Autism Review

I recall being a newbie occupational therapist and having a keen sense of "having to put my time in." It is probably a broad cultural value passed to me first from my family. My Dad was a hard working person who I saw go to work every day and sometimes even every night when he was assigned an evening shift.

When I graduated from college I gravitated toward home care and consultative occupational therapy; the freedom and responsibility of these settings matched my interests and work style. Since I was a newbie and trying to work for home care agencies all of the preferred geographic areas were taken by more seasoned occupational therapists. That left me with assignments in far-flung areas where I had to drive up to an hour to get the the patient's home. I figured that I would accept these cases and then after some time I would be offered cases that were not as far away.

So, during this time in my career when I was driving from Buffalo to Farnham and North Collins, dreaming of closer assignments, I met Peter Talty.

Peter was one of those 'more seasoned' OTs who I imagined I was competing against for favorable home care referrals. He called on the recommendation of Kent Tigges who was a mutual friend and said to me, "So I hear you are interested in some work and Kent tells me that I should call you!"

I already knew who Peter was although I never met him - and I was nervous and excited that he would call and offer me a job! Now being a newbie and most certainly not being in a position to turn away work and being flattered to have Peter Talty call me and definitely wanting to show my best for my mentor Kent I listened to myself reply, "Sure... definitely!" even before asking for any other details.

I'll never forget meeting Peter in person for the first time and I will never forget the first question I asked: "So... where did I agree to work and what kind of work will I be doing???"

Peter didn't hesitate a second in his response - he delivered the news to me in the straightest of terms. He deadpanned, "You know when you are driving along a major road like the Thruway and there is an exit for a town you never heard of? Then you look over and all you see is trees and maybe a gas station sign? You might wonder what is over there if you took that Thruway exit. That is where we are going to go!!!"

I noticed that he said "we" and that surprised me a little - after all, most "seasoned" occupational therapists only worked in places that were geographically close to their homes. I quickly learned that although Peter was very experienced he was definitely not like "most" therapists.

Although Peter lived near the Buffalo area he went with me to set up and deliver occupational therapy services in very distant places all over Western NY. We went to nursing homes in Salamanca and Machias. We went to community rehabilitation programs in Olean. We went to a residential program for children who had developmental disabilities in Bradford, PA. I will also never forget how Peter gave me directions to find these places: "Keep driving down this road and you will see a place called 'The Cow Palace' on your right. Keep on going and take the right fork in the road after that - but it won't have a street sign." Peter's directions were legendary.

While thousands and thousands of miles ticked off my odometer I never minded it at all. Peter was an amazing role model and I quickly dropped my preconceived notions of how far experienced OTs should have to travel for work. Peter Talty went the extra mile.

He didn't just go the extra mile in physical distance - he did the same for me, for the COTAs we supervised, and for all those patients including every child who had an IEP along the old Route 17 between Randolph and Belmont. In places where there was no occupational therapy, in places where occupational therapy needed to be, Peter Talty made occupational therapy happen.

I also recall Peter's phone call to me asking if I was interested in teaching some lab sections at a college. By that time I knew enough to ask "where is this college where we will be going??" Of course he was referring to Keuka College - a two hour drive for us both - but it was another tremendous opportunity to watch Peter 'go the extra mile' in so many ways for hundreds of occupational therapy students over the years.

A year or so ago Peter called me and wanted to spend some time in my private practice. Watching him work again was another amazing reminder of what he brought to patients, how he listened to their stories, and most importantly how he helped them move forward with their own recovery.

Peter Talty is retiring from Keuka College this year and I can think of no better way of honoring him than telling this story of how much good you can create when you are willing to 'go the extra mile' as an occupational therapist.

Whenever I drive along a road and wonder what is over the treeline I think of how important it is to care. I also remember that Peter showed me that you also have to care enough to actually put yourself into action. Sometimes the people who need us the most will be in places where we haven't been before and where we never imagined ourselves being. His example is one I will always aspire to.

Life is complicated enough that I try to avoid having existential crises as often as possible, but it is Monday and humans are natural meaning-makers and I can't escape my tendencies.

Anyway, I was perusing Facebook this weekend and saw a partially familiar face as a 'recommended' friend. I am not certain of the algorithm and logic that Facebook uses to make these recommendations - I imagine it is at least loosely based on 'degrees of separation' computations.

