Category: Blog

What follows below is a letter I recently wrote to someone. At their encouragement, I’m posting it here, so I can refer to it in the future, when certain things get hard to hear, and harder to say. It is unedited, except for minor details for the sake of their privacy.

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Often writing is easier than talking to someone, and sometimes even when the same words are said, they are better communicated in writing. 

I wanted to share the following recent changes in my life with you, as I think they accurately highlight a few very important things: (1) My life is entirely defined by challenges like the one described below; (2) The whole of my actions are to manage and combat challenges like the one described below; (3) These challenges are largely invisible, and I cannot consistently make the time or energy to update the people in my life when they occur—in part because they often occur; (4) My mental health has gotten ‘better’ — meaning, I cope better. In other words, these challenges have gotten less visible. But they’re still there. 

The previous week was relatively ‘good’ for me – I experienced relatively little difficulty with my sleep. I was able to focus and get work done. I was able to exercise. I was well-regulated emotionally. I was making progress in my academic goals, mainly, getting a significant amount of studying done.

Then two days ago, something changed. I have no idea what. I didn’t see it coming. And I don’t know how long it will last.

Yesterday morning, I woke up about 1.25 hours later than usual (6:15AM instead of 5:00AM). I immediately felt alert, very restless, and very anxious. My thoughts were moving quite fast. I went through my usual routine. Brushed my teeth. Drank a glass of water. Stretched my right hip. Made coffee. And sat down at my desk to study: One of the most comforting, and safest things I do every day. In the two hours I sat there, I got almost nothing done. My mind was jumping all over the place. Racing. I tried to read the sentence on the Anki card in front of me, but I couldn’t slow down enough to actually do so. I realized I was holding my breath, I was so anxious. My desk lamp was hurting my eyes. I couldn’t sit still. In short, the morning was two hours of a tooth-and-nail battle between a simultaneously physiologic and psychologic disregulation urging me to get up, run, fight, do something! and the calm, rational part of my mind urging me to just sit and get even 10 minutes of studying done.

The effects got a little bit better over the course of the day. Getting out of my house to go tutor a student helped. We found a place to sit where I could tutor standing up, and I paced back and forth a little bit to manage that restless energy. The two hour session tired me out a bit, and that helped. Even so, I went to bed multiple hours late, as I was overly alert, I thus ended up sleeping in even later this morning.

In physiology, there are two related concepts: A negative feedback loop is a process that tends towards reversing a bad outcome. A positive feedback loop is a process that tends towards increasing a bad outcome. 

Much of my challenges lie in that ‘destabilization’ for me tends to be positive feedback: 

1. I have a stressful day, which makes it harder for me to sleep

2. My poor sleep leads to increased anxiety the next day. I am in fight-or-flight most of the day, and go to sleep even later. 

3. This cycle repeats, each time round increasing in intensity and consequences. 

Whereas for a ‘normal’ person, a poor night’s sleep might mean a shitty day and the desire to go to bed early, it often doesn’t derail their entire week. The challenge for me is that many little things, like sleep, can have these massive, many factor-multiplied consequences in my life.

Now, to what this means for me: Like most people, I have goals, hopes, and dreams. I want to be a doctor, but perhaps even more important to me is that I just want to get through college with good grades. And doing this requires more from me, than it does for ‘normal’ people. 

I can be halfway through the semester, doing quite well, and then wake up like I did two days ago, and suddenly be unable to get even an hour of good work done. Remember my lab partner over the summer who didn’t study, went to see Jurassic World, and then did absolutely abysmally on her exam? Well, sometimes my mind decides that it’s going to go AWOL for a while and see some bullshit movie in Physiologic Disregulation and Insomnia Land, and against my will I can lose a week of my life to simply fighting the positive feedback loop trying to spiral everything out of control. 

Perhaps I felt so at-home in Wildland Fire and EMS because in both cases, you’re already in a constant state of fight-or-flight, and so not only did that not cause any additional disruption to my life than anyone else’s, perhaps I was even better able to handle it. In fact, the greater the pressure, the calmer I tend to be. And I think some day I’ll make a great ER physician for this exact reason. 

The point is, one little disruption can destroy a week of my life. And that can mean I can go from doing great in my classes to being so far behind I struggle to not simply fail my classes. And there are 10,000 different things that can cause little disruptions that snowball into big disruptions.

The main difference is that, as my coping skills and attitudes have grown more mature, these problems become less externally visible. Now when I wake up, feel awful, and suddenly fall behind, I think to myself ‘Good – this will give me a chance to refine my coping skills!’ But, that makes the damage no less real.

The way I see it, life has dealt me a hand, and I have to live with it. I have two options: I could never aspire to anything great, be content working a stress-free job, something where these disruptions would impact my life less, and then have more time for things like friends, family, hobbies, ‘fun,’ and so on. 

Or, I can strive to do something great with my life, despite the burdens I carry, and accept that doing so will cost me much: The ability to have many friends, or to see few friends often. The ability to ever make meaningful time for a romantic relationship. The ability to have ‘fun.’ To have hobbies. 

