Looking Downriver

On paddling, processing, pen and paper

Hey friends,

I was so psyched that Annals of Emergency Medicine published a story of mine called “Looking Downriver” in July 2024. It’s about trauma, mental health, and getting help when you need it. If you have access to Annals, you can check it out using this link. If not, you can read it below!

This picture of my brother and me after paddling a canoe for 68 hours straight ties in to the story, so you know it’s gonna be interesting!

Looking Downriver

The hallucinations started for me on the afternoon of day two. Nothing to worry about, they were just part of the deal. Almost everyone who attempts the Texas Water Safari—a 260-mile, 100-hour canoe race during which you don’t really ever sleep—experiences them at some point.

My brother and I had finished the ninety miles of the crystalline San Marcos River with all its rapids and portages and paddled our aluminum canoe into the brown slog of the lower Guadalupe at some point during the night. Squinting in the June sunlight and fighting off the weariness as the second afternoon wore on, I began seeing mysterious people wading in the waist-deep waters near the shore. I wondered what they were doing there. Were they stranded paddlers? Were they Safari competitors taking a break in the cool water and shade? Invariably as the current carried us closer to each apparition, I would discover cypress stumps or pecan trunks where moments before these people had been.

The visions became much more interesting in the gloom of night two. The large overhanging cypress, sycamore, and pecan trees that lined the river now appeared in the murk as rounded monochrome blobs. Their colors muted and the subtleties of texture and depth washed away by darkness, my sleep-deprived brain projected its own pigments and pictures onto these giant arboreal canvases. As the night wore on, I found I was looking not at trees but at giant, menacing clown faces, Guy Fawkes masks, even fanciful dragons, depending on the shape of the tree. At times, I found myself ducking to avoid the open mouth of a T Rex reaching out over the river. I learned not to look up and face the terrors but to focus on the water ahead. That’s what I’d always done. Just keep paddling. Left. Right. Left. Right.

We paddled across the finish line in the coastal waters of Seadrift, Texas at the 68-hour mark, our bodies wrecked but still afloat. My soaked and muddy clothes hung off my shaking and shrunken frame as I hugged my long-suffering wife and number one supporter on the shore in the dark. “That was the stupidest thing I’ve ever done,” I told her, and she walked me to the car. The demons had left, the sun had come up, my thinking cleared, and in a month or so, my body recovered, too.

Extreme outdoor activities like this had been for me a major form of work-life balance and wellness during my career in emergency medicine. No matter how much a string of night shifts had beaten me up, no matter how many battles I had fought and lost against the corporatization of our ED group, getting outside always made me whole again. Trail running, rock climbing, river paddling, backpacking—there wasn’t much they couldn’t fix.

On a different river a few years later, I encountered very different visions—unexpected this time. It happened during the summer when I experienced true burnout for the first time. Slow to recognize my burnout, I had started to fall apart before I could even name the symptoms—doubting my abilities to care for the seriously ill, dreading my shifts, crying in the shower for no reason, perseverating on unpleasant scenes from my ED past.

My brother, my father, and I were canoeing down the Buffalo River in Arkansas on a hot July afternoon. Our conversation turned to my uncle, an outdoors hero—one of my heroes—who had taught me how to paddle when I was a kid. His kayaking was the stuff of legend. Many years ago, he had unexpectedly taken his own life by gunshot while I was on my trauma rotation as a medical student. As we talked through this tragedy again, I confided in them that I still thought about it often.

For days in the surgical ICU after my uncle’s death, I told them, I had changed the dressings on the skull and brain wounds of a young man who had shot himself after a breakup. His cortex ruined, the patient still breathed some due to brainstem activity, leaving his prayerful family hopeful for a miracle. The prayer candles and praise songs on constant repeat in his room stood in such hopeful contrast to the sad, scientific reality of his devastated brain. I’d never really talked about how that messed with me in the wake of my uncle’s death.

Paddling downriver that day in the hundred-degree heat, my mind kept drifting back to patients I had cared for over the years with gunshot wounds to the head. As I gripped the lightweight carbon fiber paddle in my hands, switching from side to side to keep the canoe straight, I couldn’t help but remember the feel of the shattered temporal bones crinkling under my gloved hands as I readied myself to intubate. I saw before me the splintered skulls and the bulging eyes I had witnessed in the trauma bay. As I floated on, these images wouldn’t leave. They had escaped from a box somewhere in my brain that I did not even know was there. I shook my head back and forth as I paddled to snap out of it but found I couldn’t stop the replay of the horrors I had seen and held in my hands.

At home on my back porch after the trip, the disfigured ghosts from my ED past continued to haunt me. There was no sleep deprivation to explain the thoughts away this time. The unprocessed traumas I had witnessed in the ED for years, the crumbling of our ED group, and the cumulative exhaustion of a decade spent riding catecholamine surges had finally caught up with me. A strange thought flashed in my brain, unbidden: “You’re not gonna be able to paddle your way out of it this time.” It was true. No amount of outdoor activity was going to help me out of this. I was adrift. I needed help. If I’m honest, I had never thought I would.

Rest, prayer, time off, walking with my wife, talking with my ED buddies and a physician coach, reading, counseling, and therapy—these were the rungs on the ladder that helped me start the climb up from the bottom of this emotional and psychological well. Eye movement desensitization and reprocessing (EMDR) therapy helped me work through old memories and nightmares from my past. My therapist used alternating buzzing paddles in each of my hands as we journeyed down a guided stream-of consciousness exploring dark places I’d left unsearched. Left. Right. Left. Right. Steadily the EMDR transported these traumas downstream, out of my amygdala and hippocampus and into my rational brain. When the sessions ended, the memories remained, but the paralyzing emotions and fear were gone.

As therapy progressed, I found myself drawn to another form of exploration—writing. I still remember how shy I felt about sharing my first story with a friend. Why would anyone want to hear my story? How could I be so open about this brokenness? I had always wanted people to think I had it all together. But I just kept writing stories—I had to! In exploring my patients’ stories, I was discovering a side of my own humanity I had too long neglected. I found a local community for health care storytelling where wounded healers gather quarterly and create safe spaces for each other to share their stories. I found vulnerability modeled for me in such inviting ways. I learned it was okay to feel, to hurt, to process, and to share. I learned to model that vulnerability, too. Now on the other side of my struggles with burnout and unwelcome visions, I cannot imagine practicing medicine uncoupled from a regular writing and reflection routine.

We all need help, friends. We all have stories to tell. For me, therapy, EMDR, and storytelling have meant the difference between leaving medicine for good and thriving in a whole new way in palliative medicine. I still get out on the water when I can, but I am finding that pen strokes help me explore the deep waters of medicine more than paddle strokes ever could. Looking downriver now I read the water more clearly. I see brokenness and beauty, vulnerability and connection, wholeness and hope.

---

Be well, friends. Take care of yourselves and each other.