Extraordinary knowing: Remen excerpt #13

Dr. Remen writes: In response to an invitation to remember a moment in the practice of medicine that might be considered a sacred experience, a seasoned neonatologist, the director of the neonatal unit at a large southern hospital, offered a group of colleagues this account. After weeks of struggle, her patient, a tine premature baby, was dying despite everything that a state-of-the art intensive care nursery could offer. It would not be long and it was time for the parents to say good-bye. With a heavy hear she called the baby’s father and invited him to meet her at the hospital. The child’s mother, distraught after weeks of uncertainty, now required medication. She had stopped visiting a few weeks ago. He would come alone, he said.

As she put down the phone, she became aware of the beeping of the monitors and other machines and the bustle of the  intensive care nursery and felt the need for some quiet to organize her thoughts while she waited for him to arrive. She went down the hall to the chapel, the only quiet place nearby, to be along for a few minutes and find words to tell the young father that his little son was not going to make it.

Fifteen minutes later, as she was walking toward the visitors’ waiting room, she found herself thinking that perhaps she should give the baby a trial with a certain drug. The thought surprised her, as this drug was not customarily used for the baby’s problem, and she shook her head in annoyance. But the strange thought would. Not easily go away. She reviewed the baby’s course with the father, assuring him that everything possible had been done and suggesting they go to the intensive care nursery together to say good-bye. As she looked at the sadness in his face, she found herself thinking ;After all, what does it matter?’ and suggested that perhaps there was one more thing she could try, a drug not usually given for this condition, but which she was thinking of using now. She would like to have his permission to use it. He gave this readily and they went to the nursery together.

The baby appeared moribund. Embarrassed to make so unusual a request of the nurses, she prepared the injection and administered it herself. Together she and the father waited, standing on either side of the Isolette, watching the blue and gasping baby. There was no change. Wanting to give him a chance to be alone with his child for the last time, she left to do some paperwork. A few hours later, she looked into the unit and was surprised to see him still there. She approached the Isolette and found that the infant’s tiny chest had slowed and his breathing was normal. Scarcely able to believe her yes, she raised her head and found the father looking at her. Their eyes held for a long, wordless moment. This was the moment she had chosen to tell us about as a ‘sacred’ moment. Recently these parents brought their child back to visit her. He is twelve years old.

The circle of physicians sat thinking about this for a while. Then the neonatologist began to describe the way in which she had dealt with this strange happening at the time. She has a very orderly and pragmatic mind, she told us, and it had disturbed her. She had tried to find an explanation for it so she could dismiss it. Gradually she became convinced that somewhere she had read or hear a preliminary report of research which mentioned the use of this drug for the baby’s condition and this was why she had thought of it. She could not remember the journal or the meeting where she had gotten this information, but she became more and more certain that it was so. This allowed her to forget the whole thing.

About two years later, she read of a study of premature infants with severe respiratory distress who had been given this very drug and had recovered. The mystery was solved! Delighted, she called the researchers to ask where they had published their preliminary reports or presented their work in progress. She was stunned to discover that this article was the first time the study  had been written up or presented anywhere. It had just been too odd to talk about until the results were final. She told them then that she had an additional case.

 

In musing aloud about her personal reactions, she told us that she had clung to an explanation that would have allowed her to keep her familiar and comfortable sense of the way in which the world works. She had rejected the gift of awe once, so it had been given to her again.

 

Rachel Naomi Remen, M.D., Kitchen Table Wisdom: Stories That Heal (Riverhead books, 1996), page 318. 

A vision before death: Remen excerpt #12

Dr. Remen writes: My given name is Rachel. I was named after my mother’s mother. For the first fifty years of my life, I was called by another name, Naomi, which is my middle name. When I was in my middle forties, my mother, who was at that time almost eighty-five, elected to have coronary bypass surgery. The surgery was extremely difficult and only partly successful. For days my mother lay with two dozen others in the coronary intensive-care unit of one of our major hospitals. For the first week she was unconscious, peering over the edge of life, breathed by a ventilator. I was awed at the brutality of this surgery and the capacity of the body, even in great age, to endure such a major intervention.

When she finally regained consciousness, she was profoundly disoriented and often did not know who I, her only child, was. The nurses were reassuring. We see this sort of thing often, they told me. They called in Intensive care Psychosis and explained that in this environment of beeping machines and constant artificial light, elderly people with no familiar cues often go adrift. Nonetheless I was concerned. Not only did Mom not know me but she was hallucinating, seeing things crawling on her bed and feeling water run down her back.