And fundamentally, the person I am, I would rather die than live a life where I take the ‘easy road’ to avoid hardship for the sake of an easier life. On the contrary, every one of the things I’m proud of about myself were born from hardship. 

So, I’ve made sacrifices. And I’ve made my peace with them. I may never have many friends, and may often feel very isolated and alone. I may never have a romantic relationship that lasts. I won’t have hobbies. I will rarely feel relaxed. But my life will be meaningful.

It’s not visible to anyone but myself, but these last two days have been an all-out battle between me and my mind, trying to get a handle on my life, and get back simply to a level of stability where I can get more than ten minutes of studying done, or simply get a good night’s sleep. And part of that means that it sometimes takes me an entire day simply to get one email written.

I’ll add in finality: Because these disruptions can come out of the blue, and can be so incapacitating, preventing them is a constant and top priority for me. And part of that might mean spending a weekend exercising, doing laundry, and grocery shopping, instead of seeing a friend who is visiting town for a short while. 

But if someone says “David, hang out today” and I say “I can’t, I need to do laundry so that if next week my mind decides to fuck off and my entire life tries to fall apart, I still have clean clothes to wear” — well, they might “hear” it, but they won’t “understand” it. 

This is the reality of my life. And the people in my life have to be comfortable accepting me when I’m around, and equally accepting me when I’m not. They have to be comfortable with the uncertainty that I could be doing fine for months and then suddenly be unavailable for months. Because that’s the cards I’ve been dealt. 

Lastly: There are people in life who will not be understanding of this, and I have to accept that. The professor, for example, who refused to offer me a makeup exam or give me an alternative, after I spent 8 days in a hospital, despite that being clearly listed to him as one of my legal disability accommodations. And ultimately, even when the school disability office got directly involved, the professor simply ignored their emails. This sinks even further time and energy from my life. And it often leaves me with little else.

I hope this helps in some way. Sometimes in these awful states, though I can’t get any work done, I can write, and find it to be therapeutic. 

Please feel free to let me know of any questions, or just your general thoughts on this subject.

This is unedited, so I apologize for any typos.

David

I zipped up my backpack, gave my professor a grateful handshake, and then walked out the door. It was May 20th, 1930 hours—golden hour outside—and I walked down to my card, got in, and started my commute home. Just like that, my Spring semester was over. The day prior, I had driven into SF early and gotten a hotel near campus. My first final of the day was at 0800, and from the hotel I could wake up at 0700 instead of the 0500 wake-up from home needed to ensure my sometimes hours-long morning commute wouldn’t risk missing the exam. One lesson I had learned over the course of the semester was just how important sleep was. So on the afternoon of May 19th, I drove to SF and checked into my hotel. I went for an hour long walk along the water, got a nice dinner from across the street, and came back up to my room with the intention of going to bed early. But things don’t always go according to plan, and so at 0630 the next morning, I found myself lying in bed, having been unable to fall asleep the entire night.

I got up, checked out, and headed to campus. As someone who has struggled with insomnia my whole life, I know more than most people just how important a good night’s sleep is. And yet, I’ve also learned to function extremely well under significant sleep deprivation. Throughout much of late childhood and early adulthood, I was lucky to get 5 hours of sleep in a single night, and I would routinely have freak nights where I simple couldn’t fall asleep at all. I’ve been prescribed every pharmacologic approach from light-therapy to ambien, cognitive behavioral therapy, and I have at times exercised upwards of 5 hours per day to tire myself out enough to get some rest. And yet—what’s helped the most with my sleep? Toughing it out. It used to be that insomnia would scare me, frustrate me, confuse me—when I would realize I wasn’t falling asleep, my mind would start to race as I worried about the short term and long term consequences, paradoxically making my insomnia worse. Then, two things changed: I started working in EMS (where sleep deprivation is something of a badge of honor), and I began listening to Jocko Willink. As a result of those two changes, everything became flipped internally. Then, I was excited to experience sleep deprivation. The challenge in itself was exciting, and the added difficulty of the physical and mental fatigue I would experience would shape me into a stronger, better person. With time, I learned that I could function well enough without sleep: I wasn’t perfect, but I could survive. In EMS, because of mandatory overtime, you often get a mere 3-4 hours of sleep between shifts; sometimes you work night shifts, and your entire circadian rhythm gets flipped on its head. And yet, you don’t get a pass for being tired; you’re still expected to perform your job well. You don’t get a pat on the back. You don’t get special recognition. It’s what’s expected of you. It’s the minimum. I learned that I need a lot less sleep than I thought. And so the morning of May 20th, when I got out of bed at 0630 without having fallen asleep for a single minute of the night, and walked to the bathroom to get a glass of water, I quietly said to myself: I didn’t sleep at all last night. Good.

And I meant it.

