Portal de Periódicos da CAPES

Sifting through the Ashes to Find the Meaning of Resilience

2018; Lippincott Williams & Wilkins; Volume: 142; Issue: 5 Linguagem: Inglês

10.1097/prs.0000000000004907

1529-4242

Heather Furnas, Barbara Kammerer Quayle,

Health and Medical Research Impacts

You will be defined not just by what you achieve, but by how you survive. —Sheryl Sandberg Attending the 2017 American Society of Plastic Surgeons meeting in Orlando may have saved my life. On October 9, hours after a sparkling evening with my husband, American Society of Plastic Surgeons member Paco Canales, and colleagues at the headquarters hotel, I slept right through Paco’s text alert from one of our nurses: “Massive fire. I’ve evacuated. Your neighborhood is gone.” Bearing the news alone, Paco let me slumber peacefully. When I awoke, he told me—the fire had consumed our house. I felt the grip of shock and disbelief as I pictured the treasures I could have grabbed, if only I’d been home. Just 33 hours earlier, I’d shared the stage at Opening Ceremonies with my father, David W. Furnas, M.D., and Barbara Kammerer Quayle, a Patient of Courage, on whom he had performed reconstruction after she had suffered massive burns.1 I was there solely as my father’s last-minute escort to help him ascend the stairs (Fig. 1), but standing next to the man who had inspired me to become a plastic surgeon and a woman who embodied resilience was a high point in my life. A day and a half later, I plummeted to one of my lowest.Fig. 1.: 2017 Patient of Courage, Barbara Kammerer Quayle, is honored with her plastic surgeon, David W. Furnas, M.D., who stood next to his escort, his daughter Heather J. Furnas, M.D.WHEN THINGS ARE PIECES OF OURSELVES Ever since I was 14, I’ve kept a journal. Recording my days taught me that life’s details begin fading immediately. Every time I read years-old entries, I am struck by how much I’ve forgotten. Sometimes, I forced myself to write bleary-eyed so I could fully capture moments I wanted to keep. Without putting pen to paper, my recollections would have been pared down to a few memories, some vague, some altered, and most of them forgotten with time. After I had children, I wrote with greater fervor. I was no longer writing for me; I was writing for them. I preserved my children’s antics and conversations; portraits I drew as they slept; guidance and declarations of love in case I died; reflections of my life as a plastic surgeon; recipes I’d invented; and stories I made up. When they could write, I requested the same birthday and Mother’s Day presents every year: a journal entry. Their awkward lettering, simple thoughts, and childish drawings evolved into the deeper perceptions of young adults. I’d packed those 35 volumes with love into a fire safe. Art was a partner to writing in capturing the beauty of my life. When I was a sophomore in high school, my family lived in Nairobi, where my father worked as a Flying Doctor. My possessions were few—what I could fit into a small suitcase—but my experiences were rich. It was in East Africa that I first saw my father operate in the bush hospitals, inspiring me to become a plastic surgeon just like him. At my American school, where drugs were rampant and academic ambitions rare, I felt like an outsider. I quelled my loneliness through drawing and painting, working to capture the grace of the zebras, lions, elephants, and cheetahs we saw, and the majesty of the Maasai and Samburu tribes we visited in the bush. Years later, I painted portraits of my young children and the golden, oak-dappled hills of Sonoma County. All my creative history; the unscanned photos and videos of my children; and Paco’s mementos of swimming in the Olympics were ash and dust. My vibrant, Technicolor past was now reduced to the shadows and whispers of my own fallible, incomplete memory. The destruction left a form of amnesia, like losing my past. THE FIRE Through our neighbors’ texts and online news, I learned what happened.2–5 On the evening of October 8, an electrical transformer blew, and a power line fell in Calistoga, 12 miles from our home in Santa Rosa. Hot, racing winds nourished the sparks into a living, breathing monster that destroyed everything in its path. Embers flew a mile ahead of the flames, landing like incendiary devices onto structures. The electricity went out before midnight, killing the power to lights, garages, and gates. By 1:30 am, the fire had leveled our neighborhood. After jumping the freeway, it had burrowed