Adjustments

“Old age is no place for sissies.”  Bette Davis

I am just getting adjusted to the latest adjustments.  When I was in medical school, I heard that word “adjustment” used as medical terminology for the first time, as in “He’s just having an adolescent adjustment reaction.”  Before that, I had experienced the word more frequently applied to inanimate objects—cars in particular, such as “the driver’s seat needs adjusting,” or “please adjust the timing belt.”  As my education progressed, I learned about chiropractors and how they “adjust” the spinal column to relieve back and neck pain, or even foot and ankle misalignment in my friends who were dancers.   But somehow I must have missed the lectures on adjusting to the natural process of aging, since I never gave it much thought until recently when I began to make the rounds of retirement communities here in San Diego.

After my mother passed away in early January, my eighty seven year old father received the news that his heart and lungs were no longer able to tolerate the 8,500 foot elevation of their Snowmass, Colorado home.  Previous bypass surgery and a stenotic aortic valve had taken their toll, and the prospect of wearing oxygen 24 hours a day, seven days a week was not appealing to this man who had been performing cleft lip and cleft palate surgery in Africa and Viet Nam as recently as last fall.  And so a month ago, down from the mountains  he came.  The improvement in his breathing was immediate—so much so, in fact, that he has agreed to come to live here in San Diego.  Although he has been staying with us, and is welcome to do so indefinitely, he longs to reestablish a social life amongst his peers—to play bridge, to discuss great books and current events, and hopefully, to resume his golf and tennis games.  He had been half-heartedly looking at facilities for the past two years of my mother’s dementia—full service facilities that take the elderly from independent living through skilled nursing, and ultimately, if needed, to dementia care.  This time around, he is free from the constraints of her limited options, and we’ve broadened the search a bit.

For the last few weekends, we have dutifully and diligently set off to see the best that Southern California has to offer. We’ve toured low rises and high rises, condominiums and apartments, mansions and villas.  We’ve seen covered heated swimming pools, exercise rooms and movie theaters, casual coffee shops and formal sports coat requiring dining rooms.  We even saw an apartment at Casa Manana, a retirement community in La Jolla, where the floor to ceiling picture window in the all-purpose one room living/bedroom gave up a spectacular ocean view and the sound of waves so close we could almost feel them crashing against the shoreline.  But each time, my father turned away.  Neither of us spoke of the sights that gave a small nagging voice to our fears—the squeak of a walker being lifted and set down again, a palsied hand reaching for a glass of water, the faint smell of mildew in a recently vacated apartment with a silent cane propped in a corner, long ago abandoned for a wheelchair.  My father was pleasant and polite to our tour guides.  I, who will turn sixty years old this year, looked out over the gray heads and stooped shoulders in the dining rooms, and saw my future.

A week ago, after spending most of Saturday and all of Sunday morning looking at potential places for Dad to live, I had had enough.  There was one more visit to be made, to a retirement community very near my workplace.  My husband graciously volunteered while I stayed home to do laundry.  Much to my surprise, when they returned from the excursion, my father was very excited.  The community was new, beautiful, and laid out like a country club, with low slung buildings connected by gardens, grassy areas and well-tended walkways.  There were two dog parks, and folks were out and about on a sunny day.  When I asked my father what he liked so much about the place he exclaimed, “Everybody looked so YOUNG!”

I suspect that my father will adjust to his new life just fine, once his medical conditions are straightened out and the path to that future is clear.  As for me, I am adjusting  to the fact that my pantry and freezer are now stocked full of his favorite foods—oatmeal raisin cookies, bagels with strawberry cream cheese, salty potato chips and Klondike bars.  It looks like my wardrobe is going to need an adjustment soon!

The Waiting

“The waiting is the hardest part
Every day you see one more card
You take it on faith, you take it to the heart
The waiting is the hardest part.”
Tom Petty and the Heartbreakers

 

I’ve never been good at waiting for anything. Instant gratification has been my middle name, and I’ve gotten in lots of trouble because of it. I think that I have improved with age—I am less likely to become apoplectic when the stoplights fail to coordinate to green, or when the driver in front of me creeps along at a snail’s pace, or when the line at the movie theater is longer than I expected, or, God forbid, the line for the heavily buttered newly roasted popcorn AFTER I’ve gained entrance to the theater means that I might miss the opening scene. Knowing that the popcorn is always better than the movie, I wait.
When it comes to my patients, though, the waiting is still unacceptable. We have a rule in my office—a referral MUST be seen within a week of getting the phone call or faxed request—sooner if that patient is in pain, or has symptoms of airway obstruction or spinal cord compression or is bleeding from his cancer. The problem for many of my patients, especially here in Southern California, is that they have often waited far too long already. The paperwork and time and energy spent making phone calls and filling out forms is staggering. Primary care doctors are overwhelmed. Insurance companies are obstinate. It is not uncommon for a patient to have been diagnosed for over a month or longer before they are seen by me.