The partially familiar face was Freddie, who I have not seen in many years. I worked with Freddie when he was on the cusp of his adolescence. I remember him as being an intelligent and extremely likeable fellow who had some pretty tough problems with his handwriting and social skills. He made a lot of developmental progress while I worked with him, and as with most kids there seemed to be a time when he just no longer needed the direct intervention. The last day of seeing a child for therapy is always a little bittersweet.

About 5 years after he was discharged he visited my office and delivered a package of candy. At that time he was near 18 and we had not seen him for a while but he felt compelled to ride his bike over and visit. I was not there that day and I have long regretted that I missed the opportunity to see him.

What sticks in my mind about Freddie is that he opened up the first day I met him and told me that in his perception he was a really cool kid up until kindergarten and even during kindergarten he was popular and had a lot of friends. However, he had some learning difficulties and he was 'forced' to repeat the school year. In his mind that equated to absolute relegation to the trash heap of the school social hierarchy. He stated that from that moment on he was known as "Mr. Held Back" which was akin to having to experience "EMOTIONAL HUMILIATION" on a daily basis.

Now I don't know if other elementary school children actually called him "Mr. Held Back" but it didn't matter because Freddie THOUGHT they did. I capitalized "EMOTIONAL HUMILIATION" purposely, because there has to be some way I can transmit how large of an issue this was for him.

Freddie hurt, and I listened. I tried to help.

Children (and their parents!) often give little gifts to their therapists for holidays or events. At some point in time Freddie gave me a Newton's Cradle, which is the photograph at the top of this entry. It still sits on my desk and it is a daily reminder of Freddie and his keen mind that was interested in physics. To me, that Newton's Cradle also represents the significant restraint contained within those natural laws that dictate the motion of bodies in space based upon directed forces, velocity, and mass.

I never talked about those constraints with Freddie because the whole point of intervention was to find a way past the forces that constrained him. In that way it was an ironic gift - a fact that I am absolutely certain would not be lost upon him if we discussed it today because he had an extraordinarily keen skill for analysis, even if he couldn't write legibly to proverbially save his life.

There is a lot that an occupational therapist can do for a child - handwriting can be improved, organizational skills and systems can be practiced, and even to some degree an OT can help children develop social skills and point out ways to improve interaction with a peer group - even when the child believes that the peer group practices EMOTIONALLY HUMILIATION at every turn.

No matter what I tried, I don't know that I was ever able to find a band-aid large enough to cover that wound of EMOTIONAL HUMILIATION. Really, how can you fix such a thing?

Well after seeing Freddie on Facebook over the weekend I came to my office this morning, pulled out his chart and noticed that he is over 21 years old. I also noticed that I have not seen him in over eight years. Under this context, I am not obligated to keep his medical records any longer.

So I imagined I could defy the laws of physics.

I grabbed a hold of the constraining tether of EMOTIONAL HUMILIATION that returned his pain at a roughly equivalent velocity back at his actions and I dumped his file into the shredder.

Now there is no record of emotional humiliation attached to his name in the real world and I have found a way to completely bypass the rules of how momentum and energy are conserved in that system.

Only echoes remain - edited and recorded on the Internet so someone else can learn - call it a system in a parallel reality that is only loosely connected to the real thing.

And I wish freedom and peace for Freddie, who in my opinion deserves them both in large quantities.

"I love you," Kimmie's grandfather said, while gently releasing her hand and carefully pulling up the bedsheets around her thin shoulders.

"Well I love your eyes," she said back, and planted a kiss squarely on his jaw.

The grandfather gave her a wink, got up, and tipped his hat to me as he left the room. I felt a little awkward and concerned that I stepped into a personal moment, but Kimmie didn't say anything about it so we just quickly got to the business of therapy.

Kimmie was a nineteen year old young adult who had cystic fibrosis and spent many long weeks in the hospital. I got to know her pretty well because she was admitted to the hospital several times each year. She landed on my caseload after her first hospitalization and the way we divided workload kept 'repeat' patients like her with the same therapist each time.

She talked a lot about tranferring to an adult hospital but she knew her pulmonologist so well (and vice versa)that her family decided to stay as long as possible in the children's hospital where she felt more comfortable.

I didn't know a lot about CF when I started working with her; she taught me most everything that I know about the condition. My job assignment from the pulmonologist was relatively simple and straightforward: she had diminished lung capacity and frequent infections that limited her physical activity - so my job was to keep her as physically engaged as possible within the limits of her physical capacity to maintain oxygen saturation levels.

