Another sleepless night in Las Vegas. Ugh. Without my husband and without herbal assistance, falling asleep is very hard for me in my adolescent-hood home. I was able to do it last night in about one hour, but tonight was painfully unsuccessful. There are several reasons for my failure to sleep tonight. I think the strongest reason is that I couldn't stop thinking.

I am probably going to see a former friend tomorrow who I have not seen in 5 years exactly. I've been invited to a surprise graduation party for our mutual friend Ambika and I can only assume this former friend of mine is invited too. She was a fear-inducing friend and I have let myself succumb to this attribute I remember most strongly of her. I fear seeing her tomorrow (well, today). I do not think she will attack me, and I hope she doesn't give nasty stares. But I fear the awkwardness, which is a silly thing to stay up all night for. I'd be fine without talking to her, but can I really get away with that? If not, who starts the conversation? What would the conversation be about?

I think the anticipation has been built up because though we haven't been friends in 5 years, I have an occasional recurring dream of us meeting up again and calling it out directly, "hey, so we're not friends anymore." I hate these dreams because I think they imply that I want her back in my life and that is not true at all. I don't know why I have these dreams, maybe it's because we were so close before and it never feels good to lose a friend. But with her, it felt okay at least.

I also couldn't stop thinking about how uncomfortable my fucking legs are. I have this new skin rash I've never had before and I'm almost positive it's not infectious in nature. I don't know my skin diseases well, but I worry that it's autoimmune. Autoimmune diseases scare the shit out of me - my own body attacking itself? Fuck. It's caused me quite a bit of distress and I think it continues to worsen. I've recognized many times throughout my 3 years of medical school how fucking lucky I am that I'm healthy. Even shit like ear infections don't happen to me. I have acne and some mild knee pain with running - I'll take it. But with this new skin rash, my image of my health has been shaken and I don't like it. It also doesn't help that part of me is hesitant to schedule a doctor's appointment in fear of upsetting my senior resident or attending on my next Radiology rotation. But I gotta do it, so I'll make an appointment ASAP. I need an answer, I don't know what the fuck this skin rash could be.

What's really ironic and annoying is that I was sleepy when I went to bed. My eyelids were heavy and I felt the sensation of sleepiness. But as soon as I got off the phone with David, it went away. I just hope I don't have bags under my eyes if/when I see this former friend.

Earlier this week, I witnessed dying. There's this phenomenon called "air hunger." Even if a patient is obtunded, you can still see them gasping for air. Their lips curl inward and their tongue sticks out a little while you can see the muscles in their neck working to help them breathe.

The family knew her time was coming based off the glistening of tears in their eyes. But this was the type of family that held onto hope until the very end. They requested that she receive suctioning of her mucous to help her breathe more comfortably. When suctioning didn't improve her breathing, then they actually finally accepted it. The glistening in their eyes became full on sobbing and wailing. They held her head up in grieving and wiped her forehead with a damp towel.

My tear ducts have a physical reflex when I see others crying. I was able to control the tears from running down my face for a few minutes, but the family's full on sobbing eventually got to me and I had to step out of the room. Then when the whole team regrouped afterwards, I had to let my tears flow freely for a little bit. The team was supportive asking me if I was okay. I was okay, I just can't help but cry sometimes.

The family was Mien. And I felt that extra connection to them being Asian. I thought about my very stoic uncle who practically never shed a tear for his wife who committed suicide. He wasn't heartless, he was the eldest male in m Asian family, he just doesn't cry.

And I thought about David's grandma Betty who had to be on a BiPAP machine to help her breathe while she was dying. I didn't notice the air hunger at that time, she had been dying for months, so I didn't notice that she was actively dying the last time I saw her. For my patient, our team said that a BiPAP machine would be unethical/harmful/uncomfortable. It was probably true for Grandma Betty.

I'm going to be dealing with death a lot in my career. And for professionalism sake, I should try to keep my tears under control. But I'm trying to imagine what my reaction would be if I were the patient's family and I saw the doctor shedding a little tear. I don't think it would be so bad. I think shedding a tear is okay. But only a few tears, doctors have to maintain their composure. Have to.

I had my first stroke patient last week. It was a great learning experience, but also a reminder of how amazing the mind is. Mr. H presented with sudden onset of right sided weakness and word-finding difficulties. His left internal carotid artery was complete occluded. By the time he reached the emergency department, his weakness and word-finding had already improved, but not completely. Then on Hospital Day 2, when I saw him in the morning, his weakness and word-finding had worsened compared to how he was when I met him in the ED. What do I do?! What can be done?! What does this mean?! He went from responding to my questions immediately but with difficulty finding certain words to not being able to say "hello" after picking up the phone.

Turns out there was not much to be done. Even the neurologist kind of just took a shot in the dark by saying he needed ICU care for more frequent nursing checks. Luckily, he improved again and returned to how he was when I met him in the ED. Rehab is the only treatment for him now.

