January 26th, 2021

 I can't believe we're already at the end of January. Life feels like it's been so fast and so slow. Probably because so much has happened. We're slowly getting back into a routine though, which is nice. At this point we're both just staying busy with work and sort of trying to have extracurricular activities in spite of it now being the dead of winter. The good news is we now have a gym to go to again and we're planning for puppy arrival in early March.

Work has been crazy. Trying to learn critical care and being needy while our census is way too damn high has been tough. The past couple weeks I feel like I've had that mental regression where I've learned a ton, then my brain just temporarily throws it out the window so I can look like an idiot. Really just makes you want to put your head through some drywall because it would be less painful than looking like a dumbass in front of your boss who has her own problem patients. Needless to say, I gotta do a lot of studying. I also need to do better on my eating habits during work because the brain fog is real, augmented by the fact that eating too late at night is messing up my sleep. So much to work on!

Speaking of having a lot to work on, we started going to a new gym last week led by one of our favorite people. Oof working out in a mask is unpleasant, but it's really good to be working out again. It's been 10 months since we've been in a gym and it'll be a long road back for sure. 

It's still hard to wrap my head around the fact that we're really getting a new puppy. Somedays I still forget everything that happened with Mack. I see ads for these slings so you can help your older dog get in and out of the car and I briefly think "we're almost at that age" until I stop myself and remember he will never see that age. I don't think it's denial, I think I just forget sometimes. The events of last month either feel so long ago, or they don't feel like they happened at all. Somedays I can't remember what the house used to be like when he was still here and somedays I can still hear him sighing at me. It's been so all over the place. 

I'm nervous to get a puppy. I got over the hump of thinking it was too soon, because I really miss having a lab in my life and the girls miss having a 2nd sibling. But now I'm stuck in this cycle of anxiety that I'm going to take this perfect puppy and mess them up somehow. Mack was easy as hell to train. He was a blank slate that just wanted to make the people around him happy. The fact that I got to miss the puppy teething phase was gravy. Now, not only will we have a blank slate, it will be a very young, impressionable, blank slate with a troublemaker for a sister and 2 parents that have never brought up a puppy before. It's nerve-wracking. This is why I can't have human children - having to wait around and plan for 8 weeks is bad enough, let alone 9 months. So we're spending the time reading puppy books and planning. 

I was finally feeling inspired the other day to try some photography. With the snow on the ground, I wanted to find a park to do some landscape shots, but it was so gloomy and drab, I figured finding a good spot would be difficult. Instead we threw a sweater on Mara and frolicked in the backyard. 

It always shocks me how incredibly infuriating she can be, yet she's so damn photogenic. This dog has challenged me in ways I never thought possible. Remember when I said Mack was a blank slate? She was not. She was very set in her ways from Day 1 and unfortunately it meant that the things you usually want to enjoy with a dog, you can't with her because she either doesn't enjoy it or she's so hyper it makes it hard to enjoy the experience. Knowing what I know now about puppy socialization, her whole situation screams that she was never properly socialized as a puppy, and mixed with a stubborn personality, we got what we got and it wouldn't change. Several training classes later, she stayed the same, stubborn, hyper Mara. Because of that, we've never really bonded. I just can't do the uncontrollable energy, the stubbornness and the fact that you have to be really selective about which situations you bring her in. Also she snores like a diesel engine. Up until now we've tolerated each other, but with her getting older and us now having a vacation place in the 1000 Islands plus now Mack being gone, we've been trying to get her out and about a little more. She still hates the cold and wet though, and it's winter in Rochester, so that takes a little convincing.

At least on this day we were able to convince her. It probably helped having Matt outside too, because she will never stop being a daddy's little princess. I've been practicing my action shots with her because it's so damn hard to get her to stay still. Luckily this time it worked out in my favor. I loved that the snow was falling while we did it too. For this one, I basically just put the camera in sport mode and let it do the rest so I could work on aiming the camera well enough to keep her in focus, which is what I've struggled with. We even got Lilo outside for all of 30 seconds. She hated it, but it made for a cute photo with her dad. 

