Thursday, July 21, 2011

Finally inspired.

It's not that I haven't done anything fulfilling in the past 5 months. Much to the contrary. Fourth year has been intellectually and emotionally fulfilling, beyond all belief. I learned how to manage scary things and be in scary places. I learned how to talk with people about death -- their death. I learned how to actually, legitimately perform brief interventions in psychotherapy. I returned to the clinic where my love of rural family medicine began. At times, I struggled (when least expected, really); at others, I felt so profoundly gratified. But I just never really felt like writing about any of it. It's just one more thing to do -- as though simultaneously preparing for my Boards, writing my residency applications, planning my wedding and subsequent epic travel (all of which will happen within the next five weeks) wasn't enough.

I almost wrote a few weeks ago, though. I've been recruiting patients for a clinical trial I am doing next month, and I received a phone call from a woman who had seen my advertisement. I recognized her name instantly. Because exactly two years ago, she made me feel like I could actually one day be useful to a human being. To excerpt from my July 2009 blog entry on this encounter:

I spent 2.5 hours with this woman. I asked her to talk about what it was like to wake up and move about, and dress and eat and get about her day. I asked her to talk about what it was like to leave the house, to interact with her family. To go food-shopping, to attend church. To process the world around her. To communicate with her doctors, her therapist. To feel alone, discouraged, purposeless. Hopeless.

And along the way, we tapped into issues that I wondered whether they'd seen the light of day before -- her anxiety about how she communicated with imprecision, about remembering certain key things in her day. I didn't know how to manage her meds; she probably really did need all 20 of them. But I knew about her anxiety. I've not had any training -- but I knew EXACTLY what to say, how to prompt her to evaluate her thought process.

Everything out of my mouth was fluid and confident. I knew that I knew what I was talking about, and I just did it. And she did it. She engaged the questions I asked her, engaged the concept of asking herself questions, of rehearsing her coping mechanisms in advance of encountering challenges, of developing an arsenal of experiences to draw upon that demonstrate her strength and confidence.

As each word passed my lips, I line-item compared it to those that have spouted during Spinning rides, blog posts, car rides, and all of the other opportunities I've given myself to practice, inadvertently, for this one moment.

As I deliberately carved each word to empower this woman to motivate herself towards change, with the exact same words that I'd used for so many literal and figurative hills for myself and others, I was so mindful of how directly I was speaking to myself just as intently as I spoke to the woman before me.

This was what I had trained for; this is what I had trained myself for.

I made her a list to take home with her of three skills she had developed and practiced during our time together. Her ammo against her depression that was all of her own active creation, to help the meds work better. Her way of reminding herself that she was in charge, actively constructing her own experience.

She smiled and took my hand.

And I knew that I could and would never practice medicine in any other field besides primary care.

So when I heard this woman's voice on the other end of the line, I flashed back to how truly fulfilled I felt when I wrote all that. I remembered, specifically, about the "list" I referenced. I had assigned her homework that day to go home and ride her horse, which she hadn't been able to bring herself to do for several years but once enjoyed. It was an exercise in "acting opposite" to her mood.

We made arrangements that she would come in to speak with me. But unlike the downcast, tearful woman I met two years ago, here she was with a bright, sunny straw hat making legitimate eye contact. She consulted the planner book in her purse before committing to schedule her study visits with me:

"Well, you see, I simply can't come on Thursdays. Thursdays are the day I ride my horse."

I bit my lip to keep from bursting into tears. I was so proud of her, this woman I hardly knew. And I told her so.

Now flash forward to yesterday. Back at clinic, I was asked to go see a young woman with complicated psychiatric illness who had begun to exhibit some self-destructive behaviors, who had expressed an interest in my study. She didn't qualify for participation, but I thought it might be a good opportunity to practice some of the skills I'd be actually using during study visits -- figuring it was worth a shot to try to help her. Went in, introduced myself, did a little bit of an intro pitch to diaphragmatic breathing, etc. Then I demonstrated her how to practice it, same as I would show someone on a Spinner bike. No big deal. Demonstrating to her how to rest her thumbs on her navel and let her fingertips expand across her lower abdomen so that she could gauge how well she was expending her abdomen on inhalation, I noticed how intent she appeared to learn this "skill." She looked up at me, wide-eyed and timid, with an expression on her face that seemed to be asking for approval.