Sometimes that meant trying to get through self feeding in the ICU. Sometimes it meant playing air hockey in the playroom while standing and using wrist weights during the activity. She normally beat me in air hockey but one day I had an uncharacteristic winning streak. I assumed she was just having a bad day because the pulse oximeter was ticking down into the low 80s, threatening to alarm, so we decided to take a break and let her recover a little bit.

"I'm getting killed!" she said as she reached toward her chair. I had to steady her on the way down because she was a little winded. Kimmie's body was very frail and her trunk was stiff and rounded like a barrel. Her shoulders were in her typical position of being hunched up close to her ears and rounded forward. "Come on now Kimmie, let's not throw posture out the window," I answered back in a non-reply as I lowered her into the chair.

Then I continued, "Well usually you are the one who is killing me in this game, so it is about time I have a chance to beat you!"

I watched her O2 levels stabilize at 82 and I was glad that I wasn't going to have to get the nurse. "I don't think you understand Chris," she said. I looked over and saw that tears were in her eyes. Kimmie had soft round eyes with large lashes, and her cheeks were dimpled and puffy and always seemed a little rosy no matter how far down her O2 levels sank. "I'm getting killed. I'm dying and I can't stop it."

Kimmie's air hockey defeat apaprently underscored her inability to stand and underscored her inability to maintain her focus because she had to concentrate every bit of effort on finding a way to get sustaining oxygen into some functional part of her lungs. She used to tell me that she wished she could control her breathing so she wouldn't waste time and energy sending air down to places where it wouldn't make a difference. She was pragmatic that way, but now suddenly everything in front of her became a blurred confusion of loss, and gigantic tears welled in her eyes, dangled briefly on her eyelashes, and then splashed down heavily onto her cheeks.

"I hate crying," she said as I frantically grabbed for some tissues and handed them to her. Her tears welled and lingered and overflowed and then bounced off of her cheeks in a repetitive pattern that she could not blink away. "I hate crying because I can't see and its bad enough not being able to breathe but I hate when I can't see and can't breathe at the same time."

This was probably something that she spent some time thinking about before, I figured, based on the specificity of her concerns. Perhaps the crying loosened up something in her lungs because her O2 levels ticked closer to 85.

"I'm afraid Chris, that someday in the ICU I won't be able to breathe. Maybe I will know I am dying. Maybe I'll see my Mom and I'll cry. What if I cry and can't see when I can't breathe? What am I going to do?"

When you work around people who are critically ill or even around those who are dying or close to death you can develop some very sophisticated defenses that may not be particularly logical, especially in consideration of all the scientific facts and knowledge that go into your training. I never really considered that Kimmie was going to die, because the ICU doctors could save any person's life. Besides, she could play air hockey so anyone who can play air hockey and teach me about CF wasn't close to dying any time soon. Besides, it wasn't my job to think about that anyway. It was my job to help her find ways to do things and to stay as healthy as possible.

Kimmie got worse. Then she got better and went home. Then she got worse again and was on a transplant list. Then she got better and went home. This reinforced the fact to me that Kimmie was not going to die.

Nineteen turned to twenty and even her pulmonologist was pushing her toward an adult facility. We still played air hockey. Her shoulders got more rounded and her chest and ribs became even more stiff and immobile. Air hockey was something that she could still do. It was a point of activity in a senseless disaster of steroids, IV antibiotics,respiratory therapy, and recovery from impossible metabolic imbalances when she got bad enough to require temporary intubation.

Crying after air hockey started to become something of a ritual. "I hate it, but do you mind, Chris, that I cry after we are done?" she asked me one day. I didn't know what to say - so I offered to stop our air hockey activities if they were just making her cry. "I don't want to stop beating you in air hockey! I just want you to be sure that I can see if I start to cry." I couldn't decline the request, so instead of handing her the tissues it became my job to wipe the tears from her eyes and face if I won.

People develop different points of meaning around all different kinds of things. Kimmie had a thing about eyes and crying and being able to see. She talked about wanting to be able to see constantly. She hated when she couldn't see things because of crying or oxygen masks. I accepted it, and wondered about it because it came up all the time with her.

As I dabbed her tears one day I had to ask, "Kimmie, why did you tell your grandfather that you loved his eyes? I always wondered why you said it to him that way."