The internal carotid artery is a huge artery to the brain. This patient had managed to form collateral blood vessels over time to still supply enough blood to his brain even with the ICA being completely occluded to only have some R-sided weakness and word-finding difficulties. His life is going to be harder, but not as tragic as it could be with that type of occlusion.

A few weeks ago at the VA, I was involved in the incidental diagnosis of an aortic dissection. It was all really chaotic and confirmed my dislike for chaos in the face of a critical medical situation. Mr. C is a 79 year-old man who I had followed briefly in the ICU after he had surgery for a small bowel obstruction (also found incidentally) and was on a mechanical ventilator. I remember giving him sponges for him to moisten his mouth with and he was very appreciative. He was then transferred to the floor and I was no longer following him, but the cardiology service was because he had a bunch of heart problems. I was shadowing the cardiologist who was just going into Mr. C's room to do a bedside ultrasound to look for something cardiac-related (I honestly can't remember what we were looking for, but it wasn't serious). Mr. C was screaming in pain that had started pretty acutely. We didn't think much of it, just a very old man with probable arthritis in his back sitting uncomfortably in the chair. Then the cardiologist saw what looked like a false lumen in the patient's left carotid artery on ultrasound. That coupled with back pain = aortic dissection.

This mad just had surgery. He had heart disease, a recent heart attack, blood in his urine, and bacteria in his blood. He was not a candidate for aortic surgery. And he didn't want it either.

We all knew this meant the end for Mr. C. The cardiologist even used the word "goner" with nervous laughter. Not out of cruelty, but just matter of fact. This made me very sad. David's maternal grandmother also died from an aortic dissection. I felt the heaviness of it all.

Last day of Lent. I should read through all my posts from Lent. The point of this was to encourage myself to journal more often. I hope it worked. We'll see.

Connie is currently executing the plan of forcing my dad to quit cold turkey. She stayed up until 2am last night and even then checked on him throughout the night. My dad is very anxious about it all. He was not expecting to give up this crutch he's used for half his life so suddenly. He would have preferred the option of cutting down slowly, but that's not really an option in alcoholics. At least not for him, he does not have the self-control to limit himself at all really.

I received the most touching text messages from her earlier today:

"I can tell he was fighting his demons last night cuz at first he was getting annoyed and started saying random shit. Around 2, I was like dad 'it's been 24 hours, see you can do it, let us help you reach 48.' He looked at me and said in the calmest manner 'you know I'm going to get mad but when I do don't be mad at daddy.' I said 'I know dad, you're going to hate me tomorrow but I still love you.:

This makes me cry. It wraps my dad up in a nutshell. My dad is deeply flawed. He is one of the least introspective people I know. But I've always known that he loves us. And though that's all that he's been able to give us, I don't take it for granted.

Mr. V is a 60 year-old man with a history of diabetes who presented with a 1-week history of RUQ pain associated with fevers found to have a liver abscess containing Streptococcus anginosis. And he was a wonderful patient. The ideal patient really. 

Poor Mr. V was in the hospital for a total of 21 days, way too long for a liver abscess. But the damn thing wasn't draining as expected and interventional radiology takes several days to take action. Then when the drain is finally pulled, that is when the attending and resident decide to get a CT of his head to look for dental sources for his infection. He was very eager to go home. 

It was a great experience practicing my broken Spanish on him. Forming sentences came back very easily to me, but everything was in present tense. I studied Spanish for a total of 5 school years, and have rarely had to use it. I taught a 3rd grader who just immigrated from Mexico how to read in English when I was an undergrad at UNLV, I took vitals on Spanish-speaking patients at Share Ourselves free clinic, and I took care of Mr. V for nearly 3 weeks. For living only in California and Las Vegas my whole life, that's not very much Spanish usage. 

Today I said goodbye to Mr. V. After the interpreter and resident left the room, I shook his hand and emphatically said to him, "mucho gusto, senor, mucho gusto." I couldn't help it - I had to hug him. And when I did, he teared up, "thank you, thank you so much." Oh you're very, very welcome Mr. V. It has been a pleasure. 

He was the nicest patient. I followed him for almost the whole 21 days. He saw me practically every morning and I was able to communicate to him his medical plan pretty well in Spanish. Seeing him tear up was the cherry on top. It confirmed that he felt the same connection with me that I did with him. That we were both worn down from his 21 days in the hospital, that I genuinely cared about him and treated him with kindness. 

He teared up because of our relationship during his 21-day hospital stay. But he also teared up because he was finally getting out of the hospital. The best Spanish words I could think of to end things with were "el fin."

A lot of Buddhist references recently. 

