Grief

I had a brief, quiet, intense conversation with a friend today. She had just lost another friend, a close one, to a sudden and tragic accident.

“How are you doing?” I asked.

“Okay,” she replied, as she turned to go up the hallway. In a second, I knew better. “No, not okay.”

Her usually bright smile was strained, her voice soft, her features drawn.

That brief exchange, the sharing of feelings about trauma to mind, body, and soul, did what those exchanges almost always do to many of us. It triggered, instantly, my feelings and memories of the death of my father twenty four years ago.

As I have written elsewhere recently, I can’t help but wonder how dozens if not hundreds or even thousands of people are dealing with these kinds of reactions and feelings as we have been assaulted on every level by hate, destruction, and death. This on top of expected deaths from old age, deaths from illnesses that are not expected but are accepted, and accidents that leave us jarred, numb and questioning everything we’ve always held dear.

“Your father has collapsed.”

The call came at the worst time possible. We were moving into a new house, we needed to pack, and someone needed to watch the kids.

“I don’t know. Your mother is with him. They’re taking him to the hospital now. I don’t know.”

I am in the car in what feels like minutes. I don’t think I even take a toothbrush, although I really don’t remember.

“Call and let me know as soon as you find out something. We’ll be fine heel. Go.”

“Take all the time you need. We’ll cover things here. Don’t worry. You need to be with your mother. Go.”

Racing down the interstate in slow motion. Time flying by as it stands stock still. Tears and prayers and more prayers and more tears and time flying by with the miles.

“Don’t you die on me. Don’t you die before I get there. Hang on until I get there.”

There are still so many things unsaid. The scenery blurs, clears, blurs, clears, blurs, clears. My eyelids are the windshield wipers for my soul. Is it raining outside? No, it is raining inside. Come in out of the rain. I can’t. I’m getting soaked.

“Don’t you dare die on me.”

The time in the hospital is a blur. The waiting room. The ICU. The doctor. The staff with their kind eyes and kinder manner. My mother is broken, silent in the corner. I have the knowledge but not the will. There are decisions to make.

“We can make him better. We can rebuild him.” A part of my brain laughs hysterically at the thought of the old television reference, so stark against the sunshiny darkness of his bed. Beep, beep, beep. We can never rebuild him. I have seen the scans. They show me because I am a doctor. I see the vast whiteness in his brain. Clean, pure, permanent. I know what this means. I do not want to be a doctor. Oh, God, not now.

I try to support my mother as we walk up the aisle in the church. I see little. I remember little. His mother, my grandmother.

“Oh, parents are not supposed to outlive their children. Oh, ohhhhhh.”

We travel. We talk and eat and visit with folks who have known me since birth.

“Oh, how your children have grown and I remember when your Daddy…”

They put him in the ground. It is hot. Why do people die in the summer, that hysterical part of my brain laughs, way off in the distance. It laughs and laughs so that it will not cry. They put him in the ground. My little sister is there, off to his side. Others are already there waiting for him. Waiting for all of us, I think. It is so hot and the hole in my chest is so huge that I cannot get enough air. I am drowning in the middle Georgia sunshine.

Six days later I am working in an air conditioned emotional bubble. I do what I know how to do the best I know how to do it.

Six months later, I open my closet door and see the stack of papers there on the floor beside the filing cabinet. Odd, I think. That’s not like me. I sit down and go through them, filing and getting things back in order. I feel like I have just awakened from a half year’s dream. No. A nightmare.

Twenty four years later, I think about him every day. Every. Single. Day. It is not unpleasant. It is not painful. The scar over the huge chest wound is thin and tenuous, but it holds.

When change jingles in my pocket, or when someone mispronounces a word the way he did, I smile. When I hold my grandchildren in my arms, the way he held his the day he died, I feel proud. He is here with me. He will always be with me.

As my mother once described it, I am not happy with what happened, but I am content.

This is grief.

This is life.

The Will to Live

The parents, Jordan and Andre Anchondo, had just dropped off their five year old daughter for cheerleading practice. They drove to the Walmart in El Paso with plans to buy school and party supplies, as that same daughter was turning six and had a party coming up that afternoon. They had just celebrated their one year anniversary on July 30, 2019. They had just built a new home together. To hear their extended family members talk about them, they were happy people, loving parents and had every reason to think that the start of school, birthday parties and cheer practice heralded the beginning of a wonderful academic year.

They parked with dozens of other families with similar purposes in mind, got baby Paul, age two months, out of the car, and went inside to start their shopping.