 

When we moved here from Massachusetts in 1993, I had already grown accustomed to patients having to wait for treatment. Massachusetts is a “CON” state, meaning “Certificate of Need”. In order to purchase and install new radiation therapy units, which are considered “high tech” and very expensive, one had to petition the state, and undergo scrutiny and a series of tedious hearings held by self-important politicians who clearly never had a close friend or relative with cancer. I remember treating upwards of fifty patients a day on the linear accelerators, and having to triage patients with cancer into urgent, and less urgent cases. Lung cancer and brain cancer first, prostate cancer last, and everything else in between. How does one place a value on a life hanging in the balance?

 

When I arrived in California in 1993, and joined a private practice, the founder of the practice, Dr. Jack Abrams, who hired me had a very simple philosophy: “See ‘em, sim ‘em and treat ‘em.” Meaning that if we got a call from a referring physician, we were to see the patient within 24-48 hours, perform their simulation, otherwise known as the treatment planning session, the same day or the next, and start their treatment the day after that, or even the same day if necessary. This was SERVICE, defined as I had never seen it defined before. The referring physicians and the patients were very grateful and I am quite certain that this philosophy cured more cancer than the waiting, and the wading through mountains of paperwork.
Jack Abrams is long gone now, but the philosophy of service that he ingrained in me twenty years ago remains. If you are one of my primary care physicians who needs your patient seen TODAY, just call me on the phone. I will stay late and see your patient, and so will my wonderful oncology nurse. My superb chief radiation therapist will do that CT simulation the same day if necessary, and my dedicated physics staff and radiation therapists will stay as long as is necessary to get your patient– no, OUR patient treated. No one will suffer needlessly on our watch. This, I promise. The waiting is the hardest part.

 

Dedicated to Dr. Jack Abrams—we did not always agree, but you were a fine example of our breed.

Don’t Let Me Talk You Into It

When I was young and foolish and just starting out in my career, I found it very hard to take “NO” for an answer.  If a patient needed radiation therapy, and he or she didn’t want to have it, I did my very best to talk that patient into it.   I have always been a very persuasive person—if I didn’t get the go ahead on the first formal consultation, there would be another, and even another, all gratis, with a few phone calls thrown in between.  Every question that could be asked was answered, no stone was left unturned. My waking dream was that if I was good enough at explaining, finally the lights would go on and the patient would understand that really, truly, the recommended treatment would be at the very least beneficial and in the extreme life-saving.   The indications for radiation are usually fairly clear—sometimes we treat for a positive margin by pathology after surgical removal of a tumor; sometimes the tumor is curable with radiation alone, or the radiation option is less risky for a patient than a surgical option; sometimes radiation therapy is simply the best option for palliation of symptoms.  There have been very few, if any times in my professional life when I have seen a patient with cancer, and I say, “By the way, radiation therapy is optional—take it or leave it.”

Gradually, however, over the course of a long career I have been rethinking my strategy of talking patients into treatment.  Why?  Because it has become clear to me that the patients who I work the hardest to convince to get their therapy are the unhappiest patients I have.  These are the patients that, when having their breast treated, ask to see me on the second day and point to a rash on their leg, and say to me accusingly, “You told me THIS wouldn’t happen until the third week!”  When I explain that the rash on their calf has nothing whatsoever to do with the radiation aimed at their breast, they roll their eyes in disbelief.  I have come to realize that when reluctant participants are undergoing radiation therapy, everything that happens to them during the course of treatment (and for the rest of their lives in many cases) is the result of the evil X-rays.  Of course there are genuine complications of radiation, but losing one’s sex drive after having a skin cancer on the scalp treated, or developing a hemorrhoid after treatment of a lung cancer, or the breakup of a marriage after the life threatening illness of a spouse are not on the list.    It has to be the same body part that was treated—that’s how radiation works.  It’s all local.

