"The Last Time"

 

 The old man sat at the front of the drift boat as it swayed gently, anchored at the river’s edge. The guide sat behind him making final preparations for the days float down river. The man had fly fished for nearly 40 years; he even tied his own flies and made fly rods such was his love for it. Age and unwelcomed health problems, though, were slowly bringing an end to the things he loved most. Something inside him said this was his last time on the river that long before had become a part of him. He tried to explain to others the “oneness” he felt with the river, and with fly fishing as well, but few understood. The guide understood, though. They had met years earlier and, though he was still “the guide”, he was now much more than that, he was a friend. Countless conversations intermixed with countless casts to countless rising trout had cemented their friendship. He sensed his friend knew this was the last time as well. There was no hurry in his preparation for the trip. Few words were spoken.

 

A sadness enveloped him, like an early morning mist, rising ethereally from the river, the cold water caressed by the warmer air above. This was a tailwater, it’s beginning, the bottom of a deep lake that laid behind a dam, the deepest water remaining a near constant coldness. It not only provided electric power to the surrounding area, it gave life to the innumerable Browns and Rainbows that thrived in its waters. Only cold, clean, well-oxygenated water would allow them to survive. The river provided just that, and, for the man, even more.

 

He thought back to his first time fly fishing. He had no idea what he was doing that day. He only knew that as long as he could remember, he wanted to learn. Where that came from, he had no clue. As a young boy, there was a movie, “Spencer’s Mountain”, that was a favorite of his. There was a scene in the movie with Henry Fonda and Wally Cox fly fishing while imbibing in some forbidden whisky. They were trying to catch the “big one” that Fonda knew lived in that stretch of water. Maybe that was the start? His father was not a fisherman, so growing up he did not fish as much as he would have liked but he did whenever he could.

 

It was a gorgeous late October day, that first time; the trees a tapestry of orange, red, green and yellow; the sun dancing off the water in all its radiant brilliance. He was so hopeful of catching that first trout! The hours that followed, however, were spent either untangling a bird’s nest of hair-thin line or preparing to tangle with the next attempted cast. He never saw a trout, never had a strike, yet he came off the river happy, determined that he would learn to do this. Thanks to someone he met soon after, his apprenticeship began, and with it a very special friendship.

 

Brad was in his early 30’s and had previously been an Orvis guide. He saw the man’s determination to learn and over the next few years, selflessly gave of himself and his time to teach him.  Amazingly, he never fished when they were together. He simply taught, only using the fly rod to demonstrate how to do something better or to teach something new. Brad eventually did the same with each of the man’s three sons as they became old enough to learn. How many hours, how many days were spent exploring and fishing the streams and rivers in which the trout lived, dependent upon a most delicate and fragile ecosystem that are the mountains of North Carolina? It was here that his sons and he began their life-long journey of learning the art that is fly fishing. For him, fly fishing was a microcosm of life with its successes and failures; joys and disappointments. Precious memories from the years that followed of backpacking and fly fishing with each of his sons returned. His eyes glistened.

 

As he sat, his friend finishing the final preparations, the cloud of sadness began to lift just as the mist on the water does with the rising of the sun. If this was “the last time”, then he would take in every moment. His memories were enough now. His friend raised the anchor, handed him the fly rod, and the boat began to move. The man was happy.

 

Andy Lamb, MD

 

 

"The First 100 Yards"

    

You are 19 years old standing in the muck and mud that are the trenches of World War I. You are cold, hungry, filthy, emotionally, mentally, and physically exhausted; you stare straight ahead, eyes vacant not revealing deep inside you a visceral fear that defies description; a fear that only those who have faced the horror of combat know. You are an American soldier and this is your reality. You know what awaits when the order is given to “go over the top” – the withering rifle, machine gun, and artillery fire, a rain of deadly hot steel indiscriminately finding flesh and bone, mutilating and killing those around you and quite possibly you. Any sense of youthful immortality long erased by the nightmares you have already experienced.

 

The first 100 yards, survive the first 100 yards you keep telling yourself. If you can just make those 100 yards you know your chances of surviving the day increase significantly. Importantly, as well, gaining victory. A mere 100 yards…but it might as well be 1000. Knowing that many among your “band of brothers” will die, that you may die within the next few moments, you still do it. The order is given and you immediately go over the top, the fear replaced by a single thought, survive those 100 yards. How do you do it? Why do you do it? You cannot do otherwise. You cannot, you will not, let your buddies down, those with whom you have shared hardships and terrifying moments; those with whom you have a special bond that no one else can understand. You have to be there for them; you will be there for them no matter the cost.