My first final went well. I got to campus around 0715, bought a coffee, and then did about 15 minutes of Anki via a filtered deck of forgotten cards from the last 3 days. The exam was on the anatomy of the respiratory, GI, renal, and reproductive systems, plus the physiology of all of the aforementioned systems, plus metabolism, acid/base balance, fluids, and electrolytes. I felt confident on respiratory, reproductive, and metabolism, good on GI and renal, and simply okay on the rest, and my exam reflected that. I scored an 88%, which should put me somewhere near a low A / high A- for the class. And then I had a significant amount of time to kill, because my next final wasn’t until 1800. I studied for a couple hours with a friend, and then we got lunch to-go, and drove a few minutes to a nearby beach that was also a dog park. We sat on a bench, ate our lunch, and enjoyed overflowing affection from several dogs that stopped to say hi. Then, we drove back, and I headed off to my second final. My second final went quick. I scored a 96%, and just like that my semester was done.

This semester wasn’t the heaviest course-load I’ve ever taken. None of the courses this semester were the most challenging I’ve ever taken. But it wasn’t easy either. Anatomy and physiology was challenging, because of the sheer workload, the pace at which we covered material, and the fact that I haven’t taken biology since the 8th grade, nor ever taken a chemistry class, period. The ECG Tech class I was taking wasn’t academically challenging, but it meant an extra hour of commuting to a day that already involved 2-3 hours of commuting ; it meant that on Tuesdays and Thursdays I left the house at 6am, and often wasn’t home until 11pm. This semester was absolutely a challenge, but unlike any other time in my academic career, I met that challenge successfully: I didn’t jump off the deep-end, push myself too hard, perform wow-level feats on the first few assignments, only to crash and burn halfway through the semester. I worked hard. I was consistent. And I was efficient. People say that school is ‘a marathon, not a sprint.’ Indeed, the elite marathoner is not the person who has the hardest workouts, or the person with the perfectly optimized training pace tailored to his specific VO2 max. The elite marathoner is the person who consistently puts in the miles, every single week: The elite marathoner embodies consistency. His VO2 max workouts may not be ‘optimized’ and some days he might not have the energy to complete that extra rep. But he’s consistent. School requires the same.

What follows below are my observations, notes, and lessons learned from this semester.

Early in the Semester: Sleep and schedule.

For the first half of the semester, I woke up between 0430 and 0530 most days, went straight to the gym, and spent around 1-1.5 hours working out before heading to campus. This guaranteed that I got my workout done. However, as the semester went on, I realized that I focus much better in the morning. In the early morning, I can sit through 2 hours of Anki cards without needing to get up or take a break. In the afternoons, I am much more restless, and often struggle to focus for more than 10-25 minutes. Going to the gym in the morning did have some benefits to my focus – I feel good on the days I work out, and that early morning session would often put me in a better mood, which lends itself to studying. But ADHD can be unforgiving, and the morning is the only time when I can consistently focus for extended periods of time; and so in the second half of the semester, I switched to getting all of my focus-intensive studying done early in the morning

I’ve also, in learning how to work around ADHD, become a lot more protective of my attention span. Now, I keep my phone on DND almost the entire day. I don’t check my phone for the first 30 minutes of my morning. I check it once before I start studying, and then put it in a separate room, and don’t look at it again until I’ve finished all of the important focus-intensive studying for the day. I got rid of instagram, and stay off of most social media, including YouTube. Terms like “dopamine addiction” and “dopamine hijacking” get thrown around a lot these days, and while I don’t know if there is a basis of research to support those ideas, I do know that spending ten minutes mindlessly scrolling through instagram reels makes me feel awful in a way few things can, and so I avoid digital distractions like the plague.

Similarly, I noticed pretty quickly that my focus, and mood are much better when I’ve gotten a good night’s sleep, and so much of my schedule and life is heavily centered around getting a good night’s sleep as well. And as I understand the theory of learning, sleep plays a very important role in the function of your memory. As such, I rarely drink alcohol, which significantly effects my sleep. I do drink caffeine, which I limit to a 16 oz of coffee in the morning. I go beyond that only on days when I need it, such as when I have two final exams and got a total of zero sleep the night before.

Studying and workflow

Most of my college career up until this semester has been studying math, and my grades when I went to UC Berkeley were Bs and Cs on a good day, so I knew that this semester I was in for a very difficult learning curve. Thus, I spent a significant amount of time early in the semester researching both how to learn effectively, and how to be successful in the specific setting of a lab-based STEM course like Anatomy or Physiology. What I found is the following: Success in such a course requires three skills: Learning ability, remembering ability, and exam performance.

Exam performance is simple to understand: Exam-taking involves more than just understanding a concept. It involves being able to rule in or out options; being able to read between the lines; and being able to distinguish between what’s ‘textbook’ and what’s ‘real world.’ And to get better at taking exams, you take exams. Lots of them. Learning ability is the ability to, when given all the requisite information, piece together the why behind something. This comes easy to me, because it’s mostly a skill of logical reasoning, and my training as a mathematician makes that feel natural.