Days went by and my mother slowly improved physically although her mental state continued to be uncertain. The nurses began correcting her when she mistook them for people from her past, insisting that the birds she saw flying a d singing in the room were not there. They encouraged me to correct her as well, telling me this was the only way she might return to what was real.

I remember one visit shortly before she left the intensive care unit. I greeted her asking if she knew who I was. ‘Yet,’ she said with warmth. ‘You are my beloved child.’ Comforted, I turned to sit on the only chair in her room but she stopped me. ‘Don’t sit there’ Doubtfully I looked at the chair again. ‘But why not?’

‘Rachel is sitting there,’ she said. I turned back to my mother. It was obvious that she saw quite clearly something I could not see.

Despite the frown of the special nurse who was adjusting my mother’s IV, I went into the hall, brought back another chair, and sat down on it. My mother looked at me and the empty chair next to me with great tenderness. Calling me by my given name for the first time, she introduced me to her visitor: ‘Rachel,’ she said. ‘This is Rachel.’

My mother began to tell her mother Rachel about my childhood and her pride in the person I had become. Her experience of Rachel’s presence was so convincing that I found myself wondering why I could not see here. It was more than a little unnerving. And very moving. Periodically she would appear to listen and then she would tell me of my grandmother’s reaction to what she had told her. They spoke of people I had never met in the familiar way of gossip: my great-grandfather David and his brothers, my great-granduncles, who were handsome men and great horsemen. ‘Devil,’ said my mother, laughing and nodding her head to the empty chair. She explained to her mother why she had given me her name, her hope for my kindness of heart, and apologized for my father who had insisted on calling me by my middle name, which had come from his side of our family. Exhausted by all this conversation, my mother lay back on her pillows and closed her eyes briefly. When she opened them again, she smiled at me and the empty chair. ‘I’m so glad you are both her now,’ she said. ‘One of you will take me home.’ Then she closed her eyes again and drifted off to sleep. It was my grandmother who took her home.

This experience, disturbing as it was for me at the time, seemed deeply comforting to my mother and became something I revisited again and again after she died. I had survived many years of chronic illness and physical limitation. I had been one of the few women in my class  at medical school in the fifties, one of the few women on the faculty at the Stanford medical school in the sixties. I was expert at dealing with limitations and challenges of various sorts. I had not succeeded through loving kindness. Over a period of time, I came to realize that despite my successes I had perhaps lost something of importance. When I turned fifty, I began asking people to call me Rachel, my real name.

 

Rachel Naomi Remen, M.D., Kitchen Table Wisdom: Stories That Heal (Riverhead books, 1996), page 314. 

Witnessing the unexplainable: Remen excerpt #11

For the last ten years of his life, Tim’s father had Alzheimer’s disease. Despite the devoted care of Tim’s mother, he had slowly deteriorated until he had become a sort of walking vegetable. He was unable to speak and was fed, clothed, and cared for as if he were a very young child. As Tim and his brother grew older, they would stay with their father for brief periods of time while their mother took care of the needs of the household. 

One Sunday, while she was out doing the shopping, the boys, then fifteen and seventeen, watched football as their father sat nearby in a chair. Suddenly, he slumped forward and fell to the floor. Both sons realized immediately that something was terribly wrong. His color was gray and his breath uneven and rasping. Frightened, Tim’s older brother told him to call 911. Before he could respond, a voice he had not heard in ten year, a voice he could barely remember, interrupted, ‘Don’t call 911, son. Tell your mother that I love her. Tell her that I am all right.’ And Tim’s father died.

Tim, a cardiologist, looked around the room at the group of doctors mesmerized by this story. ‘Because he died unexpectedly at home, the law required that we have an autopsy,’ he told us quietly. ‘My father’s brain was almost entirely destroyed by this disease. For many years, I have asked myself, ‘Who spoke?’ I have never found even the slightest help from any medical textbook. I am no close to knowing this now than I was then but carrying this question with me reminds me of something important, something I do not want to forget. Much of life can never be explained but only witnessed.”

Rachel Naomi Remen, M.D., Kitchen Table Wisdom: Stories That Heal (Riverhead books, 1996), pages 300-301.

