Bramble Ramble
My career in medicine has occasionally dampened my enthusiasm for saving lives. I have come to believe that not all lives are worth saving despite what some people believe about redemption and hope. There are stories I don’t tell because I consider sharing them to be a cruelty to the listener, but they have shaped my view of humans considerably since medical school. Paradoxically, I probably think of life as even more precious than I did when I started, having seen how fragile it is. But, nature is a cycle and death is part of that cycle. I’ve had the opportunity to see that saving a life can preserve all of the suffering that accompanies that life.
My grandfather was a bad person. The kind that repeatedly and horrifyingly abused his entire family and lied to the people he loved. Reportedly, he was also charming and good looking. I saw him once in the window of a car and my only reaction was to have trouble imagining that he was related to my own father because, as far as I could tell, they were exact opposites.
Fanny and I were taking a break below Rainbow Falls in the Smokies, sweaty and a little tired from the steadily steep trail toward the summit of Mt Leconte. I looked up as a group of six people came down the trail and began to cross the path of rocks through the creek. One of the women was holding her hand to the back of her head and I could see some blood between her fingers. Their entire group seemed to be hiking with purpose more than leisure on closer inspection. “I have medical training and supplies, if either are helpful,” I called. The mom-aged woman and her husband came over and explained that she had fallen while looking at the upper falls and that she had a nasty cut on her scalp. I told her that I was an emergency room doctor and offered to examine her if she would like me too, explaining that I would need to ask her some questions and touch her head and neck. She agreed and, while I put on some rubber gloves, I asked her enough questions to satisfy myself that she would not likely need a CT, labs, or overnight observation in a hospital. I confirmed that it was simple scalp laceration after an exam. It was only about an inch long but bleeding pretty well.
I have learned that I am capable of saying things with a degree of confidence that strangers will often trust me and be comfortable with me being in charge of chaotic situations. It’s a good skill in situations where I actually know what I’m talking about, and a dangerous one otherwise. I think many of my patients in the ER feel relief when they sense that “there’s a plan” thanks to the confidence that I have learned to project. I have often wondered about the on/off quality with which I can use this type of charisma and whether it is a vestige of my grandfather’s sociopathic disorder; especially when combined with my comfort at doing painful things to people when necessary. Sociopaths are charming, convincing, and comfortable with violence; oddly these are useful things in an ER. Being married to a psychiatrist probably gives me more opportunities to think about this than most ER doctors, but Fanny has seen the switch that happens when I need to take control of a situation and rolls her eyes at how effective it is. Most of my close friends have been around when Dr Josh was called for and, usefully for my ego, are good at making fun of me for it. Some nurses I work with have caught on too and do a pretty good impression that goes like “Big words, big words, deep voice, it’s all fine and getting better and there’s no need to worry, would you like a warm blanket?” But it works and, most of the time in the ER, I really do know what’s going on as well as anybody could.
After making sure that she didn’t really need anything other than wound care, I said, “Well, you have a laceration that requires either stitches or staples. It’s safe to hike out and go to an urgent care if you keep pressure on it. But I’ll make you an odd offer. If you want, I can staple it up right here and you can be done with it.” She looked at her husband and I quietly waited out the do-we-trust-this-sweaty-guy-in-the-woods thoughts that were flowing between them. They quickly took me up on the offer and Fanny rolled her eyes and said, “I’ll irrigate with the CamelBack”, because we have been in this situation before. As a psychiatrist, she gets stuck with the assistant role in emergent care. We do have a fairly standard joke where she asks the patient, “Now tell me how you’re feeling about this injury” which always gets a laugh.
Women are generally much more pain tolerant than men except for professional jockeys who lack pain receptors altogether. This woman had had two children without medication and had been through breast cancer, so I had zero concerns that a few staples were gonna be much for her to deal with. They went in easily and she tolerated well. Fanny later said she thought they could have been straighter but she also routinely reloads the dishwasher after I have loaded it in accordance with her personal notions about divine order in the universe.
As we were telling them goodbye and I was enjoying having the skills and the tools to help someone, an older gentleman in their group pulled me to the side and said, “Just five minutes ago we all stopped and prayed for help, we were so worried. You answered our prayers.” I can imagine God on the other end of this prayer, realizing that the only help he could offer these poor Christians was a heresy-spouting heathen with a skin stapler and no anesthetic. I guess we all move in mysterious ways when we are short on time and tools.
Saints and sinners share a disregard for the status quo. Whereas my grandfather on my father’s side was a sociopath before the term was used often, my grandfather on my mother’s side was a preacher and a carpenter who raised four daughters and two sons at home. The older I get and become increasingly convinced that we are products of our environment as much as our own will, the more I wonder about this mixed lineage. Ancestors matter. You can’t change the past without changing the present. How do we incorporate the disparate influences of our past?