deep into the city, consuming 5300 homes. Inexplicably, the Sonoma County emergency services official elected not to use the Wireless Emergency Alert.6 Neighbors and anonymous Good Samaritans knocked on doors, forced electric gates open, and saved lives. Friends fled burning homes, driving through flames, barely escaping. Two friends fled by foot, ending up in a burn unit. But not everyone escaped. A neighbor suffers from the guilt of knocking on the doors of nearby houses, but not all, and one woman perished behind her silent door. Five succumbed in their garages, unable to raise their powerless garage doors. Forty-four people died in the region, 24 in Sonoma County, and several within a mile of our house. Mementos of loved ones disappeared, too. Eight-year-old twin boys mourn the unopened letters written by their deceased mother before she died of cancer, one for each birthday until their eighteenth. Every friend who lost a home experienced heartbreaking losses. I was scheduled to give the last talk of the meeting on Tuesday, October 10, averting any temptation to return to work on Monday. After learning how many people near our house died or cheated death by just a minute or two, I realized that last lecture may have saved our lives. In those last 2 days in Orlando, our friends and colleagues surrounded Paco and me like a safety net, and the ongoing support of the plastic surgery community has been overwhelming. As I boarded the airplane to go “home,” I wondered if this was what a soldier felt like on his way to war: part dread, part fear, part curiosity. I distracted myself with an in-flight movie. As its soundtrack played Cat Stevens’ “The Wind,” my mind drifted to when I was 16. I had listened to that song over and over as I drew the face of Mary from Michelangelo’s Pietà. For days, I had worked to get the dimensions just right, rubbing the pencil marks to create shadows, selectively erasing to create highlights. It was just a drawing, but I felt Mary’s serenity whenever I looked at her face; it was the first piece I was proud enough of to frame. From the walls of my college dorm rooms, apartments, and homes, she had comforted me with her placid calmness. Through the decades, I changed, but Mary never did. As the “The Wind” played, I broke down for the first time since the fire, sobbing with visceral agony. I’d never see her again. In the San Francisco Airport, I looked at our suitcases as they slid down the baggage chute with a sort of reverence at their survival. Paco reflected that he’d come full circle from a 17-year-old arriving in this country with nothing but a suitcase. This was an end, but it was also a beginning. We picked up our worldly belongings and began our 3-month existence in a series of hotels and a guesthouse. The fires continued to burn for days, filling the air with smoke. Burned sections looked and operated like a war zone. After nearly 2 weeks, when we finally secured an entry pass, our grown children, Diego and Siena, arrived so we could see the ruins of our house together (Fig. 2). We put on our Federal Emergency Management Agency–issued white molded masks as our car approached the entry, where a well-armed National Guard submitted us to Checkpoint Charlie–like scrutiny and then waved us through. I breathed in the pungent, noxious, acrid smell of char, which would linger for weeks, even after heavy rains. Skeletal black trees and snowy white ash with occasional lone brick fireplaces, stone entries, and collapsed walls were all that remained. Mile after mile, the landscape resembled post–atomic bomb Hiroshima (Fig. 3). Without familiar landmarks, I nearly missed the turn I’d made hundreds of times. Even the street sign had melted into letterless obscurity.Fig. 2.: The author (second from the left) stands in front of the remains of her Santa Rosa house with her son, Diego Canales (left); her husband, Paco Canales; and her daughter, Siena Canales.Fig. 3.: The aftermath of the Tubbs Fire in Santa Rosa, California. (Photograph used with permission from The Press Democrat.)The fire’s violence came to life as I stared at the stucco walls that had been sucked inward by the heat-generated vacuum, the pool-side furniture that had been thrown several yards, the shattered glass that had changed color, and the melted metal that had hardened into solid silvery puddles. Our washer, our dryer, and a bathtub survived as black carcasses, but nearly everything else was ash. Our car was ash. Our stove was ash. Even our fire safes were ash (Fig. 