. To my surprise, the husband handed me the CT scan of her head done at the hospital. I raised the images to the sunlight, a large intracerebral bleed readily apparent. I slowly lowered the tell-tale pictures and looked at Wendy. Her past history now answered.

 Clinically she was infected. She had a fever. The urine was concentrated and cloudy, a recent change per her husband. I told him we had antibiotics that could be given through the feeding tube and the importance of keeping her well hydrated. As we prepared to leave, our hearts heavy, the husband began asking more questions. Could we not give her something to make her well again? Then I understood. He believed, that as a doctor from the United States, I could heal her and bring her back to him. After all, I was from America and it had the best of everything. Such unrealistic expectations are not uncommon. I explained what the CT showed and confirmed there was nothing I nor anyone else could do; she would not recover. He began to sob, head lowered, hands covering his face, as all remaining hope vanished. We took his hands in ours, sat with him, and prayed. What else could we do?

You know this pain, the heartbreak, the suffering. It is part of being a physician. It is part of life.  Thinking back on the 30 years I practiced Internal Medicine, I remember best those patients where everything medically was done, only to fail. In their moments of deepest despair, all I could do was be present, hold their hand, listen to them, and cry with them. Words are not always necessary.

As physicians, we want to heal our patients when possible. However, maybe your greatest gift to a patent is not healing, for healing is transient.  Maybe, instead, your greatest gift is the ability to be completely present with a patient’s suffering, allowing it to transform you, and in doing so, transform it for them as well. Your presence becomes everything to the patient who feels they are losing everything. As you face what your patient faces, you are better able to bring compassion to them and, maybe, I believe, better able to extend that compassion to yourself as you do the hard work of medicine. Thank you for your selfless service to those in their darkest time of despair.

Andy Lamb, MD

"Bugle Notes" - The Wait

February 24, 1991, and I wait. I wait on the edge of my cot under the pitched canopy of my far-away canvas home; its sides pulsating from the ever - present wind; sand somehow traversing the walls, everything inside air brushed a pastel tan; outside the surrounding Saudi Arabian desert limitless in all directions. The winds of war have been blowing and the time has come. There are 10 of us inside the tent, all physicians, all waiting, all far from home and our families, all wondering, all asking the same questions of themselves – What will it be like? Do I have what it takes? Will I stand firm and do my job when the Blackhawk helicopters blacken the sky with wounded soldiers? The First Gulf War has begun. Operation Desert Shield has now become Desert Storm.

 I am Chief of Medicine for a 400 bed Army field hospital just south of the Iraqi border. For months we have meticulously planned and prepared to receive 600 plus casualties each day brought directly from the battlefield by the Blackhawks. Nurses, Corpsmen, Techs have been cross-trained to do whatever is required so the doctors could be where they are needed most. I am responsible for triage. The weight of that responsibility fully upon me, even palpable, and the questions come…. I write my mother and father and tell them I love them. I wonder how my father, a combat veteran of two tours in Vietnam, did what he did; and I wait.

Decades later, I wait again. We are again at war. This time with a relentless, invisible, merciless enemy – a virus never before seen; no immunity; a pandemic. COVID-19 has become part of our everyday vernacular. We hear the projections – millions infected, hundreds of thousand’s dead; it is surreal, incomprehensible, unprecedented. What is true; what is not? What to do; what not to do? I think of the physicians, nurses, PA’s, NP’s, the hospital staff now on the front lines, in harm’s way, waiting as well, asking the same questions I did so many years ago. Many are my friends. The “peak” is yet to come, and we wait. The wait is the hardest, at least for me.  But the waiting will soon end, and when it does, the questions will be answered, and “new heroes” will emerge. Let’s us thank them now as they wait and as they fight.

Andy Lamb, MD

"Bugle Notes" - "But Steps to Your Eternity"

                                                            "But Steps to Eternity"

“You that seek what life is in death,

Now find it air that once was breath,

New names unknown, old names gone:

Till time end bodies, but souls none.

Reader! Then make time, while you be,

But steps to your eternity.”

-        Baron Brooke Fulke Greville, “Caelica 83”

I cried Sunday morning as I sat by my fire pit. It was all I could do to keep from sobbing as I read the last pages of “When Breath Becomes Air” by Paul Kalanithi, MD. I often had to stop mid-page to gather myself together before I could continue to read.

At the age of 36, on the verge of completing a decade’s worth of training as a neurosurgeon and neuroscientist, Paul Kalanithi was diagnosed with stage IV lung cancer. “When Breath Becomes Air” is his story of his transformation from a medical student, seeking to answer the question what makes a virtuous and meaningful life, into a neurosurgeon, seeking to understand more deeply that critical place of human identity, and finally into a patient and new father confronting his own mortality.

He died in March 2015 while working on this book leaving behind a wife and 8 month old daughter. The tragedy of his premature death was heart-wrenching to read. However, the words he wrote in those final months of his life are an unforgettable, life-offering reflection on the challenge of facing death but also on the sacred relationship between doctor and patient. In his dying, he had much to teach about life, powerful lessons all too easy to forget in the busyness that is the life of a physician.