Soon, shots rang out. One, two, three, then groups of shots. Rapid fire. Pop, pop, pop, pop-pop-pop-pop. Instinctively, for how else could it have happened, Jordan enfolded and protected and shielded her tiny child from the rain of bullets. In that desperate moment, she must have known that her entire reason for being, her entire driving force as a human mother of this fragile, helpless infant was to keep him alive. She must have had little if any time to think about herself, her own wellbeing, her own life. She had one purpose. She rose to it with infinite love as only a mother can. She cradled Paul.

Her husband Andre, whose life had been immeasurably blessed by his time with this woman, by her love for him and their love for their newborn and the rest of their family, heard and saw what was happening. We can only imagine that, like Jordan, he had precious few seconds to ponder the situation he found himself and his family in. He had little time to weigh his prospects, craft a plan. He could not afford the time it would take to decide. He acted, jumping in front of his wife and only son, shielding them from the murderous hate that came for them in a stream of deadly projectiles.

Andre died.

Jordan, blood flowing, succumbed to the onslaught of bullets and fell to the floor, never failing to protect her son. When the moments of terror ceased, little Paul was pulled from under his dying mother’s body. He suffered broken fingers, but he was alive. His mother, Jordan Anchondo, would never hold him again.

The will to live is a psychological force to fight for self-preservation at virtually any cost. There is an element of conscious and unconscious reasoning behind it. Wikipedia tells us that German philosopher Arthur Schopenhauer first named this force that keeps us alive. There are other drives, as you are well aware, including the drive to find food and shelter, to find a suitable mate, to reproduce, to maintain dominance over others, and to connect with others of our own kind. Psychologists agree that all of these biological drives are important. Paramount, however, is the drive to exist, to live, to continue our lives. We, as biological beings, must ensure the preservation of the species. Absent this, of course, literally nothing else matters.

We do what we do, in all sorts of conditions and circumstances and situations, to stay alive as long as we possibly can. We survive abuse. We live through terrible wars. We battle cancer. We seek treatment for addiction to alcohol and drugs. We even cradle our tiny, helpless children in our arms, shielding them from almost certain death, even as we are willing to lose our own lives to save theirs, to make sure that life goes on.

We will push for survival at all costs, even at the brink of sure and certain death.

Self-preservation has two components, pain and fear. In the El Paso shooting, we must believe that the fear component lead to safety seeking, a rush of adrenaline, increased physical strength in the moment, and markedly heightened senses of sight, hearing and smell. Jordan and Andre knew, consciously and most likely unconsciously, that they were in a fight for survival, and they acted accordingly with little hesitation.

An article in Stanford Medicine teaches us one more very important aspect of this drive and its interaction with the possibility of imminent death.

The will to live involves hope.

Hope is manifested by a positive attitude, a view toward the future and one’s place in it.

Hope, almost paradoxically, also involves acceptance of one’s fate in life, even when faced with a hailstorm of bullets.

Live your every day with gusto. Have hope for the future. Mourn the loss of precious life, but embrace the tenacious will to go on that allowed two courageous parents in El Paso, Texas to pass along the gift of life to their two month old son.

About Face

FaceApp is the newest craze.

Make yourself younger.

Make yourself older.

See how ___________ (fill in the blank: much younger, much older, gorgeous, handsome, ugly, wrinkled, terrible!) you will look in five years, ten years, twenty years.

We are preoccupied with our looks, for good or ill. Selfies give us instant feedback. Tagged posts keep us honest. (I really do look like that?) We watch ourselves age, day by day, on social media.

Look, we are where we are. In life, in our careers, in school, in our family position, in our climb up the corporate ladder, in our steady, inevitable march toward the end of our lives.

The future will get here soon enough. Why push it, for goodness sake?

Do you want to enjoy the journey, feeling things, noticing things, accepting changes in your mind and body as you age? Do you really want to catapult yourself photographically or otherwise (Back to the Future movies notwithstanding) to age ninety, just to see how may wrinkles and chins you’ll have?

I am changing physically, and some of it I DO NOT LIKE. My stamina is not as good as it once was. I am not as physically strong. My body shape and composition are changing. My clothes don’t fit the same. None of these things keeps me from being as active as I can be mentally and physically. I try things. I push myself.

Try something. Turn your attention inward this week. Forget about your changing face, just for a week. Lines mean character. Gray means experience. Aches and pains mean you’re up and moving. “Only physically active people get these kinds of injuries,” I was once told in the ER after breaking my leg on sliding a bit too aggressively trying to stretch a single into a double.