Life is filled with mystery: Remen excerpt #10

Rachel Naomi Remen writes: I am not much of a meditator. No matter. I have come to suspect that life itself may be a spiritual practice. The process of daily living seems able to refine the quality of our humanity over time. There are many people whose awakening to larger realities comes through the experiences of ordinary life, through parenting, through work, through friendship, through illness, or just in some elevator somewhere.

The recognition that the world is sacred is one of the most empowering of the many realizations that may occur to people with life-threatening illness and those close to them, their friends, family or even their health professionals. It is one of the ways that such people heal the community around them. And should they die, it is often the legacy they leave behind.

After years of trading mystery for mastery, it was hard and even frightening to stop offering myself reasonable explanations for some of the things that I observed and that others told me, and simply take them as they are. ‘I don’t know’ had long been a statement of shame, or personal and professional failing. In all of my training I do not recall hearing it said aloud even once.

But as I listened to more and more people with life-threatening illness tell their stories, not knowing simply became a matter of integrity. Things happened. And the explanations I offered myself became increasingly hollow, like a child whistling in the dark. The truth was that very often I didn’t know and couldn’t explain, and finally, weighed down by the many, many instances of the mysterious which are such an integral part of illness and healing, I surrendered. It was a moment of awakening.

For the first time, I became curious about the things I had been unwilling to see before, more sensitive to inconsistencies I had glibly explained or successfully ignored, more willing to ask people questions and draw them out about stories I would have otherwise dismissed. What I have found in the end was that the life I had defended as a doctor as precious was also Holy.

I no longer feel that life is ordinary. Everyday life is filled with mystery. The things we know are only a small part of the things we cannot know but can only glimpse. Yet even the smallest of glimpses can sustain us.

Mystery seems to have the power to comfort, to offer hope, and to lend meaning in times of loss and pain. In surprising ways, it is the mysterious that strengthens us at such times. I used to try to offer people certainty in times which were not at all certain and could not be made certain. I now just offer my companionship and share my sense of mystery, of the possible, of wonder. After twenty years of working with people with cancer, I find it possible to neither doubt nor accept the unproveable but simply to remain open and wait.

I accept that I may never know where truth lies in such matters. The most important questions don’t seem to have ready answers. But the questions themselves have a healing power when they are shared. An answer is an invitation to stop thinking about something, to stop wondering. Life has no such stopping places; life is a process whose every event is connected to the moment that just went by. And unanswered question is a fine traveling companion. It sharpens your eye for the road.

 

Rachel Naomi Remen, M.D., Kitchen Table Wisdom: Stories That Heal (Riverhead books, 1996), pages 288, 292-293.

Pray to serve a holy purpose: Remen excerpt #9

Rachel Naomi Remen writes: A patient of mine who is very ill was recently told by his oncologist that there was nothing more that could be done for him. The physician then said, ‘I think you’d better start praying.’ For this doctor, prayer has become a kind of last resort, something to offer his patients when he runs out of ways to help them personally, where there are no more effective treatments. God has become his final referral.

But prayer is not a way to get what we want to happen, like the remote control that comes with the television set. I think that prayer may be less about asking for the things we are attached to than it is about relinquishing our attachments in some way. It can take us beyond fear, which is an attachment, and beyond hope, which is another form of attachment. It can help us remember the nature of the world and the nature of life, not on an intellectual level but in a deep and experiential way. When we pray, we don’t change the world, we change ourselves. We change our consciousness. We move from an individual, isolated making-things-happen kind of consciousness to a connection on the deepest level with the largest possible reality. And then the question ‘How did you become well?’ becomes more a question about mystery than about efficacy. A very different kind of question.

At its deepest, prayer is a statement about causality. Turning toward prayer is a release from the arrogance and vulnerability of an isolated and individual causality. When we pray, we stop trying to control life and remember that we belong to life. It is an opportunity to experience humility and recognize grace.

Sometimes the most powerful prayers are also the most simple. Once, when I was lying on an operating table waiting for anesthesia, one of my surgeons took my hand and asked if I would join him and his operating team in a prayer. Startled, I nodded. He gathered the team around the operating table for a moment of silence, after which he quietly said, ‘May we be helped to do here whatever is most right.’

This traditional American Indian prayer seems such a simple of relinquishing ultimate causality. By means of it, in operating room equipped with the latest technology, we were not alone in the house. The comfort my surgeon offered me was very genuine. I felt my fears about outcome slip away and went under anesthesia holding on to those few words with the deepest sense of peace. Like all genuine prayers, this prayer is a powerful way of embracing life, finding a home in any outcome, and remembering that there may be reasons beyond reason.