The dynamic was foreign to me, in a clinical setting at least. I felt some combination of guilty, horrified, and overwhelmingly useful (as in, more so than I really should have been able to be useful) and sad. Sad because the way this girl was relating to me, more reminiscent of a young child, was the result of so many things gone wrong: her neural wiring, her life circumstances, her poor, poor coping mechanisms.

So I thought that I might try to teach her some coping mechanisms. One of the best things I learned on my outpatient psychiatry elective a few months ago was a component of cognitive behavioral therapy, a tool called Coping Cards. The idea was that you teach people, while they're not in crisis mode, to brainstorm coping actions or thoughts that they can look to during a crisis -- so that they don't have to think straight (since they're not likely to do so): the thinking is already done for them, by them, in advance.

I encouraged this girl to come up with a list of five actions she could immediately complete as an alternative to forcing herself to vomit when she got anxious. Without questioning me, she started rattling off a few things she could do to distract herself. I explained the concept of Coping Cards, handed her a few blank index cards that I started carrying around in my white coat pocket lately -- just in case I ever got to do this. And, again without questioning this foreign concept, started writing -- in a handwriting style and content consistent with the other regressive qualities I'd observed -- the following:
"Instead of vomiting, I could draw a picture."

Again, I wanted to bawl.

I didn't know if I was actually accomplishing a darned thing. But even getting to practice this skill that I didn't think most people even knew about, which I only knew about because of a very specific opportunity I sought for myself, with the promise of doing so much good with something so simple -- felt almost as good.

Monday, February 28, 2011

10 Lessons from Third Year.

Third year of medical school: the hailed carrot dangled before medical students throughout the country, *the* motivation to get us through the grueling hours in the anatomy lab, tedious biochemistry lectures, exam after exam after exam. When I began third year, otherwise known as clerkship year, 365 days ago tomorrow, I was as excited as anyone. I wrote about how I finally felt like I "belonged," like I was going to be useful, like it was going to be the adventure of a lifetime.

My roommate during first year (one of my "med school heroes" who used to be in the class above mine before taking a year off to complete a prestigious fellowship, and will now graduate with me) has prepared me for every step of medical school along the way. She told me what basic science classes were going to run me into the ground and make me want to drop out. When she started clerkship and hated every minute of her first rotation, she told me that, too. But somehow, I thought my life would be different. I was somehow going to be "above" the misery. I was Little Miss Balanced & Well-adjusted. Whatever.

Still, I structured my third year schedule according to what I expected it to be. I expected my surgical block to be the most painful, grueling and/or torturous, so I scheduled it for the summer so as to maximize my daylight (and, accordingly, my mood). I expected that block to be *less* horrible if I'd already completed an inpatient internal medicine rotation and, like, learned how to take care of sick patients (anticipating that they would *not* teach me that on the surgical rotations, somehow assuming that I'd know that already), so I arranged to do my medicine/neurology/psychiatry rotations first. Ob/gyn and surgery came second (yes, summer). I deliberately scheduled the rotations at which I figured I'd suck least and enjoy most -- pediatrics, family medicine, and outpatient internal medicine -- at the end, so that I'd end the year on a high note of confidence, optimism, and still-wanting-to-practice-medicine-ism.

You'll note that I haven't blogged in five months. Since I only blog when I'm emotionally distraught, I guess this means that I planned well.

As I sit here today, I am happy and content. I feel like I've learned what I needed to learn this year, with a clear idea of the experiences and exposures I want to have during the remainder of medical school. I feel balanced and at peace with myself, where I am, and where I'm going. But I don't want to forget, for a second, how utterly and completely miserable most of this year was -- along with the very specific insights I've developed about why this was all so.

And, so, I will write. I will write about what I've discovered about the process of medical training, the intersections of my idealism with real clinical practice, and about myself. Some of it won't be pretty. All of it I'll want to remember.

