Monthly Archives: January 2025

No Alarm Today

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I woke up because my body was ready to leave dreamland behind and start the day. There was no beeping alarm or bright light from my sunrise alarm clock jolting me awake. Today my schedule is fluid. I have a to-do list (I always have one) but today I can ignore every item on the list if I want to. It is a rare day with no objective and no place to be. I could, if I really wanted, lie in bed and watch the day start without leaving the warmth of my covers. Or I could get up and sip mate for several hours. I could sit on the couch and watch the plants grow. I could go for a walk, do a workout, or write. I could do anything or nothing. The lack of expectations and requirements for today is freeing.

No alarm days are rare and lovely. Having spent the past many years in medical school and then residency my life has been filled with productivity and hard work. But, just as too much free time makes me stir crazy, too long spent with an overly packed schedule depresses me. Letting the day begin spontaneously reminds me of my years in Paraguay. In Paraguay, most days flowed in a semi-planned way. My life was free in Paraguay. Even though I had work, obligations, and social activities in the Peace Corps, I’ve never had as much free time during my adult life as I did in the land of the Guarani.

Sometimes, when the sun shimmers into my apartment and my houseplants glow with the joy only photosynthesizing entities have in the sun, I’m transported back to my Paraguay naps and meditations under the shade of the mango trees with the nearby palms swaying in the breeze. On those mental journeys, I’m reminded that quiet is an underappreciated aspect of life. Of course, us humans need purpose and connection to be happy. But every moment needn’t be assigned. The happiest folks I’ve met are those who embrace the slow days when they come, sometimes even setting aside calendar days for nothing. I want to be among the ranks of the happiest people. I think this goal starts with no alarm days. My no alarm days are for basking in the strange meandering that occurs when I decide to let spontaneity determine the agenda.

Today is a no alarm day. The sun is shining. The mate is perfect as the steam curls up from each pour of water over the yerba leaves. The yerba is fresh and so it bubbles. The plants in my house look good. Maybe I’ll water them later because it’s sunny and they’ll need it. Some of my orchids are blooming, some will bloom soon, and some are pondering their future (deciding if they will flourish or die for no reason). My house trees seem tall today. Beyond my plants, through the window, and past the balcony the cranes move. Richmond is constructing several new tall buildings. There are 4 cranes to watch from my balcony. The cars bustle below, sometimes their music is loud. Life continues. I sit. Today is a no alarm day. I’ll probably go for a walk later. But this moment is for drinking mate and observing my plants. What a beautiful moment it is.

Over 48 Hours Without Running Water in the City of Richmond

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“See these?” my mom asked flexing her biceps, “Hauling water.”  

When I was young, my family lived in rural Vermont in a hunting cabin without running water. My parents hauled water from the stream for bathing and we filled jugs at my dad’s work for drinking water. Those years in the woods prepared me for life as a Peace Corps volunteer in rural Paraguay where amenities were often lacking.

When my mom visited me in Paraguay, I flexed my biceps. “See these?” I asked. “Washing clothes by hand.” But it wasn’t just that. In Paraguay the water and electricity went out often. Just as my parents had done when I was a child, I developed ways of conserving water and making do when the utilities were down. One of my kitchen walls was lined with 2-liter bottles (recycled soda bottles) filled with clean water – so I was ready when the water went out. Some of my Paraguayan friends had different water sources from me and therefore often still had water even if I didn’t. My friends in Paraguay were used to the water outages and had a communal approach to getting through those annoying stretches. I could count on them to invite me to shower or to wash clothes at their homes if my water was out for more than a day.

When I returned to the US after completing my Peace Corps service, I figured my only time without running water would be when I was backpacking or camping. Self-imposed in those cases and short-lived. But Richmond surprised me this winter. In classic southern fashion (being from Vermont, I must poke fun at how the southern US handles snow), all went awry when Richmond was hit with a true snowstorm and sub-freezing temperatures. One of the city’s water pumps broke, multiple backup systems failed, and fixing the problem was harder than officials expected. As such, almost the entire city lost water for just over 48 hours and had to boil water for drinking for almost a week.

In the grand scheme of things, no running water for 48 hours and a boil advisory for about a week are insignificant compared to the water hardships many people around the world face. However, I found it interesting that such a utility failure could occur in a modern US city in the absence of a natural disaster. My husband and I (both from New England and used to winter power/water outages) were prepared. We filled pots and buckets with water just before the city turned the water off. We refilled our buckets in the river as needed to ensure we could flush our toilet. I took a baby-wipe bath one day. I washed my hair in the sink another day when the water was starting to come back but we still didn’t have enough water pressure to run the shower. I’ve known how to take a bucket bath since I was a child. Though it is a nuisance; it is simple.

