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Friday Nov 18, 2016

Bare Necessity: Communication Is Critical in a Crisis

We live in an interesting and uncomfortable time of change. There are strong feelings of anxiety among not only our patients, but also our colleagues and ourselves. The recent elections, new regulations that add to administrative burden, proposed insurance mergers and more have all created unprecedented anxiety in medicine.

Before I moved to Alaska, I would use the metaphor of a bear hiding in the woods as a symbol of fear and uncertainty, so it is ironic that since I moved to Valdez, a small frontier community in the state, I have had frequent close encounters with bears that taught me some important life lessons.  

Most people don't know that bears talk. I can tell you from firsthand experience that they do.

Sometimes you have to stand up to those more powerful than you. Even the strong don't want conflict if they can avoid it.
Not too long ago I was hunting ptarmigan with a .22 when I walked around a bush and came face to face with a large brown bear. This is usually how it happens. Here you are minding your own business, and you walk into a bear. As I stood there, I realized that a .22 is a really small gun and useless for protection against a bear. Running also is not an option unless you want to get chased, so we stood there looking at each other for a long time, deep brown eyes staring into green eyes.

Finally, the bear said, "Dude, are we cool?"

"Yeah," I answered.  "We're cool."

We both turned around and walked in opposite directions. Communication occurs in many ways and not always with words, yet when I remember this event, the words are there.

Relationships are important. You never know when you will need them.  
Another time, my wife and I were soaking in the hot tub on our back porch. We live on the edge of town, and bears come through the yard on a regular basis. Still, it was unnerving when three grizzly cubs came walking through the yard within feet of where we were enjoying the evening.

They were really cute, but where there are grizzly cubs, there is a grizzly mother. I knew these cubs, having seen them with their mother many times while bicycling. When I was on my bike I gave this family plenty of space, staying outside of charging range. I was careful to be polite, keeping upwind and making noise. I find that singing "The Bare Necessities" from The Jungle Book is a good choice.  

The cubs started playing with our fire pit, and sure enough, the mother bear came walking into the yard. My wife and I were still in the hot tub. She looked us over, sniffed, and said, "Hmph, so this is where you guys live. Nice fire pit. Come on, kids." And she walked off.

The problems you can see are rarely an issue. It is the unexpected that causes most stress, so don't fret, pick the best course you can and be ready to respond.
Once when I was covering the ER in Valdez, I listened to a patient describe his close encounter. He presented with chest pain, but it wasn't a heart attack. He had been sat on by a bear.

The patient reported that he was always vigilant for bears, and he carried bear spray in case he was attacked. He was hiking along a steep mountain trail when he suddenly spotted a bear on the slope just above him. The surprised patient jumped and made a noise. The bear, who also was surprised, fell over backward and sat on him. They both got up and yelled at each other for a while.

"What the heck, dude?" The bear was upset for having been startled.

The hiker was more upset about being sat on than he was scared. Luckily, he had bear spray in his hand, and eventually he and the bear agreed to go their separate ways. The patient came into the ER with a chest contusion, covered in bear hair and smelling like pepper and bear.

There are times when it is just not necessary to poke a bear!
Another time, my wife and I were riding our bikes when we came upon a mother and cub on the trail. The mother sent the cub up a tree, then stood up on her hind legs and huffed. She explained that she was not having a good day, that toddlers are a trial but she loved hers, and that if we came closer, she was going to hurt us.  

We stopped and waited for a while, then turned around and went in another direction. It was a sunny day, the birds were singing, there were many other ways to go. We certainly did not need to stress a young mother.

Sometimes you have to ring your bell, even if it is a goofy one.
Another time I was riding my brand new bike, a bright red Bianchi with clip pedals and a goofy little bell on the handlebars. Road biking was a new sport for me, and I was still not good at disengaging the pedals. I was riding fast along the bike path when I looked up to see a mother bear and two cubs walking toward me. They took up the entire path and evidently did not see me coming.

I should have stopped, but was afraid I couldn't get my feet out of the pedal clips and would just fall over right in front of them. So I rang my goofy little bell, which gave a little "ding-ding" sound. The effect was absolutely amazing. They panicked, bolting for the trees on either side of the bike path, and climbing so they were well above my head when I went by.

Every safety plan needs to be rehearsed, and the equipment needs to be checked.
We had just barbecued a salmon for a small get-together and had left the kitchen window open so we could pass the salmon through it. We were being loud and having a good time when a large bear stuck its head through the window to check out the party. Maybe he wanted some salmon.  

My wife yelled, "I've got this!" and grabbed what I thought were firecrackers and a lighter. To my horror, she tried to light them as she ran straight toward the bear. This scene was wrong on so many levels that all I could do was say weakly, "No, wait … "

By that time, she had reached the bear and thrown the now-lit items with an admittedly graceful motion. They stuck to the bear's chest while the fuse burned, and the bear pulled his head back out of the window. It turns out they were sparklers, not firecrackers, so we were treated to a sight of a bear on our porch slapping at his chest while the sparklers gushed silver and gold. He was not impressed by this turn of events, but he left anyway.

On another occasion, the same bear came back on our porch. My son grabbed a fire extinguisher and charged, yelling at the top of his lungs. The bear was understandably surprised and took off, with my son in hot pursuit. When my son rounded the corner of the house, the bear was standing on his hind legs, arms outstretched, and not in a good mood.  

My son tried to squirt the bear with the fire extinguisher. With a sinking feeling, he quickly realized that it did not work. He chucked the extinguisher at the bear and ran back to the house.

The best cure for anxiety about the future is the euphoria you feel after being scared.  
Nothing makes me feel better about being alive than having survived a bear encounter. There is a part of our brain that is always looking for the bear in the woods, around the next bush or around the next corner. With anxiety about the future, this part of the brain is activated and vigilant and does not reset until we fight the bear off, stare the bear down, climb a tree or run away.

We may live in cities, work for corporations and hospital systems, deal with insurance companies and difficult patients, but we evolved with bears. Our brains are hard-wired to react as if there is a bear around the next bush or tree. I have been fortunate in that some of my bears have been real and not allegorical, but my advice is the same. There will always be bears in our woods; the trick is to listen to what they are saying.

How about you? What are your bear stories, and what life lessons have they taught you?

John Cullen, M.D., is a member of the AAFP Board of Directors.

Posted at 09:45AM Nov 18, 2016 by John Cullen, M.D.

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