Early in the book, he writes about the struggles he faced during the arduous first years of neurosurgical residency as he realized he was becoming inured to the suffering and death that was now common place. Paul feared losing sight of the sacred relationship between doctor and patient. He came to the realization that saving lives – everyone dies eventually – was not his highest ideal, rather guiding a patient or family to an understanding of death or illness was. He wrote, “When there’s no place for the scalpel, words are the surgeon’s only tool”. I know this to be true as well. I have seen much death and suffering, not only in my years of medicine, but also on the medical missions I lead throughout the world. When all else has failed – medical/surgical treatment, experimental protocols, last ditch holistic therapies – what can one do? Our scalpel, our medical treatment, become the words we choose and the way we say them. The right words said with caring, compassion, a loving touch, can be healing in ways we cannot imagine. But words said otherwise can be as wounding as the cut made by the sharpest of scalpels.

He felt doctors had a duty to learn “What made that particular patient’s life worth living or, if not, to allow the peace of death. Such power required deep responsibility. Yet most lives are lived with passivity toward death”. As I read those words, I was reminded of the last scene in the movie “Braveheart” where the main character, William Wallace, played by Mel Gibson, knowing his execution was imminent said, “All men die but few men truly live”.

Paul found himself facing his own mortality while trying to understand what made his life worth living. In the end, it was his daughter that made life worth fighting for. His wife asked him, “What are you afraid or sad about?” He answered, "Leaving you." He knew a child would bring joy to their family and he could not bear to see his wife childless after he died. His wife was concerned that saying goodbye to his child would make his death more painful. He answered, “Wouldn’t it be great if it did?” They both felt life was not about avoiding suffering. They would carry on living instead of dying. They would not allow themselves to “miss the dance”.

He came to understand that life was precious and what made it so was not money, prestige, titles, or material things. He called these vanities that hold so little interest: a chasing after wind. He came to understand that we are all “but steps to your eternity”, yet few of us stop long enough from our busyness to comprehend that.

We all need to be reminded of this. We have been given a precious gift – the gift of making a difference in the lives of others; a gift of living a life that counts. We have the great privilege of the sacred trust between physician and patient. In seeking those things that truly are important, may we find life not death, breath not air as we remember we all are “but steps to your eternity”. What is truly important to you?

Andy Lamb, MD

"Bugle Notes" - Betsy

I will never forget the moment I heard the news. “What! No way! You are joking right?” But she wasn’t. “No, Andy, Betsy was just diagnosed with Stage IV colon cancer.” I was shocked. How could it be? Betsy was only 32 years old. She had finally met the man of her dreams after years of wondering if she ever would. They had married only 3 months before! This could not be happening. This is Betsy – the young, energetic, loving, caring, smiling nurse with whom I had served so many times on medical missions. She was healthy! She had no risk factors - no Inflammatory Bowel Disease, no family history. The reality finally began to set in – chances were she would not live another 1-2 years.

 She was determined to beat this and thus began what has been a 1 1/2 year battle that continues to this day. Unfortunately, it is a battle she is losing and she knows it. Yet, she has continued to fight heroically, with the loving support of her husband, as she has sought out the latest treatment options. She has tried every experimental protocol for which she qualified. Some have slowed the disease briefly but most have only caused severe, incapacitating side effects.

I stay in close contact with Betsy especially through the “Caring Bridge” web site. Betsy routinely provides updates on how she is doing physically but she also speaks openly about her emotional and spiritual struggles. My heart aches for her as she has more recently written about the increasing reality of her soon to come death. She knows she has very little time left short of a miracle from God (and she is a strongly faithful person). She writes of the heartbreak, profound sadness, and the overwhelming grief she feels to the depths of her soul.

She grieves that she will not have a long, full life with her husband – the man for whom she had prayed and waited all those years. She grieves that she will never have children and she loves children. She is the best aunt ever to her nieces! She grieves that she will not get to see them grow to adulthood. Most of all, she grieves the loss of what could have been, should have been….

Yet, through this all her faith remains the foundation upon which she lives. As a result, her life has become an inspiration to those privileged to know her. She is a constant reminder of the beauty that surrounds us every moment of every day in the world; of how blessed we are to have the life we have; and that every day is to be cherished for what it is, a gift.

 I remember the last time I saw her. Many months after her initial diagnosis, followed by multiple surgeries and intense, debilitating chemotherapy, a close friend and I flew up to visit Betsy and her husband. We wanted to see her. We needed to see her. At that time, it was uncertain if she would live another 6 months. We did all we could to make it as special a weekend as possible – dinner at a fine restaurant, a comedy play (where I vividly remember her holding her husband’s hand, laying her head on his shoulder, and actually laughing!), providing prayer, words of encouragement and love. Most of all we listened to her as she poured her heart out to us.

When I left, we hugged and said, “I love you”. As I turned to leave, the storm door closed behind me. My last image of Betsy was her standing there smiling through the sun – glared glass. We waved one final time and as I walked away it suddenly hit me that this may be the last time I see her. I began to cry. Life is too short and relationships with others too dear to let the busyness of life and work keep us from remembering this. When you are having the inevitable “horrible, terrible, no good, very bad day”, remember there is still much for which to be thankful. Each day is an opportunity to bring healing and hope to those in need. You are making a difference in their lives. You are living a life that counts. Thank you for being that person.

Andy Lamb, MD