Last week I saw a new patient, a genuinely lovely and intelligent woman of 70 years, who was diagnosed with breast cancer five years ago.  She had had a lumpectomy and a sentinel node dissection, and fortunately her cancer was found at Stage I.  But when it came to completing her breast cancer treatment, which included radiation to the breast followed by anti-estrogen hormonal therapy, she refused, despite the fact that her surgeon and medical oncologist argued strongly that she was depriving herself of standard-of-care management.  She stated back then, and again last week, “I will not do anything which will affect my quality of life.”  When she recurred, the tumor came back in the axillary lymph nodes, and the surgeon had a difficult time removing the nodes due to her previous axillary surgery, and microscopic disease was certainly left behind.  To have taken more tissue would have been to risk nerve damage and certain lymphedema.  So she was sent to me for radiation.  And, just like five years ago, despite the fact that we covered all side effects, risks and benefits during our 90 minute consultation, and she agreed to treatment, she now is once again questioning what the radiation may do to her quality of life.  Yesterday evening I called her on the phone at her request, to attempt to allay some of her fears.  I felt myself slipping into my old habits of persuasion, and I stopped.  I said to my patient, “You can have five weeks of fairly simple treatment now, or you can wait until you have another recurrence, and require additional surgery and a higher dose of radiation.  Which quality of life is worse?  Which will give you greater piece of mind?  You decide.  Don’t let me talk you into it.”

Really—don’t let me talk you into it.

Back at the Ranch

“The sun is riz, the sun is set, and we ain’t outta Texas yet!”

It takes a full day to waltz across Texas.  I’ve been reminded of this twice in the last four years—once in July of 2009 when I drove my daughter from California out to Houston to start medical school, and the second time eighteen months ago when we drove my mother’s barely used Subaru from Colorado to Houston to replace the now ancient Volvo we had bought my daughter for her sixteenth birthday.  A girl’s got to have wheels, you know. Both of these trips reminded me of the long charter bus rides that I used to take as a child competing for the Dad’s Club YMCA swim team at out-of-town meets all across the state.  My favorite ride was through the Hill Country between Austin and San Antonio in the spring, when thousands of bluebonnets carpeted the roadsides, punctuated by red dots of Indian paintbrush.  Back in those days, I would gaze out the window at the Herefords and Black Angus and I would imagine that one day, some day, I would have my own ranch.  Others would complain about the endless stretch of highway between San Antonio and El Paso, but not me.  I could easily imagine myself owning a thousand barren acres in west Texas, where I would have all of the dogs and horses I could ever want, and not have to talk to anybody, nope, never.   How I would make a living out of that ranch never crossed my mind.

That fantasy came to an abrupt end a few years ago as both of my parents faced major health crises.  Twenty five years back, they had retired from Houston to live out their dream in the Aspen/Snowmass area of Colorado. Well, perhaps “retired” is not quite the right word, since my mother never worked outside the home and my father never stopped working—he  likes to call himself “the oldest practicing plastic surgeon in the United States”, to which I rejoin, “Perhaps you shouldn’t brag about that, Dad.” But I am digressing.  They became avid skiers in the winter, and enthusiastic hikers in the summer, and they played golf and tennis and rode horses on the mountain trails.  They did that until my mother became ill in the spring of 2005, gradually losing her ability to walk, and to think clearly, and I discovered that while Aspen is a glorious place to have a cruciate ligament repaired, or to fix a compound fracture fresh off the slopes, it is no place to come down with a lymphoma of the central nervous system requiring chemotherapy to be instilled directly into the ventricles of the brain.  They don’t do that at Aspen Valley Hospital, or likely anywhere in the middle of that stretch of Interstate 10 between El Paso or San Antonio.  My father’s recent bout with pneumonia and a touch of heart failure confirmed my suspicions that, cowardly as it sounds, I want to be near good doctors and good hospitals as I age.