We headed up the trail, short on time and with a few more steep miles to go. Fanny had gotten ahold of a last minute cancellation for the Mt Le Conte lodge. We had to get there by six o’clock to make dinner and we had gotten a late start. It takes some time and some good friends to get rid of two children and a dog for a last minute evening away from home.
The Le Conte lodge was started in 1925, is accessible only by trail and is the highest lodge in the eastern United States. Mt Le Conte has the highest relief from base to summit of any mountain east of the Rockies, making it feel more mountainous than the two higher summits in the park. The lodge sits near the summit at 6,593 feet and is a haphazard assortment of log cabins built at various points. All supplies are brought in by llama train because llamas are gentler on the trails than horses.
The food was rumored to be excellent and provided us ample motivation to hike quickly. They also offer “bottomless wine” but, truth be told, I prefer wine with a nice bottom if available. We arrived moments before dinner and got shown to our small shared cabin. With three bedrooms joined to a center room, kerosene lanterns for light, and heavy woolen blankets on a rough mattress, it was our version of luxury camping. The couple in the next room clearly found the accommodations romantic as well and we tried to get ready for dinner quietly so as not disturb them and make for awkward dinner conversation.
The dining hall is small, dark, and cozy and the accumulated guest are seated closely together at tables of 8. The food is indeed wonderful and given the location and the fact that a llama train was involved, probably represents the most luxurious dinner that I have ever had. Fresh peaches, cornbread, soup, beef brisket (or a tasty but unidentifiable substitute in my case), chocolate chip cookies, ice cream, coffee and wine. Our table mates were from all over and all were astonished that we had planned this trip only the night before as it usually takes repeated efforts and months or years in advance to get a reservation. Conversation was lively; the type of folks that are willing and motivated to hike to the summit are an adventurous and interesting mix.
After dinner we took a short walk to the true summit to watch the sunset. The Le Conte summit was one of the first big hikes I ever did when I was younger and I have been there many times since in various weather and seasons. It is a rocky dramatic summit with amazing views, subalpine vegetation, and occasional ravens playing in the updrafts. On all of my previous trips, I have had to retreat from the summit before sunset to avoid a long hike in the dark. Having the time to watch the colors shift and fade over the forested mountains of the Smokies was the finest after dinner entertainment I could imagine.
We returned to our cabin satiated with food, scenery, and conversation. Exhausted, we crawled into bed and quickly fell asleep until the other couple in the adjoining room apparently also succumbed to the romance of the place. We didn't realize that we had somehow signed up for the shagadelic cabin, but I guess at the elevation, it was opportunity for various couples to join the mile-high club. It was hard not to giggle when we joined both couples on the porch the next morning and one woman asked us how we had slept. I wanted to say something along the lines of “enjoying the cool mountain air and sounds of enthusiastic nookie” but they didn’t seem like the types to be that casual about human biology and romance.
Breakfast was wonderful. Years before, a friend and I had backpacked to the summit and camped near the lodge without realizing it. As we were leaving our site in the morning we came upon the lodge at breakfast and snuck into the coffee line and I was excited to sit down to the breakfast that had made me salivate so long ago. Pancakes, eggs, biscuits, fruit, sausage and bacon; it was fantasy. Having food prepared and brought to you after waking up on a mountain was unbelievable.
We took a longer winding trail back down and enjoyed the shifting clouds and lush vegetation along the trail. As we descended we were passed by the llama train and discovered that llama train drivers do not condone llama humor or singing. After Fanny offered to sing the llama song our kids learned at camp, the llama leader said, “No. Do not sing. Wait quietly beside the trail.” I will remember to approach business llamas with exquisite gravitas and meditative silence in any future encounters.
llama train
As we descended through the biomes of the mountain and noticed the changes in the flora around us, we began to talk about how the human biome shifted as we descended as well. At the top of the mountain we mainly encountered energetic types in well worn layered clothing. As we lost altitude we began to see larger humans with slogan t-shirts. Nearing the trailhead we met people who were sitting by the trail carrying bottled water and chips and noticed that the footwear had shifted to crocs and flip flops. As we drove home through Gatlinburg we frequently saw humans who appeared challenged by the flat paved terrain between fudge shops and tattoo parlors. The experience reminded me of my college ecology classes where we had to memorize the different types of squirrels encountered at various altitudes in the Rockies. Human ecology is an odd subject but reveals a lot about the complex relationships between an organism and its environment.
Last night, Fanny and I were walking around town and conversation lead to the things we see and hear as doctors that are hard to digest. She hears stories in her psychiatric practice that make it hard to believe that any fairness at all is woven into the fabric of life. Depravity, cruelty, and needless suffering are constants in our world and bearing witness to them is the unavoidable first step to offering any hope for making them better. We agreed that walking is one of the best ways to let these experience flow through us and back into the earth. A well worn trail through the woods is a gift.