1. My job is to learn medicine; being useful is an occasional collateral benefit.
I spent first/second years with this obsessive, pathological preoccupation with being useful. I'd feel guilty for every worthwhile clinical experience I'd have, feeling like I did nothing to earn the generosity or trust of the patient who made themselves vulnerable solely for the purpose of my learning, and had no way to in any way alleviate the burdens of the folks at clinic who'd spend hours teaching me things, slowing down their day. My friends told me to stop. My mentors told me to stop. I couldn't stop. I... had... to be... useful [insert withdrawal tremor]. When I couldn't be useful as a medical student, I *had* to find ways to be useful in other realms of my life, whether that be coaching cycling groups for free, or signing up to mentor a 12-year old, or joining this or that committee, or any number of commitments I've taken on over time to get my "usefulness fix." And still, the pursuit of usefulness would continue indefinitely. Why? Because with all those little tastes of "the good stuff" comes the belief that pure, unquestionable usefulness is just around the corner.

Until clerkship year. Clerkship year, the residents make it abundantly, unambiguously clear that you are *not* useful. Your job is to wake patients up at 5AM to ask them if they've had bowel movements or passed gas. Your job is to carry around 40 lbs worth of gauze, scissors, and other random supplies (even though there's a supply closet within a 2 minute walk of any place you'd ever be). Your job is to read the minds of everyone peppering you with vague, impractical questions. Your job is to fulfill all of the random expectations that everyone has for you yet refuses to tell you about even when you ask multiple times. Your job is to finally "get" that you're not in any way useful to the team, and that you're best off finding a new goal for yourself. Like learning stuff. More on that next.

And in the end, you are useful. You're useful because you have time and motivation to translate "medical" into English for patients. You help people understand what's going on amidst the chaos, to give them a way of feeling like they have any sort of control over anything. You keep people informed about their lab results or the chest x-rays nobody told them they were having. You walk them around the floors, you help them use their incentive spirometer. You answer their family members' questions. You listen. You stop feeling compelled to prove your usefulness to yourself, finally, because you don't even want to think about how utterly terrifying a patient's experience in the hospital could be without a 'useless' medical student.

2. Showing up to a clinical experience without a specific set of learning experiences in mind to seek out is like showing up to the gym without a HR Monitor. And I sure as heck wouldn't do that.
I had an epiphany after my first three weeks of clerkship that I should be treating every day like a training session. From there on out, I had a checklist of specific things I wanted to get out of x rotation -- stuff I'd ask about, stuff I'd try to see, stuff I'd read about. A "To-Learn" List, if you will. It gave me a sense of purpose, structure, and meaning to my day. I don't know how people get through a day without doing this.

3. Hospitals are negative places.
Imagine you're sick. Really sick. You're sick enough to have to be in a hospital, where flocks of strangers wearing MRSA-covered white coats are coming in and out of your room, speaking in acronyms and jargon (to one another, barely saying two words to you) that you question whether it's even English. You get your blood drawn at least every day (then people are surprised that you're anemic), if not more frequently. You get whisked off for chest x-rays that nobody told you that you were having (let alone presented as a "recommendation" for you to accept/refuse). There are beeping alarms and monitors, and the person on the other side of the curtain is coughing so loudly that you're sure he's going to blow out his lung. You spend all your time on a hard-as-a-rock tiny twin bed with scratchy sheets and pillowcases. The only thing noisier than your room is the hallway outside your room. And then there's the silly, awkward medical student waking you up at 5AM (after you finally fell asleep at 4), asking you how you're feeling.

I've been through four hospitals now as a medical student. I used to be deeply afraid of and uncomfortable in inpatient settings; this is no longer the case. Instead, I just strongly dislike them. Two of the hospitals I've been through were small, community hospitals (as opposed to large academic tertiary care centers) that had fewer white coat-clad people scurrying about. It felt more peaceful there. Less chaotic. When it comes time to apply to family medicine residency programs this summer, I will surely keep this in mind.