"I want to be old," she told me. "But it won't ever happen. I want my eyes to crinkle around the corners when I smile. I want to experience enough to have those happy lines on my face. Then if I cry the tears won't get stuck on my eyelashes and they won't fall on my face. They will go where tears go when you have lived long enough to have riverbeds for them to flow into."

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Kimmie died that year. She was 20. The doctors couldn't save her, because no one can save you from CF. She didn't live long enough to have happy lines. I hope she didn't cry as she was dying, because I know she wanted to see. I don't know because I wasn't there when she died. No one was. She died at home in her room at night, alone.

That was almost 20 years ago. It took me a really long time to write Kimmie's story down. I'm thinking about her now because I am 45 and at the end of a long day I take water into my hands and splash it onto my face, watching drops beginning to find small patterns that follow away from my eyes. It is a gift that she wanted desperately and could not have. It is a gift that I am only now beginning to be blessed with.

I can only remember one time in my professional career that I cornered myself with a promise - and as terrified as the experience made me feel - I am so much richer for having made a promise to Dolores.

Dolores had mild learning disabilities and some motor clumsiness. She and her brother were being raised by their mom who was a single parent. Things I remember about this family focus a lot around their names: Dolores, Wally (brother), and Hazel (mom). All of these names are uncommon today, but as uncommon as the names were they fit this family well, because the names reflected precisely on the way that they did not exactly 'fit in' with most of the other people around them. The family was quite poor, and perhaps a little socially awkward, but at the same time the kindest people I have ever met.

Dolores wanted to learn how to ride a bike - she was clumsy and could not coordinate her balance with the motion of her legs. In therapy we worked on developing these skills so that she could ride - and eventually she had improved to the point that I asked her if she had tried riding her bike lately. I will never forget the sadness that she looked at me with as she said, "My bike is broken, and now even if I knew how to ride it I couldn't."

I felt my heart melt right there on the spot, and without any hesitation I told her to bring her bike to me next time and I would fix it for her. There really was no other response to offer other than making that promise.

The next time that they came in I walked them to the parking lot after the session to get the bike out of their car. Their car was quite old (of course) and from the trunk I pulled out an ancient, rusty, and dented Schwinn Western Flyer.

I took the bike home that evening and stripped it down to the frame and air-brushed it a brilliant yellow that I knew Dolores would love. It took hours of work, and I even had some parts soaking in a solution of weak oxalic acid to try to get off all of the surface rust. I found a store that had some pedals that fit, and found a new seat as well - I was really making some progress!

Unfortunately I got hung up on the ball bearings and locking nuts around the pedal mechanism that were impossibly stripped and made the bike un-useable. I almost had a friend machine me the parts but I just kept thinking that this bike would be useless again if anything else ever broke on it. Parts for this bike were just not easy to find.

Dolores asked me each session that she came in, "How's my bike coming, how's my bike coming??" Her mom would gently shush her and tell Dolores that I was busy and I had my own kids and that she should never ask me such things - that it was nice enough of me to even offer to TRY to fix it. After hitting a dead end with the parts I needed, I felt defeated. Then the final blow was delivered when she told me one day, "It's OK, really, I am just glad that you even tried to fix that rusty bike for us."

Dolores' words echoed in my head as I drove home into the sinking sunset. I felt that if I stayed on the road long enough the sun just might swallow me whole and take me with it - to wherever it goes after the day is completed. All that existed was the road. And me in the car. And the sun looming as large as the promise I made, threatening to swallow me whole with each passing moment.

At this time I saw where the earth and the sky met, with no geographic barriers that would limit my perception. The Earth curved outwardly in all directions, and the sky was equally large but in a conversive orientation. As I drove I remember thinking how beautiful it was, how large the sky was, how the earth and sky moved in and out in congruence with my breath. I prayed for an answer.

When I got home I stared at the bike in my garage, wondering what I should do. I could not find the parts I needed. But I promised her I would fix it. PROMISED her. How many people ever promised little Dolores anything? How many people ever came through for her in her short life? The answer that kept coming back to me was "No one does. And no one has." But I knew that I had to.

Here I have to be very thankful for my wife, who understood the mess I got myself into. At the time it certainly wasn't an easy solution, but together we went straight to the store and bought her the best bike that we could find. It was a beautiful pink girl’s bike with a plastic basket that had flowers on it. It was everything that the old Western Flyer was never going to be again: the bike of some child's dreams. And of course, I purchased a matching helmet.