Prayer is a movement from mastery to mystery. I used to pray for my patients. These days I pray for myself, too. Sometimes I pray for compassion, but often I pray for harmlessness, the great spiritual quality embodied in the Hippocratic oath. As a human being, I know I can never hope to have the depth and breadth of perspective to know whether any of my actions will ultimately harm or heal. Yet it is my hope I may be used to serve a holy purpose without ever knowing. So sometimes, before I see a patient, I offer up a little wordless prayer: Understanding the suffering is beyond me. Understanding the healing is, too. But in this moment, I am here. Use me. 

 

Rachel Naomi Remen, M.D., Kitchen Table Wisdom: Stories That Heal (Riverhead books, 1996), pages 270-272. 

Discovering grace within: Remen excerpt #8

Rachel Naomi Remen writes: The shamans attribute illness to soul loss, a loss of a sense of awareness of the sacred in us and around us. Sacred experience is subjective and even intuitive experience. Growing up in this culture, many people have developed and cultivated a harder-edged notion of what is real. Few of us can easily talk about those things we cannot touch or express in numbers, no matter how commonplace the experience. And the experience of God is commonplace. God is in the ordinary, the minute particulars. When you come right down to it, all life is holy. What is most real may be those very things which cannot be expressed at all but only known.

The experience of immeasurable realities is far more important than we might imagine. The things we cannot measure may be the things that ultimately sustain our lives. Much recent medical research suggest that isolation makes us vulnerable to illness and that relationship furthers survival. Medical science has demonstrated that our simple caring for each other sustains us and enables us to better survive even such physical challenges as metastatic breast cancer. Community heals. Yet when it comes to healing relationship, who’s to say that communion isn’t as important as community.

A diagnosis of life-threatening illness casts us headlong into the subjective world. People who have sought healing everywhere else are often afraid to look within, afraid to find, at depth, someone insignificant or even unworthy. Yet this is rarely the case. The soul is our birthright. At depth, everyone is beautiful. Often it is the discovery of the ‘spot of grace’ that heralds the beginning of our deepest healing.

 

Rachel Naomi Remen, M.D., Kitchen Table Wisdom: Stories That Heal (Riverhead books, 1996), pages 261-62.

Trusting has great power: Remen excerpt #7

Dr Remen writes: ‘Human being’ is more a verb than a noun. Each of us is unfinished, a work in progress. Perhaps it would be most accurate to add the word ’yet’ to all our assessments of ourselves and each other. 

If life is a process, all judgments are provisional. We can’t judge something until it is finished. No one has won or lost until the race is over.

‘Broken’ may be only a stage in a process. A bud is not a broken rose. Only lifeless things are broken. Perhaps the unique process which is a human being is never over.

In our instinctive attachments, our fear of change, and our wish for certainty and permanence, we may undercut the impermanence, which is our greatest strength, our most fundamental identity. Without impermanence, there is no process. The nature of life is change. All hope is based on process.

Naming a disease has limited usefulness. It does not capture life or even reflect it accurately. Illness, on the other hand, is a process, like life is.

Seeing the life force in human beings brings medicine closer to gardening than to carpentry. I don’t fix a rosebush. A rosebush is a living process, and as a student of that process, I can learn to prune, to nurture and cooperate with it in ways that allow it best to ‘happen,’ to maximize the life force in it even in the presence of disease.

Simply trusting process has a great power. The trust of process that comes from personal knowledge and experience is really the foundation of helping and comforting one another. Without it all of our actions are driven by fear. Fear is the friction in all transitions.

Holding and conveying a sense of possibility does not mean making demands or having expectations. It may mean having no expectations, but simply being open to whatever promise the situation may hold and remembering the inability of anyone to know the future. Thoreau said that we must awaken and stay awake not by mechanical means, but by a constant expectation of the dawn. 

There’s no need to demand the dawn, the dawn is simply a matter of time. And patience. And the dawn may look quite different from the story we tell ourselves about it. My experience has shown me the wisdom of remaining open to the possibility of growth in any and all circumstances, without ever knowing what shape that growth may take.

Rachel Naomi Remen, M.D., Kitchen Table Wisdom: Stories That Heal (Riverhead books, 1996), pages 223-225, 231.