Community hospitals have fewer people indeed -- and specifically, fewer (if any) residents. A study in the journal Academic Medicine in Sept. 2009 showed that empathy levels in medical students drastically dropped during 3rd year. I wonder if being around overworked, overtired, miserable people who complain about their jobs, their patients, and their lives all day long has anything to do with contributing to a sub-empathetic environment. Hmm.

The only residents who seem to actually tolerate, if not enjoy, their lives are pediatrics, anesthesiology, and family medicine residents. I'm glad I decided to become one of the latter.

On the rotations where I worked directly with attendings (obstetrics, family medicine, outpatient internal medicine, and outpatient pediatrics), I a) learned more; b) woke up every day actually wanting to show up to work; and c) didn't spend the whole day counting down the minutes until its end. It's hard to tell whether it was being around more uplifting life characters vs. being specifically out of the hospital vs. practicing primary care. I suspect it's a little bit of each.

4. Jadedness is not predetermined.

On my family medicine clerkship in rural Vermont, I had the opportunity to work with one of the most inspiring people I've encountered in my training to date. She was compassionate, kind, and empowering towards her patients. She was *exactly* how I want to be "when I grow up" (as one would expect, collecting various stylistic approaches along the way is a selective process -- picking and choosing "how to be" and, often more importantly, "how not to be" -- but with this mentor, she was literally completely masterful in every situation and inspiring in every way).

She was a relatively new attending, only a few years out of residency. I asked her how it was that she made it through residency without becoming jaded and cynical and awful. She told me that all I had to do was keep noticing the "awful," processing it with the people around me, and just being myself as best I can. In part, that's why I'm writing this entry.

5. "Sometimes, you just want to go home."

My obstetrics preceptor who, while having his share of shortcomings (namely, dictating overly legalized, defensive notes as he saw patients often without actually interacting with the patients -- just having them listen to what he said into the dictaphone; note to self: don't do that), was a super-smart, super-impressive character who had a lot going for him. He was a gifted surgeon and, despite his very strange and off-putting interactional style, somehow had the adoration of all of his patients. While I have no plans to model his style, I did find myself inspired by his ability to balance all of the different realms of his life. He was a competitive mountain bike racer and golfer, flew planes, was an elite pianist, stuff like that. Still, he was up on all the latest research and seemed to read everything out there in the world. He worked hard, stayed late, was meticulous about details. There'd be nobody who would ever question his work ethic or dedication.

One late afternoon, he turned to me and remarked in a profound-sounding tone: "Sometimes, you just want to go home." Tru dat.

6. There is more than one way to demonstrate one's survival skills.
A big thing that happened this year is that the athlete/coach part of me took a back seat. My long-time ankle injury persists, and cycling is really quite painful. I didn't do any distance riding (or much riding at all) this year, whereas a year ago I was banging out 100-mile rides to demonstrate to myself that I could "own my discomfort" and survive any challenge. I didn't have my fall-back "if x --> then y" construct of athletic mastery implying future clinical competence, which felt uneasy for a while (even though it didn't really make a whole lot of sense as a premise anyway). So instead, I had to focus on clinical competence itself. I read more, I asked more questions, I organized material in a way that was useful to me. In the end, it's not as disappointing to no longer identify as an endurance athlete.

Besides, I had a new kind of survival sport. The ob/gyn & surgery block. I remembered when my former roommate had done it the year prior, she told me that for her it was all about proving to herself that she could survive without sleep, proper fuel, proper self-care, etc. I reminded myself that this challenge for me, too, could serve that purpose -- I told myself every day that I was about to demonstrate a different kind of strength that I'd never before considered. Four months of daily discomfort, embarassment, fear, deprivation. Some of the longest days, the saddest moments, the grimmest outlooks. And pretty much as soon as it was over, I realized that it wasn't even half as bad as I expected.