LIVE YOUR LIFE. Don’t just document the hell out of it.

LIVE IT.

You will age, most assuredly, in good time, whether you use the newest app or not.

I can guarantee it.

 

A Day in the Life

“I’m going to cut off my head to stop the voices.
I have visions of shooting myself.
I have no income.
I’m tired of living the way I’m living.
I lost my job.
I’ve been using drugs for twenty years.
I pay for it by hustling, Doc.
Social Services took my kids last week.
I dropped out in the third grade.
Sometimes I take my kid’s Adderall.
I can’t take this any more.
My mother is in prison.
I shot myself in the face with a shotgun.
Do I look like I can afford an attorney?
On a scale of 0 to 10? How about minus five?
I will kill him. I WILL kill him. Do you understand me?
I flip out.
Maybe it’s the medicine.
Maybe I need more medicine.
I don’t need any medicine.
F—k you and your medicine.
I’m adopted. I don’t have any family history.
I don’t have any family.
You can’t help me, Doc.
Nobody can help me.”

The above short piece, entitled “A Day in the Life”, was first published several years ago after I had had a particularly hard day in the world of mental health. The comments you see there were things said to me by patients over a single twenty four hour period. One single day of stories about depression, betrayal, longing, sadness, grief, homicidal ideas, hopelessness, and resignation. Not long after the piece went up, I received a comment on Facebook from a friend.

“How do you do it?” he asked simply.

I saw a patient recently who was hurting and anxious and worried about her medical status, her mind, her ability to think and take care of herself and what would happen to her as she got older and more infirm. Her wandering narrative was punctuated by repeated questions.

“I bet I’m really bringing you down, aren’t I Doc?”

“Have you ever heard anything so sad, so awful, so terrible as my story?”

“I know you don’t care about any of this, but how do you listen to it?

“How do you do it?” she asked, echoing my friend from years ago.

I thought about that question a lot, in the context of all the misery and sadness and destructive behavior I had seen during that twenty-four hour period years ago, and in the more recent telling of my new patient’s story. I thought about what the minimum requirements for doing my job are, the ways that one can exceed those, and the ways that we must pace and protect ourselves so that we can do this job for a lifetime and help as many people as we are privileged to come in contact with.  It didn’t take me long to come up with the answer.

I had excellent mentors and excellent training.

Pharmacology professors like Richard Borison, who, notwithstanding his horrible judgment in matters financial that lead to his eventual imprisonment, had already forgotten more psychopharmacology thirty five years ago than I will ever learn in a lifetime. He had a way of making the difficult understandable, the complicated simple  and the insurmountable achievable.

Anatomy professors like Gene Colborn, who could find a muscle or a piece of cartilage or a tiny nerve in the human body by touch alone, who sat me down one day when I was struggling and overwhelmed in the early days of my first year of medical training. “ He looked right at me with clear, piercing eyes. “We don’t expect you to learn everything. Nobody can learn everything. The amount of information that we throw at you in the first year of medical school is just too much to handle. We expect you to learn how to manage everything. You can do this.” I often think about how he helped me believe in myself in a very dark time, and I use that feeling when listening and giving feedback to my own patients who might be in that same spot I was in all those years ago, not able to believe in themselves and their potential without someone helping them along.

Consultation-liaison psychiatrist Douglas Hobson who taught me about the esoteric, the strange, the interface between internal medicine and psychiatry and who introduced us to the Man Who Mistook His Wife For a Hat.

Stuart Finch, who ingrained in me the rule that a good child psychiatrist cannot and should not treat a child with severe emotional problems unless the family is all in and part of the treatment plan.

Larger than life people like my chairman Mansell Pattison, who loved life, lit up a room, ran a successful department of psychiatry out of his head, and died much too young in a tragic car accident. 

All of these and many more taught me the building blocks of my profession, drilled me on what was important,  taught by example, gave useful feedback, chastised when necessary and praised when deserved. They sent me out into the world of medicine in general and psychiatry in particular a well-trained clinician who was not afraid of hard work and who embraced lifelong learning. 

They also taught me to care. That is how I do it, even when it is so hard that I am tempted to give up. Because after all, if I didn’t care about my patients and their stories, I couldn’t do this every day.

Simple as that.

Who are your mentors? Who taught you about what is important? What lessons do you draw on every day when things get rough in your life?