What I struggle with is remembering: My memory isn’t great. Maybe it’s a function of my ADHD. Maybe it’s just how I am. Regardless, I might understand something easily, but I forget it so quickly that even an hour later I’m confused and unable to explain even the simplest concept. And so I dived into the science of memory and learning, and ultimately came across two main concepts that I believe are central to remembering what you learn: Spaced repetition and active recall.

Spaced repetition is the concept that, when studying a concept, your brain will remember the information better if you space out your studying. In other words, the person who studies for 1 hour each week for 3 weeks for an exam will remember more than the person who studies in only one 3 hour block the day before the exam. Active recall means studying by actively retrieving information from your memory. For example, explaining to a classmate the relationship between the hypothalamus and pituitary gland without looking at your notes. Answering flashcards is also active recall. On the other hand, highlighting your textbook is a passive process. Highlighting tests—and trains—your ability to recognize that information is important, not your ability to retrieve that information from your memory.

Very early on into the semester, I decided to completely buy in to the ideas of spaced repetition and active recall. I made them my life, structuring my entire study routine around them, and was rewarded for doing so:

My workflow for the semester was as follows:

First, I scoped¹ each chapter by making a list of all the major topics in that section. These I put into a spreadsheet, and separately, as headings in a google doc.

Then, I went through the chapter again. As I did so, I made Anki cards (I made around 7,500 total over the semester) and review questions that I could return to later to study with.

Then, I did the Anki cards, and answered the review questions.

About two weeks out from the exam, I would switch to using the review questions a lot less, and would use practice problems from the textbook, or Guyton & Hall Review 14e, which I bought for around $30, for exam-specific preparation.

Using Ali Abdaal’s Retrospective Revision Timetable, I would review each topic on the scope list, and rate it red/yellow/green according to whether or not I was weak/okay/strong on that topic.

Then, I would study the red topics first, doing so until they became yellows. Then, I would do yellows until they became greens, and so on.

If I had extra time, I would start reading ahead and making cards / review questions for future chapters.

Time Management

Throughout the day, I would always do my Anki reviews, and then new cards first. Then I would spend the remaining time I had reviewing material. I actually endeavored to always stay 1-2 chapters ahead during the semester, and that made all the difference in the world: Simply having an extra week to review because I started a week early made a huge difference. And, because I had gotten so much reviewing done on the back-end, when exams came around, I was able to take the day or two leading up to the exam easy, and only do Anki cards on those days.

Two thirds of the way through the semester, I did deviate from this workflow slightly: I paid for an Ankihub subscription and downloaded the Anking Step Deck, and instead of continuing to make Anki cards from the textbook we used, I almost exclusively used the Costanzo cards in the Step 1 tag. This saved me an extraordinary amount of time, and I actually wish I did so sooner.

For the Anki nitty-gritty

I had two decks throughout the semester. My ‘CURRENT BLOCK’ deck had an FSRS retention of 95%, and contained all the cards relevant to the upcoming exam. My ‘LONG TERM’ deck had a retention of 85% and contained all the cards from past exams. I optimized FSRS about once per month, and initially let it choose my learning steps using the FSRS helper add-on, but later moved to steps of 2m 10m, which ultimately I think improved my shorter-term retention, which helped for content learned in the last few days leading up to an exam.

In total, I did around 70,000 reviews over the semester, with a longest streak of 61 days in a row. I averaged around 450 reviews per day on days studied, though in the latter half of the semester I was averaging between 700 and 1,000 reviews per day. In terms of duration, I spent about 7.5 days (168 hours) total doing Anki, and matured about 5,500 of the cards reviewed. I generally did about 100 new cards per day, but if I was starting to get a backlog of new cards created, I would increase that to around 150. Moreover, my exam performance seemed to match my retention quite nicely. Exams 1-4, where I got through every card, my grades were around 95%, the same as my retention. Exam 5, I had dropped my retention down to 93%, and hadn’t covered every card: I did every Repro card, and half of Resp, but only a third each of the GI and Renal Costanzo tags, and my score on that exam was 88%.

The importance of rest

One thing that I didn’t do very well over the semester was take breaks. Aside from taking the day after each exam off, I don’t think I took a single day off the entire first half of the semester, and I think it contributed to some burnout later on in the semester. If I could go back, I would have liked to take one day every week entirely off (excepting Anki reviews, of course). It’s not that I didn’t have any fun—I still went out throughout the semester, going on dates, hanging out with friends, and doing the hobbies I enjoy. But I rarely took a full day off, and in retrospect, that did wear me down.