7. Looking forward to something good is one thing; counting down the minutes to the end of something bad is another.
I spent most of third year counting down to the ends of each day, week, and month. It started out when I spent my first four months in Maine, on rotations I would have ordinarily enjoyed if not for my poor coping mechanisms for being separated from my now-fiance. Instead, I focused on how miserable and dehumanizing hospital medicine struck me, and told myself that life would be better if I could just get to June 18 (when I'd move back home). On June 17, I asked my now-fiance to marry me. Life became amazing. But after a short summer break, it was time to start the most grueling four months of third year. I told myself every single day that if I could just get to October 15, that life would become extra-amazing. I'd saved everything I expected to love til the end. Every single morning, I'd wake up and remind myself how many days there were til October 15. I'd drive to work in the pitch black dark, dragging myself even after three cups of coffee downed by 5AM, and huff and puff to myself about how soon October 15 would come. I reminded myself of all the horrible things I could be doing besides (whatever I was doing), and fantasized about my post-October 15 life. And when October 15 did roll around finally, it was completely non-anticlimactic. It was really as good as I'd hyped it to be.

But you know what? That was no way to live. I expect to only really have one month of the next 13 that I will dislike; however, residency is bound to contain several. I'd like to think that next time, I can take these experiences as they come, treat them as though they'd last forever, and learn to be ok with that.

8. It's tempting to reflect only on the bad moments and gloss over all the good ones.
I regret that I didn't blog about any of the positive role models with whom I've interacted this year. I didn't capture any moments of inspiration, or triumph. I didn't write about how good it felt to counsel patients with mood disorders and eating disorders, to reconnect with the specific population I went to medical school to help (or to remember that this was so). I didn't write about how rewarding it was that my dream clinic decided to allow me to carry out my dream study of which I conceived three years ago, and will finally have the opportunity to carry out in a few mere months. I didn't write about what it felt like to start believing patients in clinic when they tell me I'm going to be a good doctor. I did, however, complain a lot.

9. Feeling uncomfortable/awkward really can become the new "comfortable."
This personal project of mine, taken on as a second-year, ended up being exactly how I thought it might. Every time I felt or otherwise clearly behaved awkwardly, I would just tell myself I was awkward and... keep going. Over time, it didn't faze me. I could be awkward whenever I wanted, and the earth would continue to rotate. I could look stupid or silly or whatever and, still, life carried on. I didn't have to fix it or resolve it; all I ever had to do was own it.

10. Feeling adequate is a good thing, not an entitled one.
I used to feel guilty every time I appreciated that I didn't suck at something, as though that were a dangerous omen that I was becoming cocky and over-confident. Actually, it's a pretty healthy thing to feel competent.

I just spent three hours preparing a friend now starting her third year tomorrow. I cooked her dinner, and taught her the basics of how to function in the hospital: where to go, what to do, what to cover on 5AM "pre-rounds," how to write notes, how to present patients on rounds, how to survive in the OR -- things it took me a year to learn, yet could be covered in a few mere hours. I even taught her a few new clinical facts. I never thought I'd be in a place to explain this to another person, and to be confident that I was being helpful.

I have tons more to learn, and will always have tons more to learn -- but right now, things are going exactly according to plan.

Sunday, September 26, 2010

Breaking the Numbness.

Another day in the SICU. Another code. Another death. This time, I knew the patient; yet, just like last time, I felt nothing as the end of his life was pronounced.

The scene was pure chaos. Multiple people calling out orders for IV boluses of potent medications to break the man's arrhythmia (ventricular fibrillation, with intermittent runs of what looked like the ever-frightful Torsades de Pointes), other medications to support his non-existent blood pressure. An attending physician who appointed a chief resident to "run the code," yet persisted in overriding his decisions. So many people calling for equipment and labs and answers. So many alarms beeping. The heaving sighs of chest compressions, interrupted ever so often by calls to "clear" before the defibrillator attemped to convert the man's heart back to sinus rhythm. And failed, over and over and over again.

A needle placed into the sac surrounding the man's heart revealed that it was filled with blood. Cardiac tamponade. The pericardial sac was drained, but his arrhythmia continued to be unresponsive and his pulse never resumed. After 43 minutes, the attending made the call that we would not be able to revive him. "It is 6:57pm. Mr. A. is deceased."

My eyes glossed over. A chill passed through me. But in a moment, it was gone. I helped wipe up the blood, and discard all the equipment - all the usual things that happen after an intervention for a living patient. The man's motionless, cold body looked no different than that of any other patient in the ICU. I left the room feeling just as unrewarded as I've left every room on the unit -- no more, no less.