Even more importantly, who is looking to you to be their mentor, their teacher, the one who pushes them to be their best, to go beyond their comfort zone.?

Demograffiti

Way back in the day, when I was going to medical school and my beloved Mac computer was but a gleam in its creator’s eye, we were taught to think about and to present medical cases in a very circumscribed and conventional way. After reviewing all of the pertinent medical records (which were all written down on paper and required transport from nursing station to workroom on small but sturdy wheeled carts, of course), we proceeded to the patient’s room (if hospitalized) or to the clinic exam room if outpatient and proceeded to take a history. Yes, my friends, we actually sat down, SAT DOWN, I tell you, and spent minutes if not an hour or two with the sick person at hand and actually talked to them, a la William Osler, giving them ample opportunity to tell us what was wrong with them, and then to gregariously yet sanctimoniously let them in on the secret, as if we had actually figured it out ourselves. (Most of the time, it is quite true, patients have a pretty good idea what is wrong with them and will tell us of we will only take the time to listen) Yes, the whole review and history taking process could be as long…as that last sentence was.

Now, after that was done, we of course did the requisite physical examination, which might include judicious use of a reflex hammer to the knee and a sticky wheel to test for sensation and a tongue blade applied at just the right angle to view whatever was lurking down the gullet. We came. We looked. We saw. We diagnosed.

Then we reported. To the chart. To our attending. To the nurses. To our less bright counterparts who were slow on the uptake and couldn’t tell the difference between a whiteout from pneumonia on chest X-ray and Aspen, Colorado in a February snowstorm. Our discourse almost always began as follows.

“This forty-two-year-old alcoholic white male presented to the emergency room with acute chest
pain of two hours duration accompanied by nausea, diaphoresis and pain radiating down his left arm.”

“This sixteen-year-old sexually active white female presents with new onset abdominal and pelvic pain and a moderate fever, with elevated white count and a left shift.”

“This fifty-year-old obese black female presents with abdominal pain, anorexia, listlessness and depression over the past three weeks.”

“This eighty-five-year-old male, a former aerospace engineer, presents with irritability, forgetfulness, wandering behavior, and inability to find words or name routine everyday objects.”

Now it is funny to me that in this day and age, when Google knows our whereabouts and Amazon can deliver things to us in two hours before we even knew we needed to order them, some folks take great exception to the routine practice of calling attention to one’s age, sex, race, color, creed, sexual proclivities or activity, body habitus, or other defining personal parameters and characteristics. Somehow, this is seen as invasion of a person’s privacy or is knowing too much about a person’s private information.

Really.

Well, when I was taught medicine, it was very important for me to know your sex, your age, whether or not you were HAVING sex, your weight, your alcohol and drug use habits (including the use of needles), your eating habits, your stress level, what kind of job you did, how much time off you took, your complete family history, and so forth. I needed to know those things, because in order to differentiate heartburn from heart attack, ectopic pregnancy from eructation, psychosis from neurosis and flatulence from petulance, I needed all the information I could gather, and then some. I might even have to speak with your spouse (with your permission, of course) or (God forbid) your mother to find out the things that you conveniently left out and did not want me to know.

Yes, today we who work in the healthcare industry are in the business of safeguarding privacy, and I am all for that. HIPAA (a 1996 Federal law called the Health Insurance Portability and Accountability Act that restricts access to your private health information) is king. However, I am not the enemy. Your other doctors are not the enemy. Your physician assistants, nurse practitioners, counselors, psychologists, nurses, phlebotomists, and lab techs are not the enemy. We are not Facebook. We are not Google. We are not Alexa. Okay, I think you get the point. We need to know these things because we know that dementia rarely strikes eight-year-old girls and sarcoidosis might be a little more common in a middle aged African American woman. An overweight man with chest pain who tries to keep his case of beer a day habit from me when I admit him to the hospital for depression will make treatment of his ensuing alcohol withdrawal that much more difficult as we work him up for his third heart attack.

In order to give you the excellent care that you deserve, we need to know everything that pertains to your health, including habits, mental health issues, and pattern of substance use. Please help us. Because you know, some of your demographics are written all over your history and physical and are easy for me to see. Other bits of vital information are hidden in your head. Unless you let them out, that is where they shall stay.

I’m a psychiatrist, but I’m not a mind reader.

CBD

One question I get asked a lot lately is this.

“Is it okay for me to use CBD oil?”

I thought it would be a good idea to address this general question in Mind Matters this week.