I practically lived, breathed, and dreamed anatomy and physiology for most of the Spring 2025 semester, and in doing so I nurtured a profound passion for both subjects: When I got home from a long day of studying, I didn’t want to rest: I would eagerly throw on the podcast The Poison Lab, and learn about membrane physiology, proton pump inhibitors, or the blood-brain barrier. And even though I’m currently on break, I find myself spending a lot of time reading about the physiologic topics that are interesting to me, doing practice problems, and of course, my daily Anki cards. I’ve wanted to go to med school for a long time; the passion has been there from the very first ride-along I did in EMS, before I had even become an EMT. But up until this semester, I never thought I could actually do it. I’m not equating the difficulty of this semester to medical school or the semesters ahead of me by any means. But for the first time in my life, I’ve myself shown that I can be a successful student; that I can get good grades without destroying my mental health in the process. And so because of that, I’m taking the leap to pursue the dream of medical school. I have no idea if I’ll have what it takes to ever get accepted, but I’m going to give it everything I’ve got, and I’m genuinely excited for the work that’s ahead of me.

What’s next for me?

This summer I’ll be taking Chem 1A at UC Berkeley. I’m already spending a pretty significant amount of my time each day studying to build a solid foundation for that class, since I’ve never taken a chemistry class before (even in highschool). I’ll also be tutoring Anatomy and Physiology for a class over the summer, which I’m so excited for! There are few things that sound more fun to me than getting to spend hours discussing membrane potentials, hormones and their feedback cycles, or any of the other fascinating topics I’ve learned.

After this summer, I have no idea what’s next. But in the meantime, between my daily early morning chemistry experiments, and the Sisyphean struggle of an FSRS retention > 90%, I’ll be living and breathing chemistry, and trying to fit the occasional EKG or toxidrome into the spaces in between.

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1. The ‘scope’ method comes from this and other fantastic videos by Ali Abdaal, medical doctor, and study / productivity youtuber. He also has some great videos on both spaced repetition and active recall, and is how I originally learned about both concepts. ↩︎

I don’t really know what “happy” is.

My entire life I’ve felt a sense of purpose; at times merely the drive to do something, and to do it with everything I’ve got. At other times, that purpose has been much more clear: When I was studying math at UC Berkeley, it was to become a mathematician. When I left UC Berkeley and became an EMT, it was help people. When I left EMS to be a wildland firefighter over the summer, it was externally to fight fire, and internally to do something that sucked, and become stronger from it. Purpose is a constant presence in my life, but rare are the times I’ve felt happy. Those times are usually more emotional (feeling happy versus being happy). Halfway through the summer fire season, on the Borel fire, we had been spiked out in a steep canyon, and the days had been hard. It had been an active fire with some exciting days, and little sleep. It was hot, the terrain sucked, the digging was awful, and the brush was thick. On that fire, as with many, I had slipped into a state of survival mode, simply focusing on putting one foot in front of the other. I was exhausted, sore, weak, and broken down. On our last day, we hiked straight out of the bowl. Our path took us over a significant amount of slab rock that was pretty high up, and I am deathly afraid of heights. The hike was a fear-inducing challenge on top of what had been two weeks of continuous challenge. I hated every second of it, and because of that, I loved it. When, dry heaving, I crested the top to see our captain waiting for us and the buggies just behind the tree line, I felt a sense of pride and satisfaction deeper than anything I’d ever felt before. Moments like that, though few and far between in my life, are the closest I’ve ever gotten to happiness.

Most of the time, however, I don’t feel happy. No. Purpose and mission drive me, and when I’m successful, I feel a deep sense of satisfaction. And that’s okay with me. I’ve always been a person with that negative affect. I began seeing a therapist for depression when I was still in elementary school, and at times have felt so depressed as to have let it overshadow my entire life. It’s just who I am. Most of the time it just feels like I’m really tired; that even after 9 hours of deep sleep, I just don’t have the energy a rested person should. And so I’ve always been motivated not by the reward of happiness but by the an absolute abhorrence of failure. You could say that between the carrot and the stick, I’m more of a stick guy. But there are emotions—satisfaction after doing something I wasn’t sure I could, or the pride of overcoming a difficult obstacle, and especially, the pleasure of the discomfort of doing the hard thing itself because I know it’s making me a better person—that are, in their own way, my own personal kind of happiness. And where I’ve felt that, by orders of magnitude more than anywhere else in my life, is alone on the trails, in the mountains.

I got into endurance sports in junior high school, when I started mountain biking. Ever the child to not be satisfied with “normal” I quickly became interested in a 50 mile mountain bike race, as opposed to the shorter 12ish mile cross country races that happened on occasion in my area. Training for that 50 mile race became everything to me. At the same time, school was awful—I was getting bullied daily, and my grades were very poor—but alone on the trails, there was no one there to call me names, to tell me I was a failure, to corner me and punch me—there was only the trail in front of me, myself, and my thoughts. Already an introvert and recoiling from social contact due to that bullying, the solitude of the trails became a place of safety. Free to set my own standards, I graded myself on my effort, and when I worked hard and got a good training ride in, I could be genuinely proud of myself. And as I stuck with it, the mountain biking became proof that I could be good at something. The mountain bike community was very welcoming of me, and I quickly made friends in a way that I never could at school. The 50 mile race came and went. Mountain biking turned to road biking, and the trails of the lower Sierras were replaced with the winding roads of the upper Sierras. When I got a little older, the roads of the upper Sierras became replaced again with trails, culminating in my completion of a 50km run, in 7 hours and 15 minutes. It’s no wonder then why I felt called to wildland firefighting.