Dolores is a young adult by now. I have always thought that I didn't need to see her again - and that I wanted to remember her as an eight year old little girl, kicked around a little too much by unfair circumstances, and with an innocence of humility and understanding that most eight year old children don't have.

I'll never forget the wonder in her eyes that saw her old Western Flyer magically transformed into this brand new bicycle. "Oh how did you do that?? How did you make it so new??" as she and Wally ran with the bike to try it out.

It may be the best promise I ever got to keep.

I was doing an evaluation recently - and I should know better than be shocked at the things that come from the mouths of children...

It is important for therapists to be observant: it is a skill that I drill into my staff and my students on a regular basis. There is always a lot to observe with preschoolers beyond the typical issues of how many blocks they are stacking or how they are holding their pencil.

As is usual my mind was operating on two different levels during a recent evaluation. While we were stacking blocks I noticed the double whorl pattern in the hair of the five year old I was seeing and I was drifting away into some articles I read about the controversy over whether or not this was a phenotypical expression of altered neurological development and hemispheric lateralization or if it was just an incidental finding. I think that I need to read more because of the recent challenges to this concept that I am now aware of.

Anyway, then I looked at the hands of the youngster, and he had a rather notable injury to one fingernail. I was wondering if the fingernail injury would be causing him to use that hand less than typical - and then I was considering that if he was using that hand less than usual that I could make an error in the assessment regarding reporting what hand he used to do tasks - and that in total my findings could be in jeopardy because also I had to make sure I wasn't tainting this whole picture with inconclusive opinions based on the double whorl pattern in his hair. At the crescendo of my cognitive crisis in how to interpret all this data that part of my mind that operates 'in the moment' asked in a very caring way "Oh my, what happened to your finger??"

I thought he said that he injured it in a bar, and I wasn't sure I heard him correctly because my brain was so muddled with thoughts of lateralization, Geschwind and Galaburda, etc. that I just had to ask the follow up -

"What do you mean, 'It happened in a bar??!??"

Without missing a beat the preschooler says, "I hurt my finger in a bar. You know what a bar is. The place where you drink beer?"

Now I am certain that there is a simple and innocent truth behind all this, but sometimes the way things come out of kid's mouths just stops me dead in my tracks.

The day before Christmas eve is always busy, and yesterday was no exception. The office will be closed for several days and there were so many things that needed to be done. Payroll had to be audited and sent out, some schools had paperwork deadlines for the end of the second quarter, schedules needed to be coordinated for time off so we were sure to have coverage for those families that wanted services next week, some end of the year banking needed to be done... on and on.

It was busy, and the message was delivered this year on cue in the form of Tina. At the very end of the day we had three families jostling past each other between appointments and Tina burst through the front door on a mission. She made a bee-line straight toward me, absolutely disregarding all the social cues that might have otherwise indicated she needed to wait. It didn't matter that other parents were standing near me, that we were engaged in a conversation, or that her own mom was trying to corral her into the waiting room - her message HAD to be delivered.

As Tina jumped excitedly from toe to toe she reached as high as she could to show me a gift card to a local coffee shop and she could barely contain herself,"Here is a $5.00 gift card so that when you are done working today you can go to relax a little and get yourself a really nice cup of coffee or maybe a hot chocolate or WHATEVER YOU WANT!"

The 'WHATEVER YOU WANT" is what caught me on several levels, and I suspect it caught all the other people in the room too. The parents in the waiting room all understood the impulsivity, and the lack of attention to social convention, and the excited lack of emotional regulation in Tina's voice. They deal with those issues themselves every day.

But what demanded attention was the purity of the gift and the absolute joy of giving - which at the end of a day that was filled with attention to comparatively inane issues - was exactly the message that I needed to hear.

Mrs. Kim was one of my first patients when I was a young occupational therapist. She was an 89 year old resident of the nursing home and lived there for the previous seven years. Prior to her admission she was living at home with the support of her only son. She had diagnoses including hypertension, chronic obstructive pulmonary disease, and Alzheimer's disease. She had a history of depression and severe anxiety.

Mrs. Kim was a known 'flight risk' and tried to leave the nursing home facility on several occasions. The nursing home responded appropriately by installing window limiters and door alarms. Out of an abundance of caution they also made sure that Mrs. Kim always had her identification bracelet and she had an alarm that would sound whenever she wandered outside of a designated perimeter around the nursing station.