4). Only our stone-and-metal mailbox survived. I pulled out the last delivery before our vacation hold had commenced. The envelopes were brilliant white, and I smelled not a whiff of smoke. If only our house had been built like our mailbox.Fig. 4.: The author searches for identifiable objects in the ashes of her home.POSTTRAUMATIC STRESS DISORDER Our office was in the evacuation zone for 2 weeks, but it survived. After an unsteady month of fire-victim cancellations, work returned to normal. From the office, though, I stepped off terra firma into quicksand. Our new quarters, designed for vacationers, had no desk, poor lighting, and no outlet for a laptop. Along with my computer, hard drives, and organized files, my productive days had burned up in the fire. An identity thief registered with the Federal Emergency Management Agency as Paco Canales, in hopes of collecting money, which meant that the real Paco Canales had to spend hours on the phone with the Justice Department, Homeland Security, and the Federal Bureau of Investigation with multiple fire-related transactions. Mail delivery has never completely resumed; we still receive just 10 percent of our previous volume. Some mail has been returned to senders, but most of it has simply disappeared. Six months after the fire, insurance battles forestall plans to rebuild. Every day we field e-mails, texts, and phone calls from the insurance company, the private insurance adjuster, the demolition team, the bank, lawyers, and assorted other people. The small, temporary house we now have gives us a place to tread water. Prolonged uncertainty is our new normal. In those first weeks I didn’t sleep well, awakening with dreams of flames consuming my paintings. I was anxious and startled easily. I clutched the few things I owned, fearful of losing something. Even with little to keep track of, I lost things constantly: credit card; driver’s license; clothing; purse; replacement car key; replacement credit card; replacement passports. I had difficulty concentrating on what others were saying, making decisions, and storing anything in my short-term memory. My brain was stressed, and my hypothalamus had shrunk. Only at work did I feel normal. MOVING FORWARD I lost thousands of beloved books, so my first step forward was to rebuild my library, starting with Winnie the Pooh, for comfort; King Lear, for dramatizing loss; and Robert Sapolsky’s Behave, which I had left half-read on my nightstand. Sapolsky explained the biological and environmental influences that impact the brain, and I was a textbook example of the chapter on stress. I realized that my psychological experience must be similar to that of plastic surgery patients who have experienced sudden loss. In my career, I’d spoken to replant, burn, and other reconstruction patients as if they could comprehend and make informed decisions. I was a living example that such expectations were naive. To help me process my loss, I thought of others with greater losses: Holocaust survivors who lost all; Abraham Lincoln, who navigated our nation through the Civil War while mourning the loss of his son; Deb Johnson, M.D., who led the American Society of Plastic Surgeons as president with brilliance and grace after losing her husband, Mario Gutierrez; and Barbara Kammerer Quayle. RESILIENCE Humans are resilient. But there have been fire-related suicides, including someone I knew. The number of mental health problems has increased as the months have gone by, confirming experts’ reports that psychological problems often worsen 6 to 12 months after an act of terrorism or a natural disaster.7,8 I believe resilience is an active decision, and it hangs on a sense of purpose. Overcoming past challenges helps, too. The hurdles I’ve dealt with, that we all deal with as plastic surgeons, have given me the experience of rebounding. The aftermath of the Tubbs Fire is more like an epoch than a time-stamped event, but someday I’ll write new journals, paint new paintings, and tell a new story. I’ve been lucky in life, and I am lucky still. In this postfire dystopia, Paco continues to be my anchor. My family, my work, my friends, and my dreams for a bright future give me purpose. And that’s the best medicine of all. ADDITIONAL WORDS FROM BARBARA KAMMERER QUAYLE, 2017 PATIENT OF COURAGE Loss is greatly underrated no matter if it is one’s appearance, lifestyle, parents, spouses, children, friends, possessions, job, or pets. After my burn, I felt shock, disbelief, and a bit of denial until I