perseverance

It's been such a long time since my last entry that it feels a bit strange making time to sit down in front of the screen and sort out my thoughts...  A quick update would be that I'm now specializing in Emergency Medicine after finishing my two years of basic training.  I entered my fourth decade of life as I experienced failed relationships that left me slightly more unencouraged and less confident each time, and perhaps making me all the more persistent to pass the US licensing exam to confirm that efforts really did matter, and to regain control in my life again.  I carried around a thick textbook whose heavy weight eventually became a reminder of how much the small challenge meant to me.  It was February 2020 by the time I literally got it off my shoulders, and the world had entered the age of the Corona pandemic which ended up exposing various weaknesses and strengths of our societies.

My experience in EM so far has been closer to urgent care, so I haven't had to deal with moral dilemmas of choosing one life over another.  Up till now the closest I've gotten to the virus have been when a patient comes in with a totally different complaint and unexpectedly has pneumonia; his condition would sometimes unexpectedly worsen to the point where he has to be intubated and sent to another hospital with a CV line, by an ambulance that "kind of" quarantines the patient under a plastic tent that has an opening around the patient's head so that the doctor can check on him while the car drives to an available hospital that's forty to sixty minutes away...

But then while I worked through those shifts and rewrote my CV in the hopes of maybe applying for a new hospital, my uncle a couple prefectures away had a brain hemorrhage, Haruma Miura committed suicide, and two physicians got arrested assisting the death of a woman suffering from ALS - the latter two happening this month and urging me to come back here to write this entry.

Earlier this month, I had received a call early in the morning from a wife of a patient who was apparently experiencing symptoms that sounded like paralysis.  After checking his chart and finding out he lived more than an hour away from our hospital, I suggested they call an ambulance and go to a nearby hospital, which they did - except that the doctors found nothing new on the MRI.  He was sent back home, only to start seizing thirty minutes later, which is what I found out when I got another call from the wife around five pm, asking what to do.  I suggested another ambulance call, and this time, the EMS decided it wasn't a stroke, and came all the way to our hospital where he'd had regular visits for other conditions.  He was unconscious in a decerebrate state by the time he arrived.

The neurologist who came down to the ER happened to be one of my attendings during my neurology rotation three years prior, with whom I had worked on a case study of a patient who died of a rupture of dolicoectasia, a vascular malformation.  It turned out to be a very interesting coincidence, as the ER patient happened to have the same vascular malformation, which caused a brainstem infarction, and ended up with locked in syndrome.

When I visited the patient a week later, communication was minimal as the only parts of the body he could move were his eyes, eyelids, and vocal chords.  His tongue and mouth movement were not enough to pronounce words.  He would blink every time the answer to my question was "yes", and would cry uncontrollably when I mentioned the words "wife" and "family".  My former neurology attending told me that the patient had told his wife beforehand that he did not want any life prolonging measures to be taken if this kind of situation occurred.  "It's really heartbreaking; he can't even commit suicide," the neurologist said, as we headed back to each of our departments.  I didn't ask if he had actually had a talk with the patient to find out if that was what he truly wanted at that point.

I don't remember what the case was for the young protagonist diagnosed with ALS in the Japanese TV series, "The Time I was Here".  I probably wouldn't have even recalled the series had the actor, Haruma Miura, not died the other day, alone in an apartment building only a few minutes away from the hospital I work at.  In spite of the fact that I wasn't particularly a fan of his, the news evoked sadness as if an old classmate had committed suicide.  I was shocked, and even a bit hurt.  I woke up in the dark, thinking of his unbearable loneliness; imagined him trembling as he hung himself in the same darkness.  Some people might say it was wrong; I think he may have focused too much on himself while he stayed home during quarantine, he may have saved himself with a tiny change of perspective, but who are we to judge his judgement?  He was the only one who could live his life - success, failure, loneliness and all.  It was his life, and he'd had the right to end it on his own terms.

Which takes me back to the issue of euthanasia.  Marieke Vervoort, the Belgian athlete who ended her life last year said she may have committed suicide had she not had the option of euthanasia.  The knowledge that she could end it all gave her mind a sense of peace and helped her live up to her limits despite her intolerable pain.