I never did get that ranch in Texas, but fifteen years ago we bought three level acres smartly outfitted with a four stall portable barn and a couple of grass paddocks here in San Diego County, on a street which was originally named Caballo Rojo.  My first Quarter Horse, and the first tenant here was a little red gelding named Lucky, so with a sly smile and tongue firmly in cheek we called our new place Rancho del Caballo Rojo and the name has stuck. And when I fall off my horse, as I have on occasion, I am deeply grateful that some of the best hospitals in the country are less than twenty five minutes away.  Dad, for the meantime, is living with us.  But he held on to a hundred acres or so that he bought years ago in Pleat, Texas, southwest of Houston, with its own working oil well on the property.  On a good day, that old well pumps out five barrels of oil a day.  Sometimes I dream about retiring there, so last time I was in Houston we went out to see the old farmstead.  Say what you will but I was very glad to see that a large and very modern appearing hospital has been built very, very nearby!

Tchotchkes

I’ve always been a collector.  The first things I remember collecting were trolls.  Does anyone else remember those?  Those little plastic guys with round bellies and wild neon colored hair that stuck straight up from their heads—I would always have two or three of them sitting on the starting block at the end of the pool for good luck.  From there it was Breyer horses of the earliest generation—blacks and bays and dappled greys, and then after that came the “fruit loops” from my sixth grade boyfriend’s collared button down shirts—those little loops of fabric at the back of the yoke that, if yanked hard enough, would come right out.  This habit did not endear me to his mother.  My grandmother would call these collections my “tchotchkes”, which is the Yiddish word for trinkets or baubles, but this did not discourage me from my efforts, which included an obsession with acquiring a key chain from every state in the Union.  I was nothing if not determined.

As I grew older my tastes changed, and the collections grew to include art, and vintage beaded handbags from the 20’s, and colorful silk scarves. I bought my first Hermes scarf in Paris in 1978—it was so beautiful I decided I could never wear it and it still sits unworn today in its original orange and brown box, brown Canadian geese flying across a silvery full moon, someday to be stretched across a wooden frame and hung on a wall—a reminder of a different time and world and place.  More recently the objects of my treasure hunts have been Victorian brooches, specifically Scottish silver and the multicolored agates that Queen Victoria herself favored, secured sternly at the base of her starched white collar edged with demure lace at the very high neckline.

The most fabulous, eclectic and strange collection of all, however, is the one consisting of the small tokens of appreciation my patients have given me over a thirty year career in medicine. These things I have carted with me from state to state, job to job, desk to desk—water from Lourdes, sand from the Holy Land, tiny stuffed bears wearing doctor’s white coats with head mirrors on, and stethoscopes.  I have a rosary from Mexico, and a small wood carving of Jesus on his cross from the Vatican, and angels of every size and shape and material (which is flattering even if I am somewhat less than angelic), and I have more Christmas ornaments, some homemade from painted pasta shells, than any Jewish girl in her right mind could ever want.  My patients have brought me tiny replicas of the pyramids from Egypt, made of black slate with hieroglyphics etched in gold, and enamel shamrocks and a claddagh door knocker from Ireland, and a string of pure malachite beads from Jordan. And they have brought me rocks of every size and color and variety because they figured out a long time ago that I love sparkly things that I can hold in my hands.  These are my memories, and my treasures, and the things I will never leave behind.

I am counting down the days until the annual Tucson Gem and Mineral show, where I go each year with my friends Rachel and Judy—to buy more rocks and little things that sparkle of course.  My Nana may have called them tchotchkes, but I call them magical.  I tell the vendors that I want to see moonstones and citrines because they have healing powers, and I am a doctor.

They always give me a discount.

Deep in the Heart of Texas

One of the things I have learned since starting this blog last September is how many doctors enjoy telling their stories, and how many of them do it very well.  Dr. Kevin Pho is an internal medicine physician in New Hampshire who started a website where he brings together many voices of medicine—doctors, patients, educators and policy makers.  The website is www.kevinmd.com and I have spent many short lunch breaks at my desk, reading and laughing, or crying, or just plain recognizing kindred spirits as their stories fill my computer screen. The following piece, by Dr. Pamela Wible, appeared yesterday and took me right back to medical school in Texas.  I am “reblogging” it here, with Dr. Wible’s permission.  All you Texans out there—here’s a yellow rose for you!

Learning about human relationships and the art of medical practice

PAMELA WIBLE, MD | EDUCATION | JANUARY 31, 2013

 

An excerpt from Pet Goats and Pap Smears.

After two decades of formal education, today I’m finally set loose with real patients. It’the actual moment I’ve been waiting for my entire life.