First of all, CBD oil and associated preparations are types of alternative medications, medicines that might not be mainstream or readily prescribed by doctors , but are nevertheless used by many people on their own. Alcohol and marijuana are two substances that are often used as “medicines” by those that think they function better with them than without them. Many people self-treat medical as well as psychological symptoms with nonstandard therapies.

Some of these agents, like CBD oil, do not currently have FDA approval for treatment of specific psychiatric illnesses. If you choose to use them, either alone or in combination with standard therapies, you must understand that there are several things to consider. First, they may have unexpected side effects. Secondly, they may interact with other foods or drugs that you already use. And lastly, they may or may not be legal for general public use. I will address some of these issues in the rest of this column.

According to WebMD, cannabidiol is found in the cannabis sativa or marijuana plant. There are eighty similar chemicals in these plants. THC is the major active ingredient, but cannabidiol makes up forty per cent of overall cannabis extracts. Cannabidiol may have antipsychotic properties, but we are not sure why. It might also actively block some of the effects of THC. There is really insufficient evidence for use of cannabidiol in bipolar disorder, dystonia, epilepsy, Parkinson’s Disease, schizophrenia, or social anxiety. Side effects due to cannabidiol use might include dry mouth, decreased blood pressure, light headedness and drowsiness. There is no good data on the use of cannabidiol in pregnancy or breast feeding, nor for many specific drug-drug interactions.

Some of these concerns were addressed in a recent interview on Medscape where Columbia University Chief Resident Angela Coombs, MD, interviewed Diana Martinez, MD, Professor of Psychiatry at Columbia and an addiction expert. Dr. Martinez stated that there is really very little known about how CBD affects humans and why. It may have some legitimate medicinal effects, but the jury is still out on some of these. She stated that if you buy CBD at stores, the advertised doses may not be realistic or true. Some websites of companies that manufacture CBD and have their products tested by legitimate outside companies will more likely list the actual amount of CBD available in their products. It might be very important to know about the presence or absence of contaminants as well. Some states like Colorado may do a better job at this point in testing products for factual labelling and overall safety.

CBD may be effective in treating seizures in some children with specific illnesses such as Dravet Syndrome or Lennox Gastaut Syndrome, obviously a very small group of people. If they do not respond to more traditional medication therapies, high doses of CBD in the neighborhood of 1000 mg might be effective.

The positive symptoms of schizophrenia (such as hallucinations) may be reduced with the use of CBD, but this is in the presence of traditional antipsychotics, not in place of them.

There is not much research to address the use of CBD oil in the treatment of anxiety or social anxiety. Dosing is largely unknown. 300-600 mg seems to be helpful for anxiety.

Dr. Martinez also addressed the drug-drug interactions that might occur when CBD is added to other, more traditional therapies. When the enzyme systems in the liver are affected by substances such as CBD, metabolism of other drugs might be sped up or slowed down, affecting the amount of those medications available in the bloodstream. This might lead to compromised treatment with seizure medications or antipsychotics. She also was not able to clearly answer the question about the legality of CBD at this time. Because of various bills, the DEA, the FDA and other regulators, there is not one specific answer as to the legality of buying, possessing and using these agents. Will it be regulated anytime soon? She was also not able to directly answer that question.

So, if you are thinking about using alternative therapies like cannabidiol, what are some of the things that you might need to consider?

1) It the substance an additive, food, plant, chemical, alcohol preparation or other kind of substance?

2) Is it approved by the US Food and Drug Administration?

3) Is it regulated by the FDA, DEA or other agencies?

4) Is it checked for safety by an independent lab or company for purity, quality, concentration, adulterants, etc?

5) Is it expensive or affordable?

6) Is it legal in your state or nationwide?

7) Does it interact with food, alcohol or other drugs? Are any of these interactions life threatening?

There is no hard and fast advice on the use of CBD oil yet, and much more research is needed.

And a Little Child Shall Lead Them

Funny how the world and its many events can stimulate our brains to recall things. As I write this column it is the seventy-fifth anniversary of D-Day, at that time the largest planned, multi-nation amphibious assault on an enemy defensive line in the history of warfare. I have also been reading about global warming, the flooding in the Midwest, political strife, and other natural and manmade disasters. This has been juxtaposed this past week with the wonderful visit of our two oldest grandchildren to our home, something that my wife and I anticipated with great joy and gratitude. The two opposite circumstances, and their associated emotions, brought to mind a story that I first told in 2005, as I was working as a Red Cross volunteer in Mississippi and Louisiana after Hurricane Katrina had slammed ashore and turned the world upside down for so many people on the Gulf coast. I thought I would share this story with you. It still makes me smile.