ALS doesn't cause physical pain like what Vervoort went through but the psychological pain is unmeasurable, as each patient has different scales: some people decide to live with a ventilator; needing help from other people and machines may not necessarily deprive them of their dignity -- perhaps they're very good at redefining their identity.  But to some people, not being able to do things on their own feels like losing a big part of themselves.

I still haven't had the chance to meet my uncle after his stroke, but my grandmother gave us a call telling us her son has been rejecting rehabilitation; he still has a long way until he accepts his new self, if he ever will...  The biggest problem I find in the recent assisted death in Japan is not exactly that the woman chose euthanasia but that the two doctors (one of which wasn't even a doctor) didn't follow the proper steps in evaluating her will.  There seemed to be much more room for discussion, and she also could've changed her mind at the very last moment, but there is no way to confirm at this point.

Regarding my own life, I don't think I was terribly happy during the past three years.  After spending a particularly depressing time last year both career-wise and relationship-wise, one thing I've been trying to remind myself lately is not to be too greedy.  It's better for my mental health not to chase after chances I don't get, people who walk away, things in the past I was too young to see the true values of.  There will always be another chance, another person that would come to me, maybe not now, and maybe not in the form I expect, but I must believe there will be a better future when I'm not quite happy with my current situation.  Because good things take time.

The following passage is from an article I came across when I ended my last relationship ("After the Beginning, depression or disappointment"): "There's nothing like thinking that you have failed at love to sharpen your knowledge that life is uncertain and the clock is relentlessly ticking.  One tends to ask oneself, if this relationship won't work, will I ever find one that does?  Disappointment measures the passing of time as a fall.  It is one of our harsh reminders of solitude and aging and mortality."

The writer continues: "Here's where the difference between depression and disappointment becomes crucial.  Faced with the prospect of loss, the depressed bypasses disappointment and rushes to the end of the story, even before the story begins.  All is failure, decay, rejection.  When spring begins, the depressive is already dreading the leaves turning brown and falling off the trees... ...it's a way of saying this imperfect difficult world is not good enough for me.  Give me paradise or give me death... ...depression makes the world utterly gray and uninteresting.  Then you can tell yourself, what's the use of trying?"

"The disappointed person lingers, however painfully, in the middle of the story, even though paradise has slipped through his fingers.  Disappointment keeps you connected to life as it continues to unfold and places an important choice in front of you... ...Neither a utopian outcome nor easy success nor bliss in love is just around the corner.  Life is more difficult than you thought.  The question is, what next?  Are you going to take on the vital forces of life, despite limitations and imperfections, or pull the covers over your head as an exit strategy? ...with disappointment, the plot is still taking shape, even though there may be hard work to do."

A couple weeks ago I stumbled upon a book review on amazon while I sat at the hair dresser for the first time in eight months.  It was the most popular review on a Japanese best seller book about a half Asian half Caucasian teenager boy dealing with bullying, learning to accept others and himself, and finding hope despite all the problems we face, written by the boy's Japanese mother.  The review was partly about the reviewer's perspective, how she had decided to bring her own half Asian half Caucasian son to Japan instead of raising him in the UK because she didn't want her son to experience racial discrimination; "It's great to think about racism and fight against it, but what kind of parent would want her child to actually experience it first hand in order to overcome it?"  She wrote.

This remark definitely has a point; I'd want to protect my future child the best I could.  But at the same time, I don't think I'd like to live my life to end it without a single bruise or a cut.  When my life comes to an ending, I'd like to be proud of myself despite the numerous ugly wounds (--some I may never recover from); I'd like to be able to love the world as it is despite the numerous suffering it imposed on me.  That, I feel would bring a deeper, greater satisfaction, compared to what one would experience from a life lived in a happy bubble.  Death may indeed feel like a reward when one reaches that kind of deep love despite the suffering or even because of it; that emotion would connect one to the world and enable one to become truly part of it even in the face of, or after one's death -- the deceased will go on in the form of a greater entity, that is, the world he truly loved.

So I guess my motto has slightly changed from the time I started this blog -- until the day comes, I'll try to dance like nobody's watching, love like I've never been hurt, sing like nobody's listening, and live accepting it's not always heaven on earth but still believing it deserves all my love.

update

I've been away for a long time so I don't know if there is anyone still reading this blog, but in case anyone's wondering, I wanted to let you know that I've graduated med school and have become a doctor.  I've started working at a hospital in Tokyo, and it's been a great experience.