We’re each assigned to a family doc for the month. I scroll down the list of third-year medical students, place my right index finger beside my name, slide it across the page, then read aloud: E. Sinks McLarty, Jr., M.D., III.

The next morning I find his office—a small nondescript building with his name on the side—and enter the waiting room, which features 1970s-style wood paneling, faded and covered with the grime of decades of cigarette smoke. Centrally located is a large oil portrait of E. Sinks McLarty, Sr., M.D., who opened the place nearly 100 years ago. I pass rows of empty chairs to the front desk, where I meet three bouncy women—all relatives of Dr. McLarty. I introduce myself to the friendly, frenzied group of chatty chart finders, then the garrulous gang scurries me down a narrow, smoke-filled hallway where I meet Dr. McLarty’s nurse, affectionately nicknamed “Olive Oyl.”

A friendly, slender, snappy-tongued woman with a gravelly voice, Olive Oyl chain-smokes at her desk. Her deep red lipstick and nail polish are the color of freshly clotted blood. She escorts me into a dimly lit room where I’m not at all sure I’m safe. There, on the couch, I meet Dr. McLarty—a seventy-year-old cowboy eating Metamucil wafers while puffing on a pipe. He wears Wrangler corduroys and sports a crew cut with some gray hairs shooting through. With his thick Texas twang, he slurs his words together around southern slangisms and medical anecdotes.

With pen, paper, and stethoscope, I follow Dr. McLarty around to see what I can glean from him. I’m immediately struck by his speech with patients. He calls all the men “pahdna” and all the women “shuga.” Isn’t that sexual harassment?

Dr. McLarty has no tolerance for big-government rules. When a patient needs a triplicate form signed, he snaps, “Well, now, shuga, that’s a bunch of horseshit!” or “I don’t give a ram dam or a rat’s butt!” While cursing, he signs the forms, gives one to the patient, and throws the other two across the room in a wad. “Hell, I’ll make toilet paper out of it one day,” he rambles as he tramps out of the room.

Dr. McLarty makes even the common cold an event to remember. “Okay, now, pahdna, let’s look in that there snoot. Ah, a little redness, nothing to say grace over. Let’s listen to your ticker while I gotcha here.” Slamming down the chart, he exclaims, “You’ve prob’ly got some of that damn crud we’ve seen going around!”

In the next room, an elderly woman complains of joint pain. His diagnosis: “You’ve got arthritis! Well, hell, you can see that. No need to pay for that, shuga. Now hold that cane in your left hand and tell Byron to give ya a damn golf ball to carry around in the right.” He didn’t cure her arthritis, but she looked like an avid golfer when she left.

After seeing a few patients in the morning, Dr. McLarty closes down for a two-hour lunch. We all squeeze into his office on the couch to watch soap operas. During a romantic interracial scene, they shake their heads in unison. “Oh, no! We don’t believe in that!”

So I offer the clan some of my chocolate soy ice cream and one gal gasps, “Oh, no! My husband wouldn’t like that!” Dr. McLarty puts down his Metamucil wafer and grabs a spoonful. “That’s pretty darn good!”

After lunch we’re getting ready to see a man named “Sunshine.” Before entering the exam room, Dr. McLarty pulls me aside and says, “This family’s been shot in the damn butt with bad luck!”

“What’s going on?” I ask.

“He got cancer. I’ve known a week, but gonna break it to him now.”

“Why didn’t you tell him last week?” I ask.

“If he lived by himself, I’d a told ’im right away this is how the cow ate the cabbage, but his wife, Lordy, ya couldn’t scrape her off the wall last night,” he rants as he trudges down the hall.

I gathered that Sunshine’s wife was extremely anxious.

We enter the room. Doc pats the old fellow on the shoulder and says, “Sunshine, now I ain’t gonna pull any punches by tellin’ ya we got a drug.” After a few cryptic sentences, he asks, “Ya get what I’m sayin’?”

Sunshine replies, “Yep! Lights out.”

That was the entire office visit.

Most of Doc McLarty’s patients are old white guys who have aged right alongside him. But this afternoon, we jump into Doc’s old pickup to see a young gal in the hospital. On exam, he notices her breast implants and asks, “Hey now, shuga, how long ya had these damn things blown up that way?” She answers politely and the interview continues without a hitch.