I totally flooded this with so many photos, but I actually had a lot of favorites. Getting action shots of Mara is really fun because she runs so goofily, as evidenced above. She just launches herself and it results in her ears straight up and her legs everywhere - kind of like bat meets antelope. 

Either way, it's nice to have some inspiration back. I'm hoping to capture some sun at some point, but it's Rochester so I'll manage my expectations. 

January 13th, 2021

  Man, 2020 came and went, now 2021 is like "holy my beer AND my earrings..." She's like the weird ass stepsister that you invite to Christmas dinner thinking she'll behave for once only to learn she spent an entire year thinking up ways to make life even more miserable. It feels so weird that it's already January 13th, but it also feels like so much has happened this year already that it should at least be February by now. 

I've already re-written this post twice because I was worried it was too morbid, but hey, it's my blog and I don't plan to go viral with it so I'm doing it anyway. And please don't blow me in for being in crisis, I'm not in crisis. These are the realities of my job. 

The events of the past couple months have got me thinking about death a lot. Professionally, I'm currently surrounded by the thought of it each and every day thanks to COVID. Personally, we've had some major losses too, lately. It's all been enough of an onslaught that when we get news of something really good, we've been holding onto it as tight as we can. If nothing else, this past holiday season was a serious reminder of just how freaking short life is.

So let's talk about death, a topic many people suck at. I read two books recently that I absolutely loved and just could not put down. The first was The Book of Two Ways by Jodi Picoult and the second was That Good Night: Life and Medicine in the Eleventh Hour by Sunita Puri. 

The book by Sunita Puri is an autobiography of a young physician who takes an interest in the field of palliative care at a time where palliative care was just starting and had not become widely accepted yet. Fun fact: palliative care and hospice were not an established concept until about 1948 and it wasn't until 1990 that the WHO recognized it as a specialty. That's how young it is. So she becomes interested in it as an internal medicine resident and goes on to complete a palliative care fellowship. In a way her story was ironic because the stigma and assumptions she struggled with back then are still very prevalent today. Fortunately, most healthcare providers have since accepted the specialty and use it widely now. However there is still a large group of the population that believe palliative care means giving up, or withdrawing care and standing around watching as someone dies. But really palliative care providers have a huge umbrella of skills. Sometimes we contact them for help with bothersome symptoms from a chronic illness like pain, nausea or lack of appetite. Sometimes we ask them to have a difficult conversation with family about a loved one's prognosis if we need a provider with specific training on approaching these conversations. And yes, many times we are asking them to discuss what we call "goals of care" with a patient and/or their family if it seems we're reaching a point where the risk of pain/suffering due to an incurable illness may outweigh potential benefit from continuing aggressive medical care. 

The thing that really stuck with me after reading this book was the way she approached conversations and I've tried to apply that recently with my own conversations. She approached things by asking the patient their goals and then asking the family what their goals are to get a sense of where everyone is setting their expectations. Does the patient want to continue to fight an aggressive medical disease no matter what or is their goal to optimize the little time they have left (AKA quantity vs quality)? How would the patient want to live the rest of their life? Does the family want their loved one at home with them in the same shape before they left or do they understand things will never be the same again and are prepared to face that? Are the goals and expectations realistic in the grand scheme of things? And if not, if the providers had done all they could do, how would the patient and family proceed at that point? It was a very interesting and powerful approach that really resonated with me. For one, it really gives people the open-ended opportunity to discuss where they're coming from and it helps you get to know them in ways that you can't get from the chart. Honestly I think everyone in medicine needs to read this one. I've said the words "goals of care" so many times, but this book really put that phrase into perspective. Screw that House of God book, that thing was a smutty awful mess, I'm still not sure how I finished it. 

The book by Jodi Picoult was another great one. Let's face it, anything she writes is incredible and thought-provoking. She tackles some big topics that aren't easy and she does it so well. 