 

The first 100 yards speaks directly to facing one’s fears, struggles, challenges; of persevering, of doing what has to be done despite the fear, however that may look. The war with COVID-19 has been, for those in the front - line trenches, so to speak, their own first 100 yards. Yet, despite the heartbreak – death, suffering, isolation, loneliness– and their own personal fears, they daily went “over the top” to cross those 100 yards and lovingly, compassionately care for those at their most terrifying and vulnerable time.  

 

History is replete with those willing to “go over the top” and dare to cross the “first 100 yards” to confront whatever the “enemy” was – the “Black Plague”, TB, Spanish Flu, Ebola, and now COVID-19. The risks were real; death was possible just as it was with the soldier in the trenches. Yet, time and again, they stepped up and said, “I will go. I will do it. Send me.” As a nation, we owe thanks to those who did just that. I for one am most thankful!

 

Andy Lamb, MD

 

 

"What!"

They were migrant workers in the Central Valley of California. She was expecting her first child when  she first crossed the border with her husband illegally only a few weeks before. Most everyone working beside them had done the same, the majority from Mexico, as they were, but some from Central America. The “Coyotes” were always busy in their mercenary work. They were all desperate for a “better life”, the “American Dream”, especially when a baby was soon to arrive.

 The work was hard, soul-breaking, endless; the foreman, merciless. They endured, they had to, their baby’s life depended upon it. A missed day of work meant the difference between work or no work; food or no food…. After he was born, she was back in the fields within days, the foreman was waiting. She brought the baby with her, enshrouded in a traditional cloth wrap slung across the front of her body so she could more easily nurse while she worked. What else could she do?  The foreman made no exceptions. The baby cried, often, too often. The foreman quickly became angry at the incessant crying. He threatened to fire them both if she did not keep the baby quiet. She tried, she tried hard, very hard but nothing worked, and she became desperate. Another worker suggested she do what others did, give the baby “a little alcohol” in his bottle. It would make the baby sleepy and the crying would stop. She did, the crying stopped, and they continued to work. They did so day after day, month after month, and the work continued, endless….

 “He’s a 21year-old Hispanic male who presented last night for a significant upper GI bleed secondary to esophageal varices from end-stage alcoholic liver disease”, the ED physician said. “What!”, I said. “He’s way too young to have this!”.  I was in disbelief. How could this happen? There must be extenuating circumstances The interpreter provided further history on the patient.  His parents had for many years been migrant-workers in California….

 He died a few days later but his memory remains hauntedly with me.

 

Andy Lamb, MD

 

A Knock at the Door

 

                                                             

 “There will be a knock at the door,” says Rene, an El Salvadoran Pastor and my close friend, “and they will say, ‘Give us your daughter or we will kill you and your family’.” He continues, “Gangs control many of the villages. They are in the schools; they are in this school! If the leader sees a girl that he likes, no matter her age, he sends members of his gang to her home and demand the girl be given to them to be used as the leader decides. If the parents refuse, the gang members keep their word and take the girl anyway. When a boy reaches the age of 10, if he does not join a gang, he may be killed. This is one reason why many of the children arriving at the US borders are alone, without parents, or a significant other. Their parents had to make a decision; a decision of life or death; a last resort, gut- wrenching decision; yet the decision becomes all too clear. It is safer for their children to make this most perilous journey than to remain in their own home.”

 I listen in disbelief as I sit on the crumbling concrete steps of the village school where our medical clinic is temporarily located for the week. The village is located on the side of an inactive, waterless volcano where large cisterns dot the mountain side collecting precious rain water for the people’s every day needs. This is my 12^th year leading medical teams to a country and people I have come to love deeply. It has become my “segunda casa”, my second home, yet, somehow, I have not heard this story that is the reality for many in El Salvador. It is a beautiful country of volcanic mountains and rock - strewn beaches. Its beauty in stark contrast to the ever-present violence and intimidation of the gangs. Even the capital, San Salvador, cannot escape this dark reality. Mara Salvatrucha, MS 13, are names that illicit fear in every El Salvadoran; most of all the fear of a knock at the door.

 Often, “Coyotes” will take these children, and others willing to sacrifice everything for a chance at a life offering a glimmer of hope, on this most hazardous trek where illness, injury, and death are ever present. They are soul-less mercenaries who feed on and live off this agonal reality at a precious cost to these desperate families – of money, fractured families, and even death. To live without hope is not to live, it is simply to exist. So, the decision is made and the children are sent. Hope of a better life for them and their loved ones left behind a powerful driving force.

 In the villages, lacking many of the modern luxuries of the larger towns and cities, little is known about the news of the world. For them, life is a daily struggle of survival. They know not of the “immigration problem” that is often front- page news in the US. They are oblivious to the polarizing issue, with all its ugly faces, that it has become in our country. They only know what they have always heard, that America stands for freedom, opportunity, and most of all hope. They want that for themselves but especially for their children. So, this heart-wrenching story is repeated over and over again and the tears fall, hearts break, and families separated.