I haven't been writing at all these days; I actually don't feel the urge anymore.  Whether that is a good thing or a bad thing, I don't know...  I still feel like some day I might come back with stories I want to share, but for now, I'm busy living each day, getting used to being a doctor, and finding out what life actually is!  Now that I'm finally working and interacting with people, all the things I read in books and all the thoughts I used to have seem to fade in color.

I think my sense of value has changed a bit.  I used to wonder what it would feel like to actually become a doctor and work day and night.  I used to worry about becoming one of those "disposable" doctors -- that if I quit, someone else would replace me easily.  It's true, especially since I'm still a useless resident.  But it doesn't bother me as much as I thought it would.  In short, I think I've finally accepted the obvious fact that I'm not special.  If I meet a patient though, if I meet someone I can relate to, someone I can help, that encounter IS special, and nothing can replace that one encounter.

When you're really sick, you can't really focus on anything.  When you have a strained back, all you can think of is the pain in your back; if you have a painful hemmoroid, your butt hole becomes the center of your world; you forget about your favorite book, how to appreciate your favorite painting, your favorite piece of music, and you can't focus on all the things that make you you.  But being a (good) doctor would enable me to bring you back to being a human, to being yourself again, and I think that's a huge honor.  I'd always dreamed of writing someone's favorite book, but I feel like it doesn't really matter anymore.  For now, I'm really happy with what I have.

is it so wrong to eat meat?

I haven't written here in a looong time, and so much happened while I was away that I'm not sure why I'm here to write about whether it's right to eat meat, but that's what I'm going to write about anyway.  The subject has been bothering me since a couple of days ago when a good friend of mine sent me a link to a video titled "Best Speech You Will Ever Hear" by Gary something.  I had been in Boston for two months (first time being outside of Japan in fifteen years!) and was surprised to find the vegan version of everything!  I never thought so much about it while I was there; I just felt like consumer autonomy was much stronger in America with so many choices (compared to Japan where I guess would be difficult to lead a completely vegan lifestyle).  But now that I've watched a couple of videos and read a couple of articles made and written by vegans, I couldn't help the urge to write down the stuff I personally found kind of odd, just to get it off my chest.

Firstly, it really bothers me that some vegans make it sound like there is a strong link between how a human treats animals and how he would treat other humans.  Gary makes it sound like animal lovers are peaceful loving beings while meat eaters are baby Nazis (if not full grown Nazis).  If that's true, I'd like to ask why Western countries that consume more meat are generally more concerned about human rights, compared to Asian "vegan" countries.

And I don't think it's totally wrong to say that we eat meat because we're part of the food chain.  Every creature on this planet is part of the chain, right?  Given our intelligence, we found a way to farm animals (which might seem upsetting because no other animal does it), but any species with the same intelligence would have done the same, because it's an easier (if not better) way to survive.  Of course, we should make sure that animals are treated well until they are slaughtered, and I agree that there is no "humane" way to kill an animal, but we have the technology to make sure that the suffering of a cow being killed by a human is at least better than that of a gazelle being killed by a lion.

As for the health aspect, I haven't looked into enough studies to say whether meat increases or decreases human life span, but it's a famous fact that the Japanese average life span increased and became #1 in the world only after WWII when American style cuisine came into Japan and the consumption of meat rose dramatically among the Japanese population.  Also, it's commonly said in Japan that eating meat is the easiest way to make sure you're taking in certain amino acids that you'd otherwise lack if you were to only eat plants.

I realize there are farmers that mistreat animals, and this is a huge problem that needs to be addressed.  As consumers, we should always remember that our lives stand upon the sacrifice of other lives that we do not necessarily see.  But becoming a vegan?  I need to find more data before deciding on that.  It's really a shame that so many vegans put emphasis on the emotional aspect and keep showing videos of animals treated badly.  I wonder what they think about all the animals killed in labs.  I agree humans are not "superior" or "special", but does that mean we're supposed to sit on our hands and watch our fellow sick humans die because we're not superior and we're not supposed to experiment with mice to save human lives?