The main character in the book is a death doula, a job I never knew existed until now. Basically it is a non-medical professional that is trained to care for a terminally ill person's physical, emotional and spiritual needs during the death process. Her portrayal of the character is that not only does she ensure the patient's medications are actually doing what they're supposed to, but she also takes care of tasks/projects/errands etc so the patient and their family can just enjoy their time together. While it's an interesting career choice, and certainly not one I could do, it also sounds amazing. We send people home on hospice all the time because they want to be with their families in their own home, but what happens once they get home? You get a hospice nurse that visits every once in awhile to ensure things are going well. If you're able to afford it, you could hire someone to come stay in your home and offload some of the medical responsibilities. Other than that, the family takes on a lot of responsibility, and it can be a taxing job that takes a way from that concept of "quality time." Now there's death doulas that can offload many of these responsibilities and help the family and patient actually get to spend time together. There's a lot more to the plot of the book obviously, but I'll just let you read it if you want to. 

It's tough to watch suffering, especially when you're trying to talk about it with a patient's family and they keep telling you to do everything possible to keep someone alive. I've learned there's a lot of nuances to a family's decision - some just don't know what palliative care is and worry that the alternative to aggressive medical care is standing around and not intervening when the patient is in pain or distress, some families have no idea what the patient would want because they never talked about it, some have strong cultural beliefs that guide their approach to end of life, some don't believe us when we say we've exhausted all medical interventions, and some are guided by guilt. The really frustrating times are when family members can't agree on a course of action and just hold everything in limbo indefinitely. But no matter what, we're here for the patients and their families and whatever they choose we try to make it happen. All we can really do is make sure everyone is on the same page.

I feel like I could talk about this for days because it is something I'm passionate about. As emotional as it is to have tough discussions with families, they're extremely important and being able to do it gracefully is not easy. I'm still not a pro at it. I still tear up every time I do it and I still stutter through it with as much grace as I can muster. Heck I can still remember my first goals of care discussion. It was Father's Day and I had a 92 year old man tell me that he'd had enough and he wanted me to call his family in to talk and he wanted me to do the talking. I was terrified and my attending basically said "good luck." His sons were so confused, rightfully so. Their dad was perfectly stable, so why did he want to talk about dying? Well, he was sick of coming to the hospital for his uncontrolled afib so he could get poked and prodded all the time, then get told he couldn't leave because his heart rates were too difficult to control. He decided if his destiny was to pass away at home because of an arrhythmia, that's what he wanted. And he was passionate as hell about that opinion. While it wasn't the stereotypical end of life situation and I was forced into being an advocate, he needed me to be the one to tell his family that he had reached a fork in the road where he could choose quality of time or quantity of time and he wanted the former. And that is one of our responsibilities as providers, is to recognize when someone is approaching that fork in the road and to be the person that advocates having the discussion. I've seen some providers shy away from it and instead put on a face of forced positivity that doesn't do anyone any favors. 

Anyway, I'll get off my soapbox. That's enough of a talk. 

So what do I do when topics start to weigh a little heavily on my mind? I think of sunlight (and puppies, but that's for another time). Some of my favorite landscape photos involve the sun. I love sunsets and sunrises, especially the super colorful ones, and I love photos where you can see the individual rays of sun filtering through. It just kind of brings me a little bit of peace and a reminder that the world can still be beautiful. Now unfortunately, sun has not had a huge presence here in Rochester for about a month now. We had one sunny day over this past weekend, but that was it. It's really driving me nuts. 

I know I said I was going to save this blog for photos that I take with my real camera, but this topic had me thinking about our trip to Maui and the morning we spent on the top of Haleakala watching the sunrise. Unfortunately I didn't have my camera back then, but I'm super excited to go back there with it, hopefully when I know how to photograph bright sunlight better because our poor iPhone cameras struggled with this one. Haleakala means "house of the sun" in Hawaiian. It has been said that the demigod Maui stood on top of the volcano's summit and lassoed the sun to make the day last longer. So one of the top things to do in Maui is to drive up to the top of the volcano (10,000 feet above sea level) and watch the sunrise. We did it during our trip and honestly, I don't think I've ever seen something so beautiful. I don't even think I can describe how it felt to be up there watching the sky slowly light up. Some would probably call it a religious experience. I don't think that even does it justice. Either way, I wanted to end this heavy blog post with some sunrise beauty, because we all could use some of it and I think about it whenever life gets a little sucky. 