48 hours did not restore the bicep muscles I’ve lost since returning to the US and living with modern, reliable running water and all the amenities that come with it. Yet, during Richmond’s water outage, I found myself flexing my biceps and thinking about the many people across the globe who have unclean water or minimal access to water daily. In the US reliable utilities are taken for granted. Richmond’s loss of water was a good reminder of how precious functional utilities are. I expect Richmond officials to review how the system failed and take steps to ensure such a failure doesn’t occur again. I also consider the water outage an opportunity for myself and other citizens to reflect on the event. In a world faced with global climate change which is leading to more severe weather and more chance for disasters that could cut-off utilities, how prepared are we if the systems we take for granted fail? How does one function without running water? Without electricity? What do we need to learn to be better prepared to navigate these situations when they arise? What can we do to prevent utilities from failing? How can we protect our water resources?

The Stickiness of Capacity

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“It’s my religion, my decision!” they yelled as the elevator doors closed, the climax of their escape (though no one was stopping them) from the hospital. They often spoke in rhymes. Where they would go and what condition they’d be in when they got there were mysteries. They’d been in the hospital for almost 2 weeks as we tried to find a safe place for them to discharge to. Their house was in such disrepair that their electricity had been turned off because leaving it on was a fire hazard. They’d had frostbite before, and winter was near. Their mental state was such that we did not believe they could make safe decisions for themselves. They had no way of getting home without our help. Despite all these features they were not in immediate danger of harm and so we had no legal grounds to keep them when they decided they were ready to leave the hospital. We tried to convince them to stay, but they would not listen. They were ready to leave; they wouldn’t wait for us any longer, not even to arrange a ride home. We were worried that they were leaving without a safe plan, but the US medical system is not a jail system. Except for several clear situations, our patients are free to leave the hospital whenever they please even if their doctors think it’s a bad idea.  

Capacity, a patient’s ability to make informed decisions about their healthcare, is more complex than one might think. It’s grounded in the ethical principle of autonomy, which means that patients have the right to decide what happens to their bodies. To understand the complexity of capacity requires at least some understanding of the history of medicine and how we conduct medicine today.

Medicine was paternalistic historically (and in some places it still is). It also wasn’t, seemly, originally centered on doing what was best for patients. There are classic examples of medicine’s unpleasant history, among them: the Tuskegee Syphilis Study, Henrietta Lacks’ stolen cells, stealing corpses to supply cadavers for anatomy labs, and the history of insane asylums. Given its concerning past, there are strict laws outlining which patients can be kept in the hospital against their will and for how long. There are also laws ensuring patients are informed about the risks and benefits of their healthcare and allowed to decide if they would like to pursue or decline tests and treatments their doctors recommend.

When a patient doesn’t have the ability to make their own decisions (for reasons such as acute illness or chronic conditions like dementia) we say that they “lack capacity.” In such instances we identify a person who can legally make decisions on their behalf. Capacity is decision dependent – so a patient may have capacity to say they don’t want to eat lunch but lack capacity to decide to undergo vs. decline a life-saving surgery. Capacity also can be fluid, so perhaps an acutely ill person doesn’t have capacity initially but as they start to recover, they regain capacity. For patients with conditions like dementia, often capacity is never restored if lost.

In tricky cases like the patient described above, the healthcare system can do less than you might think. We can easily treat acute illnesses that are a complication of a patient’s confusion (such as frost bite) but we have few ways to help avoid frost bite in the first place. Hospital social workers can help find nursing facilities to offer at discharge, but seldom can we force patients to go to a nursing facility if they don’t want to go. It’s also worth noting that we do not have the ability to find housing for people experiencing homelessness – so unless they need a short-term skilled nursing facility at discharge, we often have no choice but to discharge patients experiencing homelessness back to the street once they’re medically stable.

In these circumstances, sometimes those of us in healthcare are left with unsettling discharges either because our patients discharge even though we don’t think they’re ready or because we discharge them to the street (or to an unsafe home). In the case of the patient who yelled “It’s my religion, my decision!” as they made their dramatic exit, the patient declined our safe discharge ideas. Even though their medical decision-makers agreed with us, no one could force the patient to do something they did not want to do. After discharging the patient, we (their care team) found ourselves keeping an eye out for them as we drove to and from work. Our plan was to call Adult Protective Services if we saw the patient – because we all knew they had no way to get home. We couldn’t force them to wait for a ride and they had no money for the bus. We also weren’t convinced they knew how to get home. We all suspected they’d end up wandering the streets. As I drove on the lookout, I was reminded how limited our healthcare system can be. I was also reminded that balancing patient autonomy and medical beneficence is not always easy.