If animal protein is necessary to pursue better survival, the sacrifice is necessary to some extent.  Or is it human ego to pursue a longer life?  Should we simply accept a shorter life if that saves animals?  It surprises me that so many people found Gary's speech convincing.  If I had been shown the proof that becoming a vegan guaranteed better survival, I would've turned a vegan overnight.  Without solid data though, his speech was just emotionally controlling in my opinion.

every life

Two weeks ago, we visited a hospital far in the mountains where they took care of children who were mentally and physically handicapped severely.  It was sad to read their charts, how some of them ended up there -- some parents didn't want to take care of them anymore because their handicap was too much to handle, while others hadn't wanted them in the first place, abusing them until they had to be hospitalized.

But what also shocked me was when I saw full grown adults who weren't all that different from the children -- just a bit larger in size.  With medicine's advancement, the severely handicapped children can now grow up and live on to become adults.  It must be something to be celebrated.  But to be totally honest, I felt this unfathomable sadness when I saw the adults lying side by side on the futons, hardly able to move, not being able to say one word.  I was embarrassed to feel that way, because who was I to decide that they were unhappy or that they couldn't even tell if they were happy or not?

Back in the university hospital, the doctors were discussing what they should do about a two year old boy with cerebral palsy whose mother had left the hospital without notice.  The boy was so small, soundly asleep in the hospital's large bed, and I thought about the adults I saw in the hospital in the mountains, the future versions of the little boy.  Of course, the doctors had done their best to save him, and were still trying to find the best place for him to live.

Because every life is worth living.  Every life.

sacrifice

-- Sacrifice is the spirit of love

Summer vacation has almost come to an end, and as I traveled back, I finished reading 犠牲(sacrifice) written by Kunio Yanagida (published the same year Into the Wild was).  It's an essay about his son, Yojiro, who committed suicide at the age of 25 after suffering metal illness for more than a decade.  One of his problems being anthropophobia, it was difficult for him to get a job, and thus he despaired that he had nothing he could give to society.

At the same time, he was deeply moved by one of Tarkovsky's films, Sacrifice, which expresses the belief that the reason we can live today in peace is due to "the sacrifice of a nameless person who lives somewhere under the broad blue sky".  When Yanagida finds his son brain dead, he agrees to donate his kidneys as a token of Yojiro's existence, thinking that this kind of 'sacrifice' was what he had always wanted.

One of the things Yojiro feared most was oblivion -- the fact that when one dies, even the fact that he lived and suffered will be forgotten and deleted from history.  A character from a book I read last summer states the exact same thing, to which the protagonist retorts that he should get over the fear, because "there was a time before organisms experienced consciousness, and there will be time after".  Her point is that even if some people remember you after your death, they too are going to die, and in the end, there will be no one remaining to remember you anyway.  This logic applies even to the world's most famous person, because at some point, the human species will extinct, and the planet will collapse.

I guess it's a decent argument, but obviously, the truth that everyone dies doesn't really liberate you from the fear of death.  Logically, I understand that everything is going to disappear one day, that it's nonsense to dwell on whether or not you will survive death for what amounts to less than a fraction of a second in geological time.  But emotionally, I still fear the possibility of dying leaving nothing behind.  I want to give my life some kind of meaning, and I think a lot of people do, including my mother.

To tell the truth, I'm a terrible daughter -- deep down in my heart, I have not always respected her.  I've told her more than once that I will never live a life like hers, and that I was 'different'.  Apart from the years she spent working as a language teacher, she has worked as a full time housewife, and since she started seeing her 60th birthday coming around the corner, she started asking herself (and her family) the meaning of her own life.  She suddenly realized she had no personal accomplishments, and began questioning the value and meaning of her 'self-sacrifice'.

Now I realize that the real reason I sometimes have a hard time respecting my mother is only because she is too busy imagining what she could've become and regretting what she could've done that she sadly fails to see the meaning of the life she has actually lived -- the whole process she calls self-sacrifice.

After reading Sacrifice (and all the other books I've read), and living my life for more than 1/4 of a century, I have come to the conclusion that the meaning of life comes from 'giving' which often requires sacrifice.  When I give, the receiving person will also give to another person, and that person will do the same and pay it forward.  We will all die, but we will all live on as a participant of a 'giving relay' as long as it goes on.

