How does one measure time? By the moment? By the hour? By the day? By the thought?

How do we mark that passage? Do we note the sun? The moon? The stars? The leaves? The rain? The snow? The pain? The joy?

Do we count the moments? The moments missed? The steps? The breaths?

We humans have a very long history of marking time. We know this because we’ve taken note of how long we’ve been marking time.

We notice patterns. We notice seasons. 

We make associations. We’re certainly not the only creatures that make associations, but we are, as far as I know, the only ones that make calendars.

We mark time with holidays and anniversaries – symbolic reminders of the cycles of time and of life, of profound change, and of profound persistence. We note what carries through. We note what’s missing. What feels different? What feels the same?

It is coming up on a year since my friend lost his son. In Judaism, on the Hebrew calendar, the anniversary of someone’s death is called a yahrzeit – translating from the Yiddish for year (“yar”) and time (“tzeit”). The Hebrew calendar is a lunar one, but it has extra months added in cycles so that it stays in sync with the seasons and in rough sync with the Gregorian calendar. So the lunar years and the solar years, the school years, the seasons, the Jewish, Christian, and secular holidays, maintain their temporal proximity. But not exactly.

The young man died four days before the evening of the first day of Rosh Hashanah last year, on the 25th of the Hebrew month Elul, on the 21st of September. So his yahrzeit is by definition on that same Hebrew date, the 25th of Elul, four days before the first evening of Rosh Hashanah (the Jewish New Year), but this year that Hebrew date corresponds to the 11th of September. Today.

But perhaps not exactly. Because days in the Jewish calendar begin at sundown. I don’t know if he died before or after sundown. If after sundown, the Hebrew date would be the 26th of Elul, which would correspond to the evening of September 11th and the day, until sunset, of September 12th. If it happened before sundown, the 25th of Elul begins at sunset on September 10th, and goes until sunset on the 11th. 

How do we measure time? From sunsets? From midnights? From a phone call or a knock on a door?

The befores. The afters.

How do we measure time? In weeks? In heartbeats? In tides? In generations? In fishing trips?

Because there is no one way to measure time, because our measurements overlap and ebb and flow, because some cycles are regular and some wildly irregular, the consistency of both the regularity and the irregularity drives us to continual, expected, and unpredicted reminders. We make associations. Only some of those associations are on our calendars.

This year, my friend’s family will have received a yahrzeit reminder for today – a day that falls, at least partially, on September 11. A day when we mark the twenty-second anniversary of the shattering terrorist attacks, this family also marks the first anniversary of their own world’s shattering. And then they will have their second Rosh Hashanah without their son and brother. And then it will be September 21, a year in our currently accepted international calendar.

Rosh Hashanah is the Jewish new year. But there are four Jewish new years, signifying different things. Rosh Hashanah is the “new year” that commemorates the creation of the world. 

There were no calendars at the time of the big bang, but there is value in reminding ourselves periodically that there was a time before the universe existed. Just as we celebrate a birthday as a marker of an individual’s coming into existence, it’s nice to celebrate the existence of existence.

How do we measure time? In how old we feel? In tears? In laughs?

In Judaism, one of the most, if not the most, important tenets is that of the importance of a human life. The talmud (the text of rabinic Judaism and the basis of Jewish law) teaches that one who saves a life is considered to have saved the world. I find this thought particularly beautiful – that a human life represents a world. And the thought that I extrapolate from there, that every action of one’s existence, every moment of one’s existence, changes every connecting human, every connected world, and the “world” as a whole.

My friend has been posting on Facebook on the 21st of each month, marking the time. Naming the time. Reminding the world. Defining the before and the after of his lost world and of the time that was and is.

So many worlds. So many moments in those worlds, each affecting other worlds. How many do we save? How many do we enhance? How many do we enable to save others?

We know the most dramatic and obvious saves – the stopping of a hemorrhage, the opening of an acutely blocked coronary artery. How many do we not recognize? Being present in a time of need? Making someone laugh?