A few minutes later, Mr. A's wife arrived to the ICU. A frail, petite woman in a wheelchair, she was escorted into the room where her husband's body awaited her. I never saw her face, only her side profile in the distance as a nurse told her what had happened as she opened the door.
I'll never forget the gray color her skin took, as she dropped her jaw in horror.

Then, only then, did my own tears flow.

I think and talk and write a lot about empathy, the importance of "inhabiting someone's existence" - truly trying to understand the multiple facets of their lives, their values, their influences. I don't think I've ever experienced true empathy but for the moments where I imagine what it would be like to receive the news that my soon-to-be-husband has died, or is dying. Every organ in my body twists up and squeezes. My ribs stiffen, preventing my heart from filling and beating as it should. I get cold and light-headed. Everything around me feels purposeless. In that moment, there is nothing worth living for.

I need to keep this pain in mind every single time I deliver this kind of news.

The difference is now that the pain isn't permanent. It feels real as can be in that moment. But then I return to the rest of my day. I move on to the next patient, a 28 year old who suffered an aortic dissection the day after he married his college sweetheart and spent 18 hours in the operating room, receiving practically the entire blood product supply of our state. I've been checking in on him throughout the day, watching his unstable blood pressure and persistent blood leaking into his chest tubes, feeling the coldness of his limbs and the weakness of his pulses. He's intubated and unresponsive, the same as he's looked all day.

But when I enter his room this time, his new bride is by his side. She strokes his hair and whispers into his ear. My eyes brim with hot, burning tears all over again. I look up at the ceiling to drain them, afraid that the young woman may see.

She asks me questions about how he's doing, what the beeping alarms and numbers reflecting his cardiac and renal function mean. I bite my tongue inside my mouth to stay focused as she speaks, as even my lip is to much of a give-away.

She bends closer to her new husband, resumes stroking his face beneath the twisted cords of his endotracheal and feeding tubes. This time, I hear her as she speaks to him.

"You're so strong to fight this. You have so much to live for - we have so much to look forward to in our new lives together."

I say goodbye, find a supply closet, and bawl.

Thursday, September 16, 2010


Overnight call in the surgical intensive care unit. Arguably one of the scariest places in the hospital, the SICU consists of 30-something rooms with sliding glass doors lining the perimeter of a huge cluster of desks and monitors and collections of tubes and people and chaos. Most of the patients within each glass cubicle are hooked up to 2-10 different foreign bodies: central and peripheral IV lines, arterial lines, Swann-Ganz catheters, nasogastric tubes, drains, chest tubes, endotracheal tubes attached to ventilators, a dozen different kinds of ports of which I still don't know the names. Most of them are so heavily sedated that they do not even grunt when you poke and prod them, lifting their gowns to inspect their oozing wounds and measure the output of their bodily fluids. They're kept alive with positive pressure ventilation and potent vasoconstrictors to support their blood pressure. They're monitored more closely than anyone else in the hospital - besides the doctors (who actually do check on them repeatedly), they are cared for by ICU nurses, who are exceptionally smart and demonstrate more dedication and compassion than anyone around.

Still, I hate it here. I am so viscerally uncomfortable, the minute I punch the combination code to enter the SICU fortress. Every time I hear something beeping, my stomach curdles and I want to go home. This is why I requested to do a 27 hour shift here: to own my discomfort, immerse myself in the overwhelming chaos. And maybe, just maybe, learn a little bit about how to take care of the sickest patients I'll ever meet.

I've spent most of the day being just as useless as on my other surgical rotations - tagging along and lurking behind hardworking residents. But I'm actually learning a ton. I'm already far less overwhelmed by the mysterious collections of "things" to which people are attached, and things that beep. It's been a relatively smooth day...

... until tonight.

I accompanied my resident to see an 86 year old woman whom we intubated earlier this afternoon, who was now coming off of her sedation and beginning to appreciate the circumstances of her world. She was not pleased. Pulling at her breathing tube, moaning, gesturing to us to take it out. My resident explained that she needed it to breathe for now.