I don't know how much I will be able to give in my lifetime, how many people I will be able to help when I become a doctor, but every patient I help would not have been saved without my mother's 'sacrifice'.  Will my patients think of my mother's existence?  Most likely not; they wouldn't even remember the doctor after a while.  And does that make my mother's life meaningless?  Is she eventually going to disappear forever in cold oblivion?  I'd say yes to the latter.  But does that matter so much when the unmovable truth is that my mother's sacrifice has helped me help the patient (in some way) to live his life and pay it forward (to someone who hopefully will pay it forward)?

Yojiro, at some point, encounters the concept of "indestructibility of human existence" which appears in a passage written by Mircea Eliade, and states as follows:  Every death has contributed to the continuity of life, and my own current life is standing upon the sacrifice of numerous nameless soldiers.

We all fear oblivion because that is our final death.  It's scary to think that the evidence that we ever existed is as fragile as a drawing on sand.  But even if it is a picture on sand, there are new pictures that will not exist without it.  Our life, our sacrifice and love will always be of someone's support, and it's encouraging to think that just because we will never escape oblivion will never change that fact -- something we might call the meaning of life.

I should now call my mom and tell her how much I've appreciated her 'sacrifice'.  Because that is why I also want to live to love and give.

the cards we are dealt

We cannot change the cards we are dealt, just how we play the hand.
-- Randy Pausch

I read the rest of the book (Into the Wild) while I traveled back home, and it reminded me of the fact that many patients who came to visit the psychiatry department had divorced parents and other family issues.  McCandless doesn't seem to have suffered any mental illness, and what brought him to Alaska was his intense character and adventurous spirit combined with his love of nature, but what pushed him to the extreme -- cutting off all contacts with his family for two years, and ultimately all human contact for his "great Alaskan odyssey" -- was apparently his discovery of his father's past bigamy (which had ended a couple of years after his birth).

McCandless was never withdrawn, and he actually left some lasting memories in the hearts of many people he met in his last years, but obviously had some problems building intimate human relationships, and it seemed to stem from his parents' mistakes that made his "entire childhood seem like fiction".  Maybe he needed something to believe in, and nature -- its absolute existence and its merciless honesty -- was what he turned to.  He was apparently criticized of his arrogance for trying to live in the wild without enough preparation, but perhaps it was his naivete -- he'd put too much trust not only in himself but the wilderness as well.

The tragedy was not really the fact that such a young man had died alone in starvation, but that he had to die when he was finally ready to go back to civilization and human community -- his severe experience of developing a bond with the wilderness had somehow helped him move on and it seemed like he had just found a way to forgive his parents' imperfections and his own, but that was when one careless mistake took his life.

Then again, I found a not-so-tragic answer to what I'd been wondering when I wrote my last entry -- how he had felt when he realized he was going to die.  It reminded me of what Viktor Frankl had said in his book, about how we were always -- always -- free to choose how to react to a circumstance (and death too is one of those circumstances).  The author of the book, Krakauer observes that McCandless was unmistakingly at peace in his last picture, "serene as a monk gone to God", and I don't think it was the author's wishful thinking -- the below is what McCandless had written before deciding to walk out of the bush to possibly end his "great Alaskan odyssey".  It was shortly after he had shot a moose and regretted it due to his failure of preserving the meet and wasting it.  He'd always demanded a great deal of himself (and others) but this moose episode seems to have taught him the value of acceptance:

Consciousness of food.  Eat and cook with concentration... Holy food.

I am reborn.  This is my dawn.  Real life has just begun.
Deliberate Living: Conscious attention to the basics of life, and a constant attention to your immediate environment and its concerns, example→ A job, a task, a book; anything requiring efficient concentration (Circumstance has no value.  It is how one relates to a situation that has value.  All true meaning resides in the personal relationship to a phenomenon, what it means to you).
  The Great Holiness of FOOD, the Vital Heat.
  Positivism, the Insurpassable Joy of the Life Aesthetic.
  Reality.
  Independence.
  Finality -- Stability -- Consistency.