How do we measure time? In its finiteness? In its eternity? In the power of a profound or a seemingly inconsequential moment? Maybe simply sitting with someone – on a porch, by their bed, on a boat – gives them the strength to hang onto life for just a tiny bit longer, with that tiny bit longer of time enabling the growth and temporal elongation of countless other worlds.

We mark time. Birthdays, yahrzeits, seasons, memories, associations – the cyclical reminders of people’s coming into existence, the cyclical reminders of people’s exiting physical existence, both the cyclical and the seemingly random reminders of the times in between. The entire worlds of overlapping calendars, of dates that mean the world to some and nothing significant to others. The worlds of unmarked time march through as well, with their own ebbs and flows, with joy, with anguish, with fear, with hope.

I wish strength for people through the official markings of times of loss today and every day, and through the unofficial markers. Every moment of the lives and worlds that have gone by mattered and matters. 

I wish everyone a New Year with sweetness, with love, with peace, with connection, with memories of the good stuff, and with curiosity and hope for the beauty of the infinite, interconnected, unique worlds that we will help unfold in the year to come. May we all appreciate the beauty, the importance, and the potential of our time together in this universal world of humanity. Shana Tova – to a good year.

Another day, another mass shooting in America. And last night’s is close to home.

At 8:30 p.m., our house phone rings. Must be one of our parents or spam (they’re the only ones who call our house line). I look at the caller ID – it says “Michigan State.” Because I’m faculty for MSU’s med school, I’m on the list for their emergency system’s warning calls. I answer, and the computerized voice begins: “There are reports of shots fired on Michigan State’s East Lansing campus…”

I tell Doug. He pulls up the police scanner app on his phone, puts it on speaker, and we listen. It’s real.

Multiple casualties. They’re requesting all available emergency medical support.

We have three children. A subset of their friends are our children. We have friends. A subset of their children are our children. We have friends whose children are friends with our children. Those children are our children. Our sons are in their 20s and we live in the metropolitan Detroit area. You can do the math – this is close to home.

I call the kid down the street, a junior at MSU. He doesn’t answer. Of course not. Kids don’t talk on the phone. I text him: “There’s a shooting on your campus. Are you ok? Call your parents to let them know you’re ok, and then text me back.” Two minutes later I text him what we’ve heard on the scanner about the location of the shooting. And I implore the kid to call his folks and me. Three minutes later I’ve somewhat lost it and text him something to the effect of “Jesus Fucking Christ, call me.” That does the trick. He responds. We talk. He’s safe.

At this point, I’m in my clinical detachment state. Doctors have to have this psychological skill or we wouldn’t be able to do our jobs. Everyone, medical or not, employs this defense mechanism at times.

Youngest son and girlfriend are home with us, middle son in Ann Arbor, eldest in D.C.

Family group chat is going. We try to figure out whose kids, whose siblings, which friends, are in East Lansing. I’m no longer trying to message known East Lansing kids first to have them contact their parents – I’m reaching out to parents directly, even though I know what it will do to them if they hear from me before they hear from their children, because I would want to know if my child were there. Some parents have heard. Some haven’t. At some point, it’s late enough that they all know. Our/our kids’ most direct connections are safe.

Clinically detached.

Listening to the scanner.

Texting in family group chat. Detached, but listening for tone, observing, watching for evidence of any danger sign in psychological state of offspring. Watching, listening to offspring/significant other in my house, observing body language and facial expressions, listening to tones of voice. Watching and listening to my husband, who hasn’t stopped listening to every word on the scanner.

Talking to other parents. Clinically observing tones of voice. Figuring out who needs to hear what words as they process the situation of texting with their children who are locked and barricaded in buildings on campus.

Watching news briefs. Detached.

Listening to the scanner. Clinical.

That scanner, though.

Detached. Clinical. Listening to the radio conversations between dispatch and the rescue response teams. Listening. Observing. Drawing parallels, as I am wont to do, to medicine.