Trail running, since I first fell in love with it, has become an act of spiritual reverence. When training for an event, I would routinely spend my entire day alone, on various legs of the nearby mountains. With nothing to do but think for hours, I would work through all of my thoughts and feelings, all while putting one foot in front of the other. It would get hard, and I would get to measure myself against my own force of will. Some days I would run eagerly into the Pain Cave and emerge from it standing tall, head held high. Other days I would crumple over and find myself sitting on the side of the trail, head buried in my hands. What I’ve always loved about (ultra) trail running is that it’s allegorical for life: Alone on the trails, nobody else can do the work for you. If you’re having a bad day, and you’re still 10 miles out from the trailhead, nobody can come carry you to your car. You can either sit down and give up, or find a way to keep moving forward. It’s not about how fast you can go, but instead, about your ability to continue moving forward, no matter what happens. The successful ultra runner is the one who never gives up. Over the course of a 5 hour run, there are incredible highs, horrible lows, and everything in between; Fighting up and fighting down the trail, over mountain after mountain, trail running gives you complete ownership over everything immediate to your life. It shows you what you’re made of.

Thus, running appears at every important moment of my life. For the last three years, I’ve been struggling with chronic pain in my right hip, and after many doctor appointments, and many confused doctors, we finally came to a diagnosis of psoas impingement. Since then I’ve been working with a physical therapist, and making improvement, but it’s been slow progress. As a result of this pain, I’ve been limited in what exercise I can do, and have felt distance grow between myself and my roots as an endurance athlete. I’m following the mantra of “do what you can.” These days my runs are 5 miles long, and my lower body workouts are limited to 2 sets x 8 reps of trap bar squats (just the bar). But I still get out into the mountains whenever I can.

Last month, I went for an 8 mile run hike: When my hip felt good, and when on flat or moderately downhill grades, I would jog. The rest, I would hike. While I ran and hiked, I listened to Episode 415 with Arthur C. Brooks of the Jocko Podcast. Brooks is an author, professor, but most importantly, a happiness researcher. On the podcast, he argues that young men need four things to be happy: Hard work, ambition, “a sense of the divine,” and a partner who will stand by them and yet hold them accountable when they fall off of their path. It seemed as if Brooks took everything I had understood about my own life but had not been able to articulate, and explained it succinctly to me. Hard work and partnership are as concepts self-explanatory. Ambition is the act of having a specific goal (a purpose) to work towards that is challenging enough to legitimately warrant that hard work. A sense of the divine is a spiritual foundation to that ambition; that your goal is something bigger than yourself. It is the why to the hard work. I thought about these things as I listened. I can work hard. I’ve always had ambition in the sense that I’m never satisfied with simply being ‘okay’—I expect absolute commitment from myself in achieving my goals. And I do have a sense of the divine, though it is vague and undefined. I grew up with a very deep mistrust of organized religion, and there is a remnant part of me that is repulsed by any attempt to specifically outline one’s spiritual beliefs. Brooks, on the other hand, is devoutly Catholic, and it permeated everything about his discussion with Jocko. And as I listened to him, I wondered at my own spiritual beliefs, and how I might define them. I struggled, and failed, to put them into words. I don’t accept that. And so, motivated by the discussion between Brooks and Jocko, I’ve set out a project for myself: To be able to define, clearly, that foundation of happiness that Brooks describes: Hard work, ambition, the sense of the divine, and partnership. I have a general sense of all four, but that repulsion towards religion I still feel from childhood has prevented me from ever sitting down to define them, to understand them beyond the amorphous feelings I have of them. And now, I see that as a failure, and a weakness.

Because writing has always been the cornerstone of my own understanding, the plan is simple: To explore those four foundations of happiness in my life, to then write about them, then iteratively explore further. Hard work is the easiest for me to understand: I’ve never been satisfied with just being ‘good’ at something important to me; with the things I care about, I’m all-in. Ambition is also more clear to me: My path in EMS showed a deep sense of purpose in helping others and a passion for the physiologic underpinnings of emergency medicine. The divine is less clear: An amalgamation of Albert Camus’ interpretation of The Myth of Sisyphus, The Path as Jocko Willink describes, Stoicism, Judaism, and Absurdism. The central themes are of finding purpose through struggle, of overcoming one’s own weaknesses, and of working towards something greater than oneself. And finally, partnership is both clear and indistinct; I view romantic partnership as ‘us’ versus ‘you and I,’ and believe in the importance of aspects such as self-sacrifice in a partnership.