 

I had an encounter with a beautiful little girl in Mississippi, just days after the monster category 5 storm had entered her family’s life. It reminded me, harshly and painfully, of what present-day Red Cross workers and thousands of other volunteers are going through right now, trying to do what they can for and with people who continue to suffer in various scenarios in our country and around the world.

 

I met Erica at the First Baptist Church in McComb, Mississippi. We were deploying out of the Red Cross shelter there, and I would often see people in that setting at the church or in the gym where they were making their temporary homes until the aftermath of Katrina’s wrath could be sorted out. She was a frail seven-year-old with beautiful dark skin and large eyes. She had not been eating or drinking in the five days since Hurricane Katrina had demolished her family’s house. She now lived in a small trailer with her parents and younger sister. She had nightmares where her parents and teachers were brutally killed and maimed, and she had lost all interest in playing or singing. We sat crossed-legged on the floor of the education building hallway, busy volunteers bustling around us, a tired Red Cross worker and a little girl who had literally lost everything in her life but her family. I leaned against the wall, happy for a few minutes to sit down and rest. She sat with chin in hands, looking down at the polished floor of the church building. I had tried to engage her in conversation, to no avail. I thought I would try one more thing.

 

“Erica, what’s your favorite food in the whole world?” I asked.

 

She looked up slowly, her interest piqued. She sized me up with those big eyes as only a child can, and I saw a faint glimmer of a smile.

 

“Fortune cookies.”

 

“Fortune cookies?!” I said, truly surprised. I had expected the usual hamburgers, hotdogs or ice cream. “I’ve got your number,” I said instantly, my way to this child’s fragile and damaged psyche suddenly made clear to me. “Give me twenty minutes and I’ll be back.”

 

She looked at me quizzically, but a simple “Okay” came out.

 

I returned to a Chinese restaurant I had just found the day before. I had enjoyed a meal there that nourished my mind, heart, and stomach, and I had struck up a brief conversation with the staff while I was there. Wearing a Red Cross vest was almost always a stimulus for questions from those who lived in the local communities that we served. I sought out and spoke with the hostess, who listened to my story about the little girl whose life had been ravaged by this storm that came out of nowhere and changed everything forever. She stepped toward the back for a half minute, returned and immediately began filling a large shopping bag with handfuls of fortune cookies plus a few dinners for Erica and her family. As I pulled out my wallet to pay her, she pushed it away, tears streaming down her face. “Hurry back to little girl who will not eat,” she said, handing me the bag full of food. “Go. Go now!” I thanked her, many times over, for her family’s generosity and goodness that would mean so much to this little girl and her family.

 

I returned to the church education building hallway, finding Erica sitting exactly where I had left her, surrounded by boxes of peanut butter and tuna that reminded me of a protective wall.

 

The little girl and I sat cross-legged once again on the floor. She looked in the shopping bag that I set down between us, eyes growing big as saucers. There was no mistaking fortune cookies, with their brightly colored wrappers.

 

She looked up at me.

 

“Can you eat just one of these for me, right now?” I asked.

 

The faint smile returned.

 

“Yes.”

 

“Could I eat one with you?”

 

“Yes.”

 

Little hands plunged into the bag. Cellophane wrapping papers crinkled happily. We munched contentedly.

 

“Now, how many of these do you think you can eat?”

 

The little girl from New Orleans gave this some serious thought.

 

“ALL of them,” she said emphatically.

 

“No way! You haven’t eaten anything in five days,” I teased. “You’ll be sick!”

 

More serious thought, eyes narrowing.

 

“Well,” she said slowly, “maybe not TODAY!”

 

The smile broke through.

 

Disasters are overwhelming and ubiquitous. Our personal response, our personal ability to do anything helpful, sometimes seems tiny and insignificant. If we listen, look, and pay close attention, we can make contact with those who need us most and deal with one small crisis at a time. Much like Erica and her bag of fortune cookies, we may not be able to help thousands of people in one day. We can start with one fortune cookie and one little girl with dark skin and beautiful eyes and a smile as big as Louisiana.

 

Erica, wherever you are, you should now be a vibrant young woman. I hope you are doing well. I am so glad that I was able to share your favorite food with you that day, and I hope that your fortunes have made a giant turn for the better.