It’s all about communication. It’s all about objective information. It’s all about being methodical. And yet the communication is fragmented – so many moving parts, reports from all over the place. The theoretically objective information is overwhelmed by the subjective tainting of terrified humans. The method takes time, it is not instantaneous.

I am detached, clinical. Observing, considering, interpreting, and synthesizing information, trying to make sense of it.

Sons are scouring internet. Mostly Twitter. Texting in our group chat. D.C. son, who lives in a sea of helicopters, is incensed that the shooter is still at large and that there isn’t chopper support. Engineer son is incensed that all campus security cameras haven’t been used to triangulate and locate the shooter.

But there is helicopter support. It’s not on the scanner channel available to us (much of police communication occurs on encrypted channels inaccessible to the public). There is analysis being done on what has been captured on the cameras.

The scanner channel we’ve got access to covers communication between a central dispatch and rescue response teams. But at this point, there are hundreds of police officers from campus police, city police, state police, police from not only the local county but other surrounding counties as well, the FBI, all on campus, all coordinating to ensure students’ safety, to secure buildings, to question witnesses, and to find the shooter. We are hearing one part of that.

The rescue teams are checking out all of the areas of reported shooting. And Doug is keeping track of all of the reported locations – at least ten buildings on campus if not more. But most of the reports of shooting turn out not to be actual shooting. The dispatcher will report that people heard gunshots at building X, and there will be a response from a team at that building saying they’re there, and nothing is going on, that all is quiet.

But there are 50,000 scared students. A door slamming can sound like a gunshot. If you hear something, you report it. We hear the dispatcher relay a report that someone saw someone throw something into a trash can. An explosive device? A gun? A sandwich wrapper?

There are multiple reports of people with guns. Of course there are. It’s dark. People are looking out of windows. There are tactical units of law enforcement everywhere, carrying guns. Is one of the sightings the shooter?

It’s like practicing medicine.

As a doctor, I have a person in front of me. One whole person. With a lot of parts, a lot of systems. And a family. And friends. And perhaps an imperfect memory of his symptoms. Or an interpretation or a descriptive term that differs from a specific medical term.

Get five people reporting “dizziness” and get five different phenomena being reported. Feeling of room spinning? Feeling that you are spinning? Feeling lightheaded as if you are about to faint? Feeling “off balance”? Feeling a little “fuzzy”? What was tossed into that trash can above?

Did the dizziness start last week? The patient in front of me is adamant that it did. His wife is certain it’s been going on for a month. His daughter never heard him complain about dizziness, but right now she feels like she is going to pass out. Is something serious going on with her right in front of me?

Figuring out what’s going on. Clinical. Observing. Detached enough to stay objective, to see what’s in front of me and find the answers and find the problems, and at the same time looking and listening closely so I can connect and communicate and help.

Diagnosing and assessing and planning. History, family history, social factors, lifestyle, physical exam, laboratory testing, imaging studies. All take time. If a family member only focuses on one, it looks like we’re not doing anything and why is it taking so fucking long to figure out what’s happening? And no one is talking to anyone else! No one knows what’s going on!

But we are talking to one another. It takes time. We’re all caring for multiple people and multiple families and coordinating with multiple departments. Information comes at different times, and one piece may come for one person while we’re looking at a different piece for another person.

The coordination and communication logistics are mind-boggling.

Detached. Clinical. Seeing how the moving parts in East Lansing are analogous to the moving parts in my own profession. Seeing the reactions of those outside of the active team, those who have no control over the situation and who feel that lack of control to their core. Their fear. Their anger.

We hear on the scanner that the shooter has shot himself as officers approached him. We hear that officers are doing CPR on the suspect. A short time later, there is another briefing – confirms that the shooter is dead. And three of the people he shot are dead. And five are in critical condition. There will be more details later. The investigation is ongoing. There is no further physical threat.