December 31st, 2020

 Well, here it is. The last day of 2020. Spent it sweating my ass off double gowned and double gloved doing 2 back to back procedures on a COVID patient. Probably going to be dehydrated for a week after that one. 

I had a feeling 2020 wasn't done with me. After October I just had this gut feeling that 2020 wasn't done with me yet....and I was proven right. 

December 13th was the day I had to say goodbye to one of the best things to ever happen to me. After weeks of not acting himself and having to watch him lose more and more weight, we were given the news that Mack likely had cancer. I had the option of putting him through a horrendously invasive work-up and potentially an even more invasive chemo regimen just so I could spend up to another year with him (half of which would be spent on weekly visits to the vet for lab work and chemo), or I could end his suffering. I ended up going with the latter. I knew deep down that whatever this thing was, it hit him hard and fast, so there likely would not be a "best case scenario" outcome that didn't come with its own pain and suffering. As much as I wish he would be one of those dogs to beat the odds and live until he was 15, I don't think I'd forgive myself putting him through cancer treatment to try and figure that out. As it is, the night we took him to the emergency vet, I had to physically drag him out of the car. Doing that to him and then watching the vet techs pull him away from me was soul crushing enough, so to do that week after week, I just couldn't do it. 

None of this feels fair. He was robbed of some of the best years of his life. We'd just gotten to that beautiful phase where he only cared about being with his family. I could let him off leash because even though he enjoyed the independence, he was always looking for me to make sure I wasn't too far behind him. As long as we were with him, he was happy. He still loved meeting other dogs and people, but he just wanted us. There were times I missed his puppy energy, but I also really enjoyed the sweet, wise old man he was becoming, until that was ripped away from us. 

In a way, I think I'm at a point where I'm starting to be grateful things ended quickly. We have no idea when any of this even started. He had gotten a clean bill of health at the end of August. Then just 2 weeks before everything went downhill, we all went on a long hike through Mendon Ponds. That dog could have gone for miles. He was pretty tired by the end of it, but not to the extent of being worrisome. Then literally 2 weeks to the day, probably even to the hour, we're on a cold floor with him in a vet's office as his heart stopped beating. And I know that dogs compensate and hide their pain until they just can't anymore. The logical side of my brain knows that. But the other side keeps telling me I was his mother and I'm a PA, how the hell did this fly under my radar. Maybe I had a false sense of security after being told it was just gastritis? Who knows. But what would have knowing about it sooner have done for me? I probably would have just ended up having to put him down sooner, thus missing out on the 2 weeks I had with him before my new job started. So I can't even be that resentful against the universe. He hid this thing until the day he just couldn't do it anymore. And I'm so grateful for the memories we'd made in the past couple months. I truly am grateful that I don't have to look back on them and have memories of constant pain and worry. But I also wish I'd had more time to make his last days the best they could be. Maybe taken him to the park one more time, or had some ice cream, or really anything but how it actually went down where one of his last memories of being with me was a car ride to the vet where I dragged him out into the rain and handed him off to a bunch of people he didn't know so he could never see the outdoors again. Just doesn't seem fair that that's how it all ends for a dog as special as he was. And maybe that's why I can't forgive myself for not seeing this sooner. 

I think what made this doubly hard was the fact that it was so close to Christmas, which was literally his favorite holiday. My very first year with him, I brought him home to my parents' house. I tied an old Christmas bell around his collar and taught him how to open presents. The rest is history - he was obsessed after that. He didn't even really care what was in the presents, he just wanted to open them. He even taught Mara how to do it on her first Christmas. We also found out that he loved Christmas roast beef. He never was super pushy about begging for food, but one year he picked up his dish and dropped it at my mother's feet for some roast beef. And it actually worked! He turned my mother into a marshmallow whenever he was around her. I swear she loved that dog more than me. Which is ironic because she was terrified of him at first, but he wiggled that brown little butt straight into her heart. So on top of being completely devastated when everything happened, I came home to a house decked out in Christmas shit and his stocking hanging by the fireplace. It took all my strength that night not to just tear everything down and burn it all. Our inflatable lawn decorations? Yeah they almost got butchered. Matt offered to take everything down for me, but after I'd calmed down a little I realized packing up my dog's things AND Christmas was way worse than just letting it stay up. We pretty much cancelled all traditions though. I feel bad because it's Lilo's first Christmas with us but maybe I'll make it up to her later. 