 Many in the U.S. ask the question, “Why?” Why would parents send their children on a potential death march? How could they ever do that? How could they be so heartless, unloving, irresponsible? Did they not care for their children, love their children? “I would never do that”, we all easily say without hesitation. But, in those same circumstances, would we? Fortunately, we do not live such a cruel reality.

 My heart aches and eyes glisten. There are children at the school now that we will see in the clinic who live in this “Twilight Zone” of reality. I feel helpless. As a physician, I seek to comfort, treat, and heal. As a father, I do everything I can to love and protect my children. The people of El Salvador seek to do the same for those they love, no matter the cost, no matter the sacrifice. May we not forget this. I never will.

 Andy Lamb, MD

 

 

 

 

"Fire Pit Time"

 

                                                                

The flames flicker, tantalizingly reaching upward, and I sit mesmerized. How many times have I sat by my back yard fire pit and watched this ageless dance? I think, I meditate, I pray; a cigar and bourbon often accompany me. I especially love to stand by it while the snow falls enveloping me in all its beauty. The memories are many; and they are good.

My sons are with me around the pit. I cherish these times. I try to remember every moment for I know they are numbered, the passage of time unrelenting. Our conversations varied, often deep, always important. I learned their hearts and better yet, they mine. I am happy and so very proud.

I am with friends, my "Band of Brothers", fellow physicians with whom I have served through the years. With cigar and bourbon in hand, we, too, talk about "anything and everything", sometimes medical, most often not. I sit in awe of them as I ponder the lives they have touched, and more, the difference they have made. We are growing old together. It is good to have such friends. I love them as my own brothers. 

I sit surrounded by young faces; the heart of the medical staff; those who are coming behind me; their "yet to come" of the future still greater than their "already been" of the past. They are my passion, the real reason I have remained in medicine for as long as I have. I want to invest in, teach, encourage, and mentor them any way I can. They are the future leaders of medicine - the visionaries, the decision-makers, the catalyst behind the inevitable changes that must come if we are to provide the best for those entrusting their care, often their lives, to us. They want someone to mentor them. It is an often unspoken request conveyed through a language unique to each of them. I have learned to "hear" the subtleties of this language through my years of leading medical missions and teaching  medical students, PA's, and NP's. I want to be there for them so I make my self available. I do so around the fire pit as often as possible. We share food, drink, and life-giving conversation. Relationships are made and strengthened between different specialties and trust created. Only trust can bond them together so they can be the unified, cohesive, and effective team required to lead us forward. "Fire pit time" brings them  together and that brings me joy.

Medicine demands much from us and we need much in return. We all need our own "fire pit time", however that may look. I hope you will find yours.

Andy Lamb, MD

Getting Personal

I once spoke at a Leadership Forum on Opioid Abuse. I was asked to speak to the role of hospital systems in addressing this important issue. As I thought on what I would say, I realized there was very little I could add. The crisis is epidemic and hospitals are ill-prepared to do anything proactive. It is that overwhelming. Leading medical missions, I learned an important lesson that has given me a different perspective on this. The needs of the world are overwhelming as well. These needs, though, do not become real to us until they become personal – you live it, breathe it, taste it, smell it, touch it. In 2009, the opioid crisis became personal to me, it became real.

 As a physician leader, I have sought to be transparent. Transparency is critical to establishing a culture that is safe and caring. Others can then feel safe to be the same themselves. In a culture characterized by openness and transparency, great things can happen! My “Bugle Notes” through the years hopefully have reflected this transparency to you.

 I decided, after much thought and prayer, to be very transparent with you. Doing so leaves me feeling exposed and vulnerable but I choose to do it anyway. My hope is that through my story this crisis will become more personal to you and thus more real. This is my story of how close I came to going down that perilous path that is opioid addiction (or any addiction for that matter). I was fortunate that I stopped before I went too far down that path. Unfortunately, too many are unable to stop and continue the downward spiral toward that deep, dark pit called despair and its brother hopelessness. If this could happen to me, it could happen to anyone. If my story prevents even one of you from experiencing this, then the trepidation I feel sharing this will be worth it.

 It began after my first back surgery in 2009 for an acutely herniated disc while leading a medical mission to Moldova in Eastern Europe. It was the worse pain I had ever experienced. My right leg was weak and numb. I had to be carried into my host home and put to bed – no running water, primitive outhouse, hit or miss electricity. It was not a good situation. I placed myself on prednisone hoping it would help but the following morning I was no better, in fact, worse.  As the team leader, I realized I would have to be urgently evacuated to the U.S. However a “miracle” occurred that allowed me to regain neurologic function temporarily and I was able to finish the mission. That “miracle” may need to be the topic of another “Bugle Notes”!