It’s one a.m. and I’m exhausted. I’m clinically detached. I hold Doug as I try to fall asleep. You know that little jerk awake that sometimes happens as you’re falling asleep? That happens. But the jerk involves a scream. I’ve never done that before. It wakes Doug up. I apologize.

I have no idea what actually happens with my sleep last night. My exhaustion this morning is overpowering. And whatever tossing and turning I did has pulled a muscle in my neck.

There is more information today. All of the dead and critically injured are students. Two names of the victims have been released. The shooter has been identified – a 43-year-old man with no (as yet known) affiliation with the university.

I’m clinically detached.

Our neighbor kid gets back home this morning. I see his car, knock on his door, and hug him. He knows one of the deceased people.

I’m clinically detached.

A 43-year-old man has killed three people’s children and critically injured five other people’s children.

I’m clinically detached.

Putting ice on my neck makes it worse.

I’m clinically detached.

Another day in America, another mass shooting.

I’m clinically detached.

And if you believe that, I have a bridge to sell you.

In last night’s Monday Night Football game, Damar Hamlin, a 24-year-old player on the Buffalo Bills, made a tackle, stood up, and collapsed on the field in cardiac arrest. CPR was administered, a defibrillator restored his heartbeat, and he was taken, still unconscious, to the University of Cincinnati Medical Center, a level one trauma center. As of this writing, he remains in critical condition and there has been no information released as to the cause of his cardiac arrest.

The lack of an official diagnosis, however, does not stop speculation, including my own.

There are a number of possibilities high on the differential (the list of potential causes). Vascular injury (injury to a blood vessel – for example a severed artery, or a ruptured aneurysm) can occur spontaneously or after a forceful blow. A spinal cord injury can occur with a forceful collision, and a severe, high (neck-level) injury can lead to cardiac arrest. An issue within the heart itself can lead to cardiac arrest – a heart attack (blockage of an artery that provides blood to the heart muscle) or a problem with the electrical conduction system of the heart can cause the heart to stop.

Mr. Hamlin was running fast to tackle the ball-carrier. The ball-carrier was running fast as well, and his shoulder hit Mr. Hamlin’s chest as they ran full-force into each other, and you can see effects of the rapid deceleration forces on their bodies as you watch video of the collision. Mr. Hamlin stood up and quickly collapsed.

Because of the timing of his collapse in relation to the collision, and because emergency medical personnel were able to get his heart to resume beating, I think there’s a significant possibility that his cardiac arrest was caused by “commotio cordis,” a phenomenon where a blow to the chest occurs at exactly the wrong time in the heart beat electrical cycle and can lead to ventricular fibrillation (fibrillation is a disorganized electrical firing of the cardiac electrical system which stops the normal, coordinated electrical pattern, and instead of an organized, coordinated, functional heartbeat, you end up with ineffectual random, uncoordinated contractions of cells that do not create a functional heartbeat – were you to touch a heart in ventricular fibrillation, it would feel reminiscent of a bag of worms). A physical blow actually creates an electrical impulse, and this impulse can affect the heart’s electrical cycle just as an electric shock from a damaged electrical cord or downed power line or a lightning bolt can. It can be caused by a baseball or soccer ball to the chest (the sport it occurs in most frequently in the U.S. is baseball), a punch or kick to the chest, a fall onto the chest, etc. at a very specific time when the heart’s electrical system is resetting itself for the next beat. It is rare, because of the specificity of the timing in a tiny window.

If commotio cordis is the cause, the fact that he had immediate CPR and defibrillation gives him the best chance of a positive outcome, and I very much hope that this kid is ok (and yes, he’s a man, but he’s the same age as our middle son, so to me he’s a kid).

In medicine, we are always weighing risks and benefits. Risks of differing treatments. Risks of not treating something. And we all do this in life in general. We assess which potential risks are worth which potential benefits and we live our lives accordingly.

Which brings me to the topic of playing football in general.