could grasp the full impact. Then reality gradually set in, accompanied by fear of the future. My life had been easy until the day I was a passenger in a rear-end car collision. I sustained severe burns of my face, head, back, arms, and hands, and my life turned upside down. I knew nothing about burns, I assumed that the burns on my face were like a severe sunburn, and I would eventually look like I did before. I was afraid to see myself, and I avoided reflective surfaces in the burn center. The staff never asked if I’d seen my face, having no idea I’d need their support that first time. My first look was in my bathroom mirror the day I was discharged. My image looked like a woman from a Hollywood horror film. I ran from the room screaming and crying. That was the beginning of reality and my emotional and psychological healing. No patient should be discharged without seeing his or her face with the support of staff and family. I was single, and I had to work. I feared I couldn’t handle teaching again, that the kids might reject me, but no one said the “D” word to me: “Disabled.” Going back to the classroom gave me purpose. Still grieving my former life, I slowly adjusted to a “new normal.” Burn survivors grieve a life they can only partially retrieve. I grieved not being able to play tennis, and I could no longer watch it. I grieved thinking I’d never have another boyfriend, let alone be married. Sometimes on Saturday nights, when I knew others were out on dates and having fun, I felt very sad. I was also faced with social changes. Now whenever I walked into a public place, startled glances, stares, whispers, intrusive questions, avoidance, even laughter became overwhelming. Then a dear friend told me: “Walk in that restaurant with your head held high and stand up straight!” Though I may have been a burn victim, I didn’t have to act like one. No longer would I allow strangers to ruin my day, and that vow was a life changer. To help me project an image of confidence and to feel socially comfortable, I developed a tool: Self-talk, Tone of voice, Eye contact, Posture, and a Smile. Those five letters, S-T-E-P-S, gave me confidence, even when I was scared. To be in control of social situations, I developed another tool: Rehearse Your Response. Whenever a stranger asked an intrusive question, I used a response I’d created and memorized: “I was burned in a car crash. I’m doing better with my recovery. Thanks for your concern.” I headed off persistent questions with: “That’s all I care to discuss today.” Then, I would smile and walk on. A stare, unlike a glance, can make anyone feel like an object. People who stared could make me feel angry for hours. One day I decided I’d no longer be a victim. Using my STEPS tool, I would look directly at the person staring, and I’d say, “How are you doing? Isn’t this a beautiful day?” The opening line allowed them to see me as a person. I became active in the Phoenix Society for Burn Survivors (https://www.phoenix-society.org/), the largest worldwide organization assisting survivors, families, and professionals with aftercare community reentry programs. I have also assisted plastic surgeons with online programs I developed. My plastic surgeon, David W. Furnas, M.D., was my partner in the reconstructive process, and he applauded my successes. Before my first surgery, my therapist encouraged me to say, “Dr. Furnas, I don’t want to be just a file sitting in a cabinet; I don’t want to be just a label: ‘teacher who was burned.’ I need to know that you really care about me as a person and that you will do your very best to help me.” In those days, one did not say something like that to a doctor. But David, as I came to call him, put his arms around me and hugged me and told me he did care a great deal, and he would do his very best. Thinking of that still brings tears to my eyes. I have always held a quote of his close to my heart: A crisis, at the onset, usually augurs nothing but ill. In the long run, however, my crises have more often than not marked a new course in my life, which is more fulfilling, and more exciting than anything in the past. Yes, a bit of good luck is needed, but the special feature of a crisis is that you are suddenly cut off from past patterns, habits, and interdependencies. Along with the distress and pain is freedom! Freedom to build again, with a new foundation and modern structure, using wisdom you didn’t have the last time you built. —David W. Furnas, M.D. The trick is to find your way out of the depths.