Last night, I explained to David the philosophy of Buddhism. Can't remember how it came up exactly but I know it had something to do with my dad. I was explaining how one becomes a buddha, an "enlightened one." One has to relieve oneself of all desire. When you relieve yourself of desire, then you relieve yourself from suffering. Desire leads to suffering. From what I've observed in my 25 years of life, human nature is incompatible with Buddhism. One has to very active and conscious to just let things go. It is not human nature to just let things go. And that is why very, very few people achieve enlightenment. 

Buddhism teaches that all things are temporary. There is no truer statement. Everything, everything is temporary. So why suffer when we lose things, people, health? When it is all temporary. 

Way easier said than done. 

Buddhist monks are the closest humans can get to enlightenment. They live their lives without material wants. They eat whatever is given to them through charity. Food is sustenance, not desire. 

What I love about Buddhism is that it recognizes that most of mankind cannot live up to this. So there is The Middle Path. The middle between poverty and luxury. I love The Middle Path. It is a huge part of who I am, it is a huge part of my value system. I want a clean, smooth-running, reliable car - not a luxury car. I want a comfortable, brightly lit, warm home - not a mansion. I want a well-made, quality purse - not a closet full of purses. 

Explaining this to David rekindled my passion for Buddhism. We need to explore it more together because I desperately want Buddhism in our lives and our future children's lives. 

Then today on facebook, 2 posts that were Buddhism-related. 

First was by Connie, "Remember that the best relationship is one in which your love for each other exceeds your need for each other.” 
― Dalai Lama XIV

Never heard that quote before, but related to the idea of not desiring. David and I confess a need for each other as well as our love for each other. I have thought about the negative repercussions of this. Not to be morbid, but I do sometimes think about how I would cope if he were to die young. And I admit I don't think I will cope well. Precisely for the reason Dalai Lama is mentioning here. I don't think my need for him exceeds my love for him, but it is a very strong need. We are a very co-dependent couple. 

Second was by Marie, the mother of my former student with autism, who is now a very dear friend: "Be happy for no reason, like a child. If you are happy for a reason, you're in trouble, because that reason can be taken from you." - Deepak Chopra. What poetry. I have never heard a quote with a message like this. I'm on The Middle Path with this quote. I really am the kind of person who smiles when they walk just because the full moon looked pretty in that early morning sky when the sun is almost starting to rise, just because that dog is so cute, just because I look forward to seeing my husband. I believe this trait is genetic as well as learned, my mom and most of my mom's side of the family are just cheerful fucking people. They just love to laugh. While my dad's side is much more serious and solemn. On the other hand, I can pinpoint many reasons for me to be happy: I married the right man, I'm going to be a doctor, I'm going to be financially comfortable, I'm healthy. Would I be as happy as I am now if I were missing any or all of those things? I don't believe so. I would be less happy. But, will I still be happy? Probably. I was happy before I met David and got accepted to medical school. But not as much as now. I've always been healthy, I don't know what it's like to not be healthy, thus I don't know what I'll be like if that were ever taken away from me. 

Connie had been more distant from my dad than me in the past few years. As in she talked to him 3-4x/year and I talked to him 5-6x/year. As in I live in Davis and don't see him, but they both lived in southern California and didn't see each other.

Now she's the one who has him living in her home disrupting her life. She even texted me today about how she's thinking of letting my dad drive her car while she's at work so he can do feng shui and keep busy (my dad's car-less at the moment). Now she's planning on forcing him into alcohol withdrawal this week.

Not only is it medically scary and she's responsible for taking him to the ED when it's time, he's going to throw a fucking grown-up fit when he finds out that we're cutting him off cold turkey. He is nowhere near ready to face his alcoholism head on. He said he wanted to cut back and we wanted to believe him. But he's lied too many times already in his short week with Connie, and tonight Connie found like a dozen cans of beer hidden in different parts of her apartment. He doesn't even recognize himself as an alcoholic.

He said he wanted to cut back and that his health will suffer because of alcohol...but he never thought of himself as an alcoholic? He asked me tonight if he's an alcoholic. I told him, "yes, you've been alcoholic for 10+ years."

He said what we wanted to hear. He's good at that. That's why the fuck my mom is still putting up with his shit 37 years later.

An ED visit and hospitalization is our last hope to slap him in the face to wake up. If this does not wake him up...then I'm worried we'll have to let him live alone. No one wants to or should put up with his ass. He is not worthy of the company of anyone in his family. I meant what I said last night: I want him to be the grandfather to my children if he's sober.

Boy, a lot has happened in 24 hours.