 Two days after returning home, I went to surgery. The surgery was a complete success. I was discharged on Oxycontin with a refill, which was common practice at that time. It did help the post-op pain and I was surprised how good it made me feel overall. It had a calming effect as well. Prior to the mission trip, there had been a lot of stress at home, my practice, and the hospital. I began looking forward to taking it. Since I was still on medical leave, there was no concern with it affecting my patient care. I would be at home enjoying the feeling. I rationalized that there was nothing wrong with that and, besides, I could stop anytime I wanted.  Little did I realize the dangerous path I was choosing.

 I found myself counting the remaining tablets each day. I started to dread when they would run out. I was embarrassed to call the neurosurgeon for another refill and have him think I was an addict or drug seeker! After all, that could never happen to me! Then reality set in. I used the last pill and within 24 hours I began having withdrawal symptoms- restlessness, abdominal cramping, diarrhea. Though relatively mild, it frightened me. I never imagined I could become physically and mentally dependent. I thought this only happened to people who were “weak” or lacked “self-discipline”. I was wrong.

 It was a surreal experience in addition to being scary and humbling. Surreal because I never thought this could happen to me, humbling because it exposed my vulnerability. It gave me a new perspective on those who struggle with addiction of any type. If it could happen to me, it could happen to anyone! No one is immune.

 The reality is that many of our colleagues are at risk if they are not already on a downward spiral. The pressures of medicine can cause anyone to seek an escape mechanism and substance abuse of any type is an easy way to go. I care for you and do not want any of you to fall into this seductive trap. The consequences are devastating. So, I share my story, not knowing how you will respond to it, whether it will change your view of me, or even question my fitness to be a leader. My fervent desire is that it will make this crisis more personal and thus more real to you. Only then can you better know the enemy you face and how best to defeat it.

 Andy Lamb, MD

A Matter of Honor

 

A few years ago, I went to my 40^th West Point class reunion. I had a wonderful time especially renewing friendships with those with whom I lived, studied, and trained during those four arduous years. We truly were “a band of brothers”. 44 years later my time at West Point continues to significantly define who I am today.

 While at the reunion, I was interviewed by West Point’s Center for Oral History as a result of my experiences while a cadet, in particular during the Honor Scandal of 1976. At the time, it was a huge event receiving national attention and threatening to destroy the very foundation that makes West Point great - it’s Honor Code. Though innocent, I was caught in the middle of it. I found myself in a battle to prove my innocence and defend my honor. Instead of being innocent until proven guilty, I was guilty until proven innocent. It was a terrible, transformative time.

 The honor scandal involved an electrical engineering exam that my entire class took just before Spring Break my Junior year. This was a take-home test, yet, as was true with any work at West Point, you were honor bound to not ask for or received any help from anyone, no matter how minor. If you did, you were required to footnote the help you received and your grade was reduced accordingly. Many of my classmates, for reasons known only to them, chose to help each other and not footnote that help. Thus, they had violated the code. An investigation of epic proportions ensued.

 In the months that followed, I and others under investigation, were moved to barracks separate from the rest of the Corps of Cadets; relieved of leadership responsibilities within the Corps for the summer; assigned a lawyer; and given a trial date. The first time I met my lawyer he told me I had a 20% chance of being found innocent! I was shocked to my core. I responded, “Sir, you’re telling me, someone who is completely innocent, that I have only a 20% chance of being found innocent?” He reminded me that up to that time, scores of my classmates had gone before the Honor Committee and all had been found guilty and dismissed. It was the lowest, darkest time of my life. To be accused of something you did not do is one the worst things that can happen to a person.

 My lawyer came to believe in my innocence and so began a many - months fight to prove it. I won this battle, but at great emotional cost. I was extremely embittered toward West Point and all it represented. It was an institution that prided itself on over 200 years of unparalleled education, military, leadership, and character training. Yet I, and many other innocent classmates, were caught up in an investigation that became a witch hunt. Eventually, hundreds of us were investigated and over 150 found guilty and dismissed. It left a chasm within my class that to this day has not completely healed.

 The day I graduated was bittersweet for me. I was happy beyond words to have survived the blood, sweat, and tears of my four years there. But I was also extremely bitter toward West Point. When I drove my car through Thayer gate into “freedom”, I intentionally flipped my rearview mirror up so I would not see a trace of it. I was so angry I refused to wear my class ring for years. I was not convinced that what I had been through had been worth it. Eventually, with time, bad memories begin to fade and my anger softened. With my acceptance to medical school, I realized the critical role West Point played in opening that door for me. I came to understand that all the pain and sacrifice had been worth it.

 I am a better person for having gone through that most difficult time. As a result, I have a strong sense of justice and a resolve to be a man of honor and integrity, living up to the West Point motto “Duty, Honor, Country”. As a leader, I continually seek to create a culture of respect that allows people to do what they  do best, better, and to reach their fullest potential!

 Andy Lamb, MD