All that being said, it's starting to feel better. We're learning how to adapt to life without him. The first few days were some of the worst because everything was just so raw and I literally was seeing him everywhere. It felt like my entire world had been ripped apart. Not only was my dog gone, but also a lot of the things that I learned to love because of him like taking hikes and even photography. I still haven't been able to bring myself to do any of those things but I at least no longer feel crap when I think about them. I can even look at some pictures of him now without immediately bursting into tears. I still get moments where I feel intensely sad and dark, especially when I get hit with a wave of guilt where I wonder if I'm moving on too quickly. It's just been an emotional couple weeks overall. I JUST became ok with vacuuming the house and cleaning things up a bit, so it's been a slow process. Lilo and Mara are doing ok. Mara won't let us out of her sight, she's pretty much been attached to us like glue, mostly Matt. Then you have Lilo, who has been my little shadow. So they definitely miss him.

We've started talking about getting another dog. I really want another lab and this time I want it to be a puppy. I know a puppy is going to be a huge change/challenge for us, but I think we're ready. I always wished I knew Mack as a puppy and after he got taken from us early it makes me even more upset that I missed out on that time with him, so I really just want a dog that I've been with for their whole life (minus the first 8 weeks of course). We actually met a breeder this past week who has 2 moms giving birth next week. At first I was really nervous that I wasn't ready to see another lab yet and I would lose my cool, but as soon as those happy wiggly butts came near me I felt a little more whole again. So I think I'm ready to love another critter again. If all goes well, I can at least have something to look forward to in March. 

It's funny that Mack was my muse for photography because he HATED having pictures taken of him. I have no idea why. If he sensed a camera was looking at him, he immediately put his stink face on so almost all the pictures I have of him are candid or taken as quickly as possible. I tried doing photos with my real camera, but with him being so dark colored I found I couldn't get the exposure quite right for most of them. I was so excited for winter coming because I figured a snowy background might help me and I was really sad when it hit me that I wouldn't be getting that opportunity. But it is what it is. Regardless, here's some photos that I was able to get of him that are halfway decent. 

This one was taken at Black Creek Park late November. I woke up one morning and decided to just take our time and have fun even though it was cold out. So I packed him and my camera up, threw on some boots and we just aimlessly walked the trails. We ended up walking a lot further than we originally anticipated but it was so worth it. I made a deal with him that if I was going to let him stop and sniff things, he could put up with my photographing. It sort of worked...

This was one of the last really nice days we had this fall. I wanted to let his sister enjoy it too so we just spent time in the backyard. Must have been a good photography day too since it seems I actually got the exposure right on a lot of these. I loved when he would close his eyes and sniff the air. It was those moments I knew he was just so happy and taking it all in. My favorite thing about him was his face, particularly his eyes. Those eyes looked straight into my soul sometimes and his facial expressions could be just as intense. He had the ability to go from puppy eyes to super serious in 2 seconds. Swear to God that dog did jedi mind tricks on me on a regular basis. He wasn't the smartest dog ever, but man he could melt you with just one look.  

Another gorgeous day we had this fall. We actually had a decent amount of them now that I'm looking back!

And finally, this was the day we put our Christmas tree up. I was super excited to take photos of them with the tree until I realized combining a novice photographer with a large inanimate object and 2 fiesty dogs is not ideal. But we made it happen. 

Obviously I could post photos of him all day long, I probably have thousands at this point, but these are just some I've taken with my camera since that's mostly what this blog is for anyway. Originally Matt told me he would have a professional make a photo album of photos of him, but I've decided I would rather make a scrapbook instead so I'll post updates of that as we start making it. We've become scrapbooking aficionados with all of our travels, so why not make one for the dog. Plus it means I can customize it. 

I'll miss you forever, Mack Rafiki. I don't know what I did to deserve you, but thank you for all of the adventures and the lessons you taught me. Say hi to everyone up there.