On a side note, the plane I took yesterday had a problem landing, and it flew past the airport into the city.  It took the staffs quite a long time to announce what the problem was, and until then, I seriously wondered if the plane had been hijacked or something, and if we were all going to die.  To be honest, I was quite upset by the thought of it, mostly because I thought my life hadn't even started yet, but after a while, I just started wondering what the last thing I had said to my mother had been.  Had I ignored her last call?  Had I been nice to her?  I was actually still holding the book in my hands but the whole McCandless story seemed to have dropped off from the surface of my brain.

After a lot of useless and unnecessary panicking and finally landing on the airport, I went straight to my grandmother's place only to find out she was sick, though it was mostly a mental thing; she is always too busy worrying about dying and feeling sick that it almost looks like she never has enough time to have fun.  When she started feeling better, I was going through a pile of books on her shelf, and she told me the novel I was holding was supposedly really good: "What was it about... yes, yes!  It teaches you how to survive!"  She hadn't read it, and I was pretty sure she never would, so I just told her maybe she could just forget about surviving for a moment, and relax.  Otherwise, I really wanted to ask her what she wanted to survive for so badly.  If she knew, I think she would stop worrying too much, but then again, I will never know how it feels to be 86 for another sixty years.

into the wild

Since I last wrote, I went through training at the neurosurgery and anesthesiology departments, and finally our first term has ended.  As soon as I came back home a couple of hours ago, I started reading Into the Wild.  I've only read 1/3 of it yet, but I'm slowly beginning to understand this Christopher McCandless -- a kid in his early twenties who ended up dying in the wilderness of Alaska in 1992 after hitchhiking for two years.  In one of the letters he wrote to people he met on the road, he talks a great deal about the importance of getting out of your comfort zone.  I've heard a lot of people talk about this, and it's a piece of advice that makes me wonder a bit if I'm nearing the end of my twenties missing out on important experiences I could've had had I chosen different ways.

I say this because I've never really tried to get out of my comfort zone in the sense McCandless did.  Some people tell me it was very brave of me to decide to switch to medicine after majoring in law, probably because I had to endure some sense of insecurity until I got a place in med school, but it wasn't a crazy plan, like ditching all my possessions and travelling to "see the world" and meet random people on the way.  I've always planned my future carefully for a stable job, a stable life, and I value stable human relationships.  And actually, I don't necessarily think it's a way of life to be criticized the way McCandless probably did:

So many people live within unhappy circumstances and yet will not take the initiative to change their situation because they are conditioned to life of security... ...nothing is more damaging to the adventurous spirit within a man than a secure future. ...The joy of life come from our encounters with new experiences, and hence there is no greater joy than to have an endlessly changing horizon, for each day to have a new and different sun.

Personally, I think it's perfectly possible to be happy with a "life of security" with no "adventures" or "new experiences" as long as you have good eyes to notice the little reasons to be happy in your sedentary repetitive existence.  But maybe it's a totally different type of happiness that you find in the wild -- "the great triumphant joy" to be alive -- and I can only imagine because I've never hitchhiked my way to Alaska, and I probably never will; that is not my dream.

Perhaps I will try to "get out of my comfort zone" in some other way at some point in my life once I start working as a doctor and gain financial freedom.  I can almost hear McCandless point out that I have totally missed the point here, but I have no courage to abandon everything and take the risk of dying alone, cold and hungry.  I cannot help but wonder if McCandless still believed in his values and the reckless choices he had made when he realized he was going to die.

Still, any life is transient, a passing phenomenon after all, and the security I value is only a borrowed hut I will have to let go anyway.  In that sense, there may be nothing to lose at any point in life.

Regarding human relationships, I've learned to value ones that don't necessarily last; it's not only those "stable relationships" I mentioned earlier that shape my life and who I am.  Sometimes, a one time encounter can make a mark on someone's life; a single memory can make someone feel glad to be alive.  But I have always valued human relationship, and there is one passage Chris wrote that has kind of opened my eyes, of course not in the same way as his "raw transcendent experiences" had opened his own eyes, but I think it's worth quoting:

You are wrong if you think Joy emanate only or principally from human relationships.  God has placed it all around us.  It is in everything and anything we might experience. ...My point is that you do not need me or anyone else around to bring this new kind of light in your life.