Perhaps I’ll post some of that writing as I come to a better understanding of those four foundations, and myself. But since understanding of oneself rarely obliges to follow a strict deadline, when, and to what extent I have writing to share on those subjects is unknowable. Finals start today with a lab practical exam, and end next week. My summer is going to be very busy, between taking Gen Chem at UC Berkeley, and tutoring Anatomy & Physiology for my current A&P professor, but I’ll have a couple weeks off between this semester and summer classes where perhaps I can dive deeper into these issues. Then again, life is always busy, and you either make time for the things that matter to you, or you they don’t matter to you.

My bookshelves are filled with stacks of journals cataloguing my inner thoughts—sometimes with brutal honesty—through the best and worst moments of my life. At times the writing is near-incoherent. At others, every word has been carefully and methodically placed to spell out an important thought. I did morning pages for a year. But aside from the occasional poem, my writing was a very private piece of my life. Then a few years ago, I started a blog. I was going through a very difficult time in my life: I was severely depressed. I was in danger of academic probation. I was isolating myself from the people that mattered to me, and spiraling down a very dark drain, and I didn’t know how to communicate that to them. Vulnerability is something I have always struggled with. The times when I let down even the most superficial walls around my inner self are few and far between, and only with the most trusted people in my life. In some areas of my life, this has been a strength: The ability to maintain a calm, confident exterior regardless of how you’re feeling inside is an asset in my line of work—Emergency Medical Services—where your job is to present a calm presence of reassurance to your patient, though internally you might be feeling scared, or panicked for any number of reasons. Perhaps you realize how sick they are, and are worried they’re going to deteriorate, even die. Perhaps you recognize the signs of violence escalation, and are worried they might attack you. Perhaps you’re just horrified, because your last call was a DOA (“dead on arrival”), but your current patient is in pain and right now your job is to remain calm and reassure him or her that they are safe, that they are not alone, and everything will be okay.

I remember one day in particular, where immediately after one call—a police stand-off with a barricaded suspect—my partner and I were dispatched to a young child with a dislocated knee. The staging call had been a mess: This call involved a major freeway being shut down in both directions, and so the resulting traffic made our access to-, or egress from the scene, an absolute nightmare. After hours of waiting with nothing happening, our dispatcher keyed up: “Engine 24, Battalion 2, Medic 337, your scene is secure: Single adult male, GSW to the head.” Traffic was such a cluster-fuck (bystanders were standing in the street to film and were slow to move out of our way) it took two minutes to get from our staging location to the actual scene, only to arrive and be told by police that we were cancelled, as the patient was DOA. There he sat, a 6 inch hole in the right side of his skull, brain matter spilling out and splattered all over the place. Interestingly, there wasn’t a lot of blood visible. An automatic rifle of some kind lay across his lap. He was pale-white. He was dead. A firefighter from the engine checked a pulse, found it absent, and the engine went through confirmation of death protocols. We were shortly cancelled, and soon after dispatched to the kid with the dislocated patella. And so a few minutes later, there I found myself, standing on a school playground with my partner, splinting the knee of this kid. He was crying his eyes out, and in a world of pain. While I finished the splint, my partner drew up some intranasal fentanyl. And because it was our job, both of us did our work professionally, with calm, reassuring expressions. I told this little kid that he was going to be okay; that my partner was getting some medicine to make his pain better, and that his mom and dad were already on their way. The whole time, all I saw was brain matter spilling from the DOA’s skull. That scene was a bare half-mile east of us.

That invulnerability—”compartmentalization” has a more professional ring to it—is great when you’re in EMS. Except, the rest of your life, when you’re not going directly from DOAs to injured little kids, vulnerability is a strength; a lack thereof, a curse. My first blog was, originally, an exercise in learning to be more vulnerable. I wrote in it for almost six months before I even shared its existence with anyone, and it was another six months before I actually let anyone read it. The blog was technically public—though hidden deep in the maelstrom of the internet. Because of this, I was able to write with a relative degree of vulnerability, knowing that practically the blog was private, I let down my walls and bared my inner thoughts for the whole world—that is, anyone lucky enough to stumble upon my blog—to see. The result was that I was able to write with a level of raw honesty about how I was doing that I could not give to anyone else in my life, and when I finally felt ready to share that with some of my friends and family, I merely had to hand them the blog, rather than speak everything directly from the heart. Once they had read it, it was like a dam had been broken, and a flood of trust and communication poured into those close relationships. In this way, the blog was a massive success.

Time has passed since then, and I’ve outgrown that blog. It’s theme was heavily centered around motifs that had a strong current in my life then, that I’ve grown out of since. That blog, which is now both private and offline, served its purpose. Enter this blog, the natural evolution of, and next step in, this ongoing exercise in vulnerability. I’ve found myself wishing that I had a blog where I could write to a larger audience. That wish turned into a project, and this inaugural post is its fruition. The goal of this blog is as follows: To write more in a structured manner; to have a platform to exercise vulnerability by carefully letting down some of my walls and opening myself up to wider group of people in my life; to serve as a personal journal of my thoughts, feelings, and observations; to be a place where I can explore my passions and share them with the world: Namely, ECG interpretation, creative writing, emergency medicine, jiu jitsu, weightlifting, running, and any other topic that I find interesting.