Despite all of these precautions she still managed to find her way out of the facility on at least three occasions in the preceding seven years - which resulted in the firing of several staff for their lack of attention to the detailed plan that was put in place to keep her safe.

Having seen friends and co-workers fired over this 'high-maintenance' patient, many of the staff at the nursing home viewed her as a 'problem' and a 'burden.' Some of the direct care staff were thrilled at the prospect of the occupational therapist taking Mrs. Kim off of the unit for therapy because that meant that they wouldn't have total responsibility for her continued monitoring.

In addition to the elopement risk, Mrs. Kim's behaviors caused other difficulty on the unit. Despite her advanced age and some physical frailty she was still very mobile and active. She would frequently run into other patient's rooms, frantic and screaming, trying to pull them out of their beds. Although the nursing home's policy was to minimize use of restraints, there were times when the physician ordered both chemical and physical restraints with the intent of maintaining Mrs. Kim's safety as well as the safety of other patients on the unit.

Mrs. Kim's communication skills were severely impaired, generally limited to a fast paced string of syllables that no one could interpret. The staff thought that she might be sometimes speaking in her native Korean language. The nursing home arranged for a Korean interpreter to meet with her once and it was determined that she was not speaking in Korean.

The Activities Director noted that Mrs. Kim enjoyed watering plants, watching television, and that she used to participate in a weekly Bingo group several years ago. Even then she required moderate to maximal assistance but it was the last functional group activity that anyone at the nursing home remembers her being able to participate in.

I read Mrs. Kim's chart thoroughly before I went to get her, so I knew that she had a history of depression and anxiety and I knew about her elopement risk. During the evaluation she bolted away from me and headed straight for the facility's side door. Fortunately I was well-trained by my supervisor to know how to handle the situation - I followed the facility procedure, paged "Dr. Walker" to the 'B' unit which prompted the rest of the staff to converge on the area. I was able to catch up to her in the parking lot not far beyond the side door. Mrs. Kim was frightened, and scratching at my arms, trying to get away - but she eventually calmed and I was able to complete the rest of the assessments that needed to be done.

Although the social and medical history in the chart seemed relatively complete, I asked my supervisor if I could try to contact the son to talk to him about his mother. It wasn't part of the standard OT evaluation to contact family members but Mrs. Kim's lack of communication and the way she grabbed at my shirt made me want to find out more about her.

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I will never forget the son's explanation of his family's experiences as survivors from a civilian prison camp. When soldiers from Communist North Korea retreated from Taejon in 1950 they intended to leave no one alive from the camp. Although his father was executed, he and his mother survived - pretending to fall over dead as they were bound with wire to other members in their family who were strafed with machine gun fire in a mass execution.

Some years later the family emigrated to the United States, but the psychological scars never left. The son recounted a recurring nightmare that haunted his mother her entire life:

In her dream they were running. It didn’t matter where they had come from – but where they were going did. Forward. She pushed them ahead, as instinctively as breathing.

So many weeks, months, or years ago she would have needed his directive to move. Her husband taught her how to move forward, afraid of the day that he would no longer be with them. That day came a long time ago – so long ago that he was barely a distinct memory now. But his message was clear to her. Run! Run! His words roared in her ears; the muscles in her legs contracted, and she ran.

Thunderous shock waves buffeted them from all sides as they ran. Then on the horizon there was a flash of light: magnesium burning white light that lasted just a second. A column of earth and smoke plumed, mushrooming miles into the sky. She heard her son ask, “Is this the kind that we are not supposed to look at?” These were the final words that any of them would ever speak again.

Mortified, paralyzed, wondering how and why someone could hate someone so much to use such a weapon, and nodding to her son all at once, she made them run in the opposite direction.

Running didn’t matter, but she did not have time to realize this. Time and space instantaneously became irrelevant. In real terms they were incinerated immediately, but the moment in time was stretched out infinitely. Every horror that had driven their survival merged into a single event horizon. In the end, as she hallucinated that her children were drowning and melting into the Earth in front of her, hearing the horrible whir-chop of military helicopter blades as they ran, they all unmercifully died in a moment that lasted for an eternity.

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Ever since the son told me about his mother's experiences and nightmares, I never quite looked at patient elopement the same way.