We only saw one kid that month. As the boy raced around the exam room, Dr. McLarty quickly warned, “Hey now, pahdna, get back up there on that there table. We don’t want ya to bust your gazoo!”

I’ll always savor my month with E. Sinks McLarty, Jr., M.D., III. I didn’t learn much about diagnosing or treating disease, but I learned a lot about human relationships and the art of medical practice.

I sure miss him.

So, after fifteen years, I track him down to thank him.

He answers on the first ring.

With my heart pounding, I ask, “Is this really Dr. McLarty?”

“Yep, this is Doctor McLarty. Who the hell is this?” he shouts.

“I’m a medical student you mentored long ago, and I just want to say thank you.”

“Well, thank you, sweetie, but I got cancer of the bladder and just had therapy today, and I’m bleedin’ like hell!” Before I can express my sympathy, he quickly blurts out, “What comes around goes around. Thanks for calling on me, but I gotta go pee again!”

He hangs up on me.

That’s it.

I never even tell him my name—not sure he would have remembered me—but I do get to thank him before lights out.

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Pet Goats and Pap Smears.

Happy Place

“Think of a place that’s really perfect.

Your own happy place.

Go there, and all your anger will just disappear.

Then putt.”        Happy Gilmore, 1996

I don’t know if I have ever heard my radiation therapists say this to a patient, anxious on the treatment table, “Go to your happy place.”  I think I may have imagined that they say this, because I remember thinking it might help, and also remember thinking to myself, at various times in the past, “I don’t have a happy place.”  And I didn’t, until a year ago when I finally took the trip to Africa that I had wanted to take my whole life.

I was a child obsessed with animals—all animals, but especially elephants and lions. I learned in school that elephants were like us–they lived long, they loved, and they mourned their dead.  By the time I was ten I had seen the movie HATARI! (Swahili for “DANGER!”) five times, and the only song I ever learned on the piano that I can still play, besides the ubiquitous Fur Elise stamped in the far recesses of my brain, is the Baby Elephant Walk. Born Free came a few years later, and I wept with joy over the story of Elsa. By the time I got to college, I had read Beryl Markham’s biography, West With The Wind, George Schaller’s The Serengeti Lion and after that came Isak Dinesen’s Out of Africa, and all of Hemingway.  In 1984 I was swept off my feet by the Robert Redford/Meryl Streep movie version of Dinesen’s book, and in 1993, imagining myself to be a latter day Beryl Markham, I gave myself a flying lesson for my fortieth birthday.  Unfortunately I chose to do this in gusty winds in Aspen Colorado in the middle of the winter—needless to say it was my first and last attempt at becoming an aviatrix.

We all have our romantic notions of where and who and what we want to be when we grow up, but life gets in the way.  In my case, “life” was three kids and a highly specialized career which did not lend itself to the African bush. But just over a year ago, fortune smiled on me and the constellation of circumstances necessary to make a trip to Tanzania suddenly came together—the time off work, the housesitter (my daughter) for my dogs, cat and horses, and the delusion that I could sell my Corvette, purchased by me for my own fiftieth birthday nine years prior, in the middle of a recession to make the trip affordable.  Armed with binoculars, a new camera, sun proof clothing, DEET 30% and malaria pills, off we went.

I think that it is a rare thing in life when one’s expectations are not only met, but exceeded.  This was my experience in Tanzania, from New Year’s Eve spent looking out over the Great Rift Valley, to seeing the famous “tree lions” in Lake Manyara National Park, to the early morning game drives as the sun rose over the Serengeti plain, to the old bull elephant, long tusks still intact and unharmed for over sixty years, lumbering across the floor of the Ngorongoro Crater.  We had a full moon rising over Mt. Kilimanjaro on our last night in Arusha, temporarily blotting out the light from the Southern Cross.  The air was clear and smelled of hibiscus and I knew, unequivocally, that this was my happy place.

I am pretty certain that with my family history, one day I will find myself lying on the treatment table awaiting my radiation, nervous despite my years of experience on the giving and not the receiving end of this specialty.  If my therapist smiles and says, “Relax, go to your happy place—this will be over in just a few minutes”, I will know exactly where to spend the next 15 minutes, among the zebra and the wildebeest kneeling beside the crater lake, the song of a thousand flamingos softly taking wing ringing in my ear. And if that fails me, there is still a shiny red Corvette to drive home.  Happy places, indeed.