A speech therapist once reminded me that there’s a pretty big gap between what is possible and what the laws of physics won’t allow, when she convinced a stroke patient with aphasia that he could, in fact, relearn to speak.

I remember feeling my own kind of helplessness when, during internship, my resident pointed to a guy rolling into the Denver General ICU from the ER. “He’s yours,” she said. He was bleeding, seizing, septic, in shock, hypoxic on a ventilator. He had a high “tube to orifice ratio” — a lot more tubes going into his body than orifices to accommodate them. He smelled of the compacted grime, sweat, urine, feces, dirt that was under his fingernails and caked on much of his body. And he smelled of booze. I was looking at his bloodwork (his kidneys had failed; his liver was failing) and thinking, "No way he’ll survive" when she got up and said, “I gotta run down to the ER.”

“Wait!” I said. “I have, er, no idea where to start, this is impossible."

“Not impossible. Break it all down into systems. Neurologic, cardiac, pulmonary, renal, GI. When you take his problems, system by system, you’ll know what to do. Call me if you get stuck.” And she was off.

I was alone with the sweaty shiver cold on my spine. By systems, I treated the seizures (neuro), then adjusted the vent (pulmonary), tweaked the meds to raise his crashing blood pressure and increased fluids (cardiac and renal), and before she got back, he settled into a workable blood pressure with good oxygenation. Days later, he was joking and walked out of the ICU.

The lesson repeated when, a little later, I climbed Long’s Peak, a 14,000-foot mountain in the Rockies. We left basecamp in the dark. Sunrise lit up the clouds below us, which were just above tree line. Above us, Long’s Peak was impossible, far, unobtainable. But each step, each stage, was achievable. The boulder fields, the scree, the steady climb, the switchbacks, the keyhole. Another climb. Hoisting up to the top and looking thousands of feet down, through a cloud, at the mirrored mountains in the face of Echo Lake was otherworldly. But exhilaratingly in the realm of the possible.

Recently my wife and I were travelling in Cortona, Italy, carved onto a mountaintop in Tuscany, where every street is a steep climb or descent. We stayed in an old monastery at the top of the town and ambitiously descended for lunch, caffe, the town sights, and then dinner.

Walking back, Carla looked exhausted, so I got behind her and jokingly started pushing. The streets were so steep, my head was at the small of her back, even though I’m a foot taller than she is. We both were laughing, struggling to breathe, and slogging up the hill as we heard this clacking sound on the cobblestones. When we turned, panting, it was an octogenarian woman with a cane, walking uphill and impossibly passing us as if she were taking a nice, everyday stroll, which, in actual fact, she WAS doing, just as she had probably done every day, step by step.

I think about this blurry line between what’s possible and what’s impossible a lot when I see my older patients who feel stuck in wheelchairs, unsteady on their feet, unable to move about, and tell me it’s impossible. I am not skilled enough to know where their true ability bumps against impossible, but I want to believe that by breaking it into small steps, bit by bit, they can get unstuck and more mobile.