This blog is titled Itself Towards The Heights, in homage to Camus’ famous words—

“The struggle itself towards the heights is enough to fill a man’s heart. One must imagine Sisyphus happy.”

The myth of Sisyphus has always fascinated me, and served as a powerful image that has gotten me through some very dark times. In fact, during one long and particularly dark stay in a hospital, the social worker involved in my case printed out that quote on an image of Sisyphus, and taped it to the wall of my room for me. Every time I wanted to give up, I would look at that image, and find the will to keep going.

In Greek Mythology, Sysiphus cheated the gods. In punishment, he was sentenced to roll a boulder up a mountain for all eternity. Each time as he neared the top, the boulder would slip from his grasp, roll back down the hill, and he would be forced to descend to the bottom and start over again. I first discovered Sysiphus through Albert Camus when I read The Myth of Sisyphus and Other Essays in an introductory philosophy course I was taking, and was deeply moved by the work. Since then the image of Sisyphus has become an important symbol of perseverance to me. When I close my eyes, I see Sisyphus toiling without complaint or fear against his gargantuan boulder. Though he never completes his task, he takes his strength from the challenge set in front of him. He finds purpose in the immediate moment: Each agonizing step up the mountain, muscles straining, blood and sweat staining the path below. In my mind, Sisyphus’ fate is actually a blessing: What the Gods thought would be a cruel punishment has instead given him endless purpose in a world otherwise devoid of meaning. The question of how far he will make it each time excites him. “The struggle itself towards the heights,” as Camus wrote it, gives him joy. And when the boulder eventually slips from his grasp, it gives him rest: He walks back down the mountain, sun shining, with the beauty of the whole world laid out below him. In those moments, he experiences tranquility known by no other. And when he finally reaches the bottom, without pause he throws himself back against the rock to again struggle upwards. It is in his attitude that I strive to model my life.

And so arises this blog.

Along with this blog, I owe you, The Reader, an update on what’s new in my life. Perhaps that will become its own post, but in the meantime: I withdrew from UC Berkeley in 2022, and at the start of 2023, I went to school to become an EMT. In April of 2023, I was hired to work in Alameda County’s 911 EMS system. From April of 2023 to May of 2024, I worked full time in 911 EMS. That experience changed the whole trajectory of my life. I’ve seen things I can’t unsee. I’ve had the privilege to serve my community, advocate for people, and genuinely help make the world a little bit better of a place. I’ve learned how to stand up for myself and others. I’ve learned how to remain calm during a crisis. I’ve learned how to function on very little sleep. And perhaps the most importantly of all, I’ve found passion and purpose—in medicine. From May of 2024 to October of 2024, I took a turn away from 911 EMS, and worked as an EMT and firefighter on a US Forest Service Hotshot Crew. That was also an incredible learning experience, especially with regards to wilderness EMS. I returned from firefighting confident that I wanted to go back to school, and that I wanted to work in healthcare. But I wasn’t sure in what capacity, or how I’d get there. I set my sights on paramedic school, and began taking classes at community college. One of my classes, Anatomy & Physiology, is taught by a professor who, aside from just being flat-out amazing, is a physician, trained as a neonatal intensivist. Despite teaching an incredibly challenging class, he has an amazing way of engaging with his students, myself included.

And so it happened that I found myself sitting in class, and a thrill of excitement shot through my body. The material we were learning was so damn cool, and I was captivated listening to my professor talk about his experiences in medicine. And I thought to myself, “I’m going to become a doctor.” And it was settled.

Well, shortly after deciding that you as a 27 year old without a bachelors degree want to pursue medicine, the sheer amount of work ahead of you sets in. So aside from working hard to stay on top of my coursework, I’ve been spending much of my time recently sitting with my decision to pursue medicine, and making the necessary changes in my life to prepare and plan for the long years of school and work ahead of me. I’ve also been dating a bit, continuing to try to work through this nagging right groin injury I’ve been dealing with, working on this blog, and I’ve also started therapy again. I even got a tattoo (I still need one more session before it’s complete).

A former friend of mine used to ask her friends “what’s something that’s been on your mind recently, that you haven’t been able to talk about?” I guess this blog is my way of both asking, and answering, that question. And so if there is something on your mind, Reader, that you have been unable to share with anyone—I hope you’ll reach out to me and share it. I want to hear what you have to say. So Reader, I leave you with this:

Life has its moments of darkness. Sometimes the darkness extends so far that you feel like you might never escape it. When that happens, let the dust and crashing sounds of your boulder as it tears back down the mountain guide you forward. Put one foot in front of the other, and somehow, you’ll find your way back down to the bottom. There it is: Lying patiently, waiting for you. The Boulder. So throw yourself against it with abandon, and begin to struggle again towards the heights. And maybe from out of your own darkness, you might find yourself—happy: Sisyphus, struggling once more against gravity.