Last night around midnight, I got a very long text message from my sister telling me that my dad went berserk when he found out we're thinking of selling our house in Vegas. He said things to the effect of "I'm going to kill myself and anyone who comes to look at the house." Saying that our mom set him up by having him come down to Orange County. I was asleep when I got that text; I stayed up for 2.5 hours after reading it. My mind kept going. Then the most upsetting thought that my imagination never allowed me to realize finally came to fruition - the image/dream I have for my future does not include him. My subconscious does not include him when I imagine my future. So what upset me the most in that 2.5 hours was the thought that my peaceful, comfortable, full future that I've become very attached to will have to include my mentally ill, alcoholic dad. I don't imagine it being as peaceful or comfortable any longer.

Then Connie texts me in the morning saying he apologized and they agreed that he'll only drink 3 beers today.

Then Connie texts me again this evening saying "I'm defeated." He ended up drinking 8 beers.

I call her to talk to her. She ends up putting him on the phone too. It was spontaneous and unexpected, and part of me thought "oh shit." But I was ready, I knew what I would say. See, I have not talked to my dad about his drinking since I last saw him in June 2012 when I left our Vegas home in a rage because he was being a lunatic drunk. But tonight I was put on the spot and I was prepared. I said to him that I'm working in the hospital now and I see lots of alcoholics. They can't remember anything and they have no family in their lives, and they are very sick. "You need to stop drinking."

"Do you understand?"

"Yes."

"I am almost a doctor. Do you believe me that you need to stop drinking?"

"I believe you."

Sigh. And then...he opened up to me in a broken, choked up voice about his suicidal ideation and his depression. "I have a mental illness. I want to commit suicide, I'm very unhappy. I don't want to live anymore."

"Why are you so unhappy?"

"You and Connie are so independent now."

That was weird. First of all, he should be proud and happy that we're independent. Second of all, he really is in denial about how he fucking failed as a care provider. He cooked for us and cared for us. I'll give him that. But he is not the reason we had a roof over our heads and clothes on our backs.

In the best Cantonese I could muster: "Dad, I know you are a good person. I know you love us. I want you to be the grandfather to my children because I know you are a good person. But you must stop drinking."

That is all the truth I can offer him. And I think that is all the help I can offer him too. In those few sentences, I gave him more love, more recognition, more of a reason to live and be a worthwhile person than I have ever given to him.

Getting the sense that my dad needs extreme measures to stop his extreme drinking, I suggested to Connie to let him go into alcohol withdrawal with requirement for medical care. Alcohol withdrawal is serious and possibly fatal. Yet I am so okay with it. Maybe I don't fully appreciate how dangerous it is because all I get to see are the ones who make it to the hospital, get treated with Valium and do fine. Desperate times call for desperate measures. And there is no better word than "desperate" to describe my dad, and even my mom too.

That blog yesterday really did help my willpower. I had no problem with avoiding the cookies in the workroom table this morning. I looked at it several times, but never contemplated it.

Anyway, my blog today is about my mom. My strong, hard-working, wise woman of a mom. I can almost think no more highly of her than I already do. Almost. Her weakness is my dad. "Weakness" is the perfect word - it works as the opposite of her strength and as the thing she allows herself to succumb to. She does not have the heart to kick him to the curb. She literally does not want to be "black-hearted," which means evil in Cantonese. She has never been able to separate herself from him completely. They've known each other since 10-11 years old, he's part of her identity.

My mom was very wary about my marrying David. She did not want me to follow in her footsteps by marrying someone I would have to take care of financially. There's a huge difference between David and my dad though. David has always put me and us #1. My dad has been putting himself before my mom since 10-11 years old. I might be the breadwinner, but David is worthy of my income and I am worthy of his love and kindness.

My mom recently began sharing with me deeper and more thorough thoughts and emotions than she ever has before. It's all related to my dad and his downward spiral into severe mental illness. She's not hiding her tears from me. She's asking for my opinion about what she plans to do with my dad. She's freely expressing how much she dreads the idea of him returning and how it's weighing on her heart. But, she also told me today how happy she was. My Aunt Vicky and Uncle Steven are visiting and invited her to go with them to the Grand Canyon. My mom spontaneously took a sick day today and went with them. But, he comes back in 2 days. Sigh.

She needs to get away from him. NEEDS to. I wish I could get her out sooner. I'll have my MD in a little over a year, I just keep on hoping she can see the light at the end of the tunnel. This fucking dark tunnel.

So all that she shared with me is beyond anything I've ever experienced with her before. She has always protected me from the truth about herself. I knew this, understood why, and accepted it. I am the youngest crybaby daughter in medical school. Connie is her rock. I am her secretary (inside joke - I pay all her bills online). Connie is the one who is burdened by my mom's suffering. I am the one who can pretend to be blissfully ignorant. I had come to the conclusion that all my mom wanted from me was that I think about her and want to hear her voice several times a week. I was happy to oblige this very easy duty.

But after the past few phone calls, I must now face our changing, maturing relationship. I can't be a crybaby forever. I knew I had to be my mom's rock one day, but I thought it was going to be when she was old and sick...not now with my dad's alcoholism.