I love watching football. The beauty of the strategy, the athleticism and skill of the players, the teamwork, the meticulous planning and also the changing of plans in response to unexpected situations, the constant action – when you know what’s going on, it’s a remarkably fun sport to watch.

I hate watching football. I hate seeing players’ heads jerk sharply when they collide with another player or hit the ground.

I won’t watch professional boxing. I appreciate the skill needed to be a professional fighter. I appreciate the work that needs to be put in, the fitness level, the practice. I cannot ignore that the goal is to knock your opponent out. The objective is to cause a degree of head injury that renders your opponent unable to stand for a full ten seconds. The intent is to harm. I cannot, will not, condone this as a sport.

But in football, the goal is to move a ball across a goal line (or through goal posts). The intent is not to harm. The intent is to move a ball. The intent is not to render your opponent unconscious. But the effect, even if not the intent, can indeed be harm.

I hate CTE (Chronic Traumatic Encephalopathy) – the condition that comes from repetitive sub-concussion-level head hits (or even non-head hits – when you slam into a tackle dummy bag and your body stops, your brain continues to move and hits the inside of your skull, and if forceful enough can then snap back and hit the other side as well) and/or repeated concussions. It’s a progressive brain disorder which can eventually lead to dementia. It occurs mainly in people who participate/participated in sports with repetitive collisions (e.g. boxing, football). It occurs with hockey and soccer as well.

Concussions suck. Spinal cord injuries suck. Knee injuries certainly aren’t desired.

All three of our sons are athletic. All three of them wanted to play football in middle and high school. I told all three of them “no.”

Our sons are athletic. Our sons are not big. Basic physics – when a small guy and a big guy run into each other, the small guy is going to take a lot more force in the hit.

Would they have had fun playing? Yup. Would they have learned things they wouldn’t have learned elsewhere? Yup. Would there have been other potential advantages? Also yup. Were these benefits to my kids worth the repetitive collisions? In my calculations at the time, nope. And if I were to have it to do over, my answer would remain “no.”

But every time I watch the Michigan Wolverines play, I’m watching other people’s children take those risks, and I really enjoy watching. I kinda suck as a human, if you think about that.

But here’s the thing: We allowed our kids to do plenty of things that involved not-insignificant risk. They all ski. They all did track and cross country through high school (dehydration and physical exhaustion are not benign, and runners certainly frequently experience injuries). They all did martial arts (in a dojo where you worked with “partners” rather than “opponents,” and where respect and safety were emphasized, but I’m not an idiot – I am well-aware it was not a risk-free activity). There are plenty of folks who would not allow their kids to take on the physical risks of skiing or of martial arts, but they enjoy watching the competitions in the Olympic games – I don’t think these people are unethical for accepting a risk for others they don’t accept for themselves. We all have our level of risk tolerance, and for so many things, even if the risk isn’t worth it for us, we can appreciate those things (think air shows, or gymnastics, or car racing).

So when one of my friends asked me if I think Damar Hamlin should retire from the NFL after this, assuming he recovers fully, and if the cause of his cardiac arrest was a piss-poor-luck timing of impact and not an underlying cardiac condition, I honestly cannot answer. His risk of continuing to play would be the same risk of brain injury that all players assume, and that I would not want my children to assume.

And the cause of his collapse may be something else. We don’t know yet.

I would like to see football evolve so that there is less collision. One may ridicule me here, but two of our boys played flag football, and it’s a great game. We have technology that we could adapt with sensors on uniforms to make football more of a two-hand-touch type of game. It would be different. But a new football could evolve that would keep much of the strategy, athleticism, and esthetics of the game and mitigate some of the more catastrophic risks.

Note that I said “mitigate” and not “eliminate” risk. To live is to be at risk. But risk mitigation allows us opportunity to do more. A freak accident can happen anywhere, with any sport, and in life in general, but we can set things up so that there are fewer accidents expected.

Risks. Benefits. Intent. Mitigation. It’s a lot to think about.

Again, I hope this kid is ok. And I hope all the players get the professional emotional support they need.