Out of the corner of my eye, I saw her tapping her bed - waving, almost. I asked her if she were trying to tell us something. She nodded.

I offered her paper and a pen. She began to scribble, slowly. I translated aloud, spelling the letters as she wrote.

D ...a....e...d....d...p...u...d...e...d...

This went on for five minutes. She kept tapping the pen in frustration every time I misread a letter.


My heart sunk. I knew exactly what she was trying to write now. Should I continue? What if I were right? Or worse - what if I were wrong? I ignored my predictions. I dared not suggest it, just in case -- how scary and rude and horrific for her to hear this if it had not already been on her mind.


I read it, silently. Now there was no mistake. I couldn't ignore it -- now it was in plain sight. She was truly communicating to us that she wished us to withdraw support, right here on my little scrap of paper. My eyes glossed over. Chills down my spine, down my left leg.

"I can't read what you're saying -- maybe we can talk later?" said my resident.
I wasn't sure if he was dodging the issue, or truly couldn't see what I saw.
"I think she just spelled out d-e-a-d..." I said, softly.

Our patient began to tap fervently and nodding her head. We both stood there, frozen. I didn't know what my role was supposed to be at that moment. I hadn't even introduced myself as I tagged along with my resident into the room. I didn't know her, I didn't know her family. I didn't belong here. But here she was, telling us that neither was she. We had something in common.

I don't know anything about ventilators and central venous catheters and fixing people who are dying. But I knew a little bit about being scared in a hospital.

"I know you're scared. The breathing tube is just temporary. It comes out soon, as soon as your blood tests come back normal to make sure you're safe."
Blank stare.
"Is that what this is about? The tube?"
She shook her head no. I had no idea where to go from here.
"In the hospital, it's very common and normal to feel depressed and scared and hopeless. It goes away, it gets better..."
Blank stare.
"Your family -- do you remember them coming today?"
Shook yes.
"How about we wait for them to return tomorrow so you can talk with them?"
Shook no.
"Have you spoken with them before about your wishes?"
Shook yes.
"Are you close with your family?"
Shook yes.
"So how about we wait til tomorrow - maybe the tube will be out and you can speak freely..."
Shook no. She pointed again to her tortured letters on my notepad.

I hurt for her. She was so hypovolemic that her eyes were tearless. Mine made up for hers, I guess. I was at a loss. I understood her. I understood her loud and clear.

And I didn't know what on earth to do about it.

Monday, September 13, 2010

My First Death.

Rule #1 of a medical student on a surgical rotation: Never walk into an OR without first meeting the patient.

Today, I broke that rule. And it's probably the one reason I'll be able to sleep tonight. If I'm able to sleep tonight.

I was assisting my surgery preceptor with an elective surgery for a man with end-stage renal disease who needed better vascular access for dialysis. Was it the most fascinating thing in the world? No. Was it cool to see named vessels in a real, live person? Definitely. But then the phone in the OR rang, alerting us to an emergent case of a women presenting to the ED with a ruptured abdominal aortic aneurysm. See also: the scariest thing in all of medicine, wherein people bleed to death into their abdomens and/or their pericardial sacs.

"Go see that, Melissa!" my preceptor said. "That'll be definitely more interesting."

I didn't want to go. I knew I wouldn't be useful. I knew I'd be overwhelmed. I knew I wouldn't have met the patient before she was intubated and put under general anesthesia. I figured, however, that any other medical student would have loved the opportunity to observe the surgical management of a ruptured "triple A." I figured that I'd be an idiot for passing it up.

So I went. I gently opened the OR door -- and then *BAM* was blown away by the sights. There were 30 people, scrambling all over. Blood everywhere. Lots of monitors beeping. Surgeons calling out orders, calling for equipment and instruments. Organized chaos, if you will.

I slid up against the side of the wall. This was not my world. I didn't want to engage.

After a few minutes, the EKG alarm started going berserk. I recognized the pattern from televsion. The patient was in SVT. In my head, I silently reminded myself what drug to give her. Immediately thereafter, I heard the anesthesiologist announce that he was giving the patient this very drug. But the alarm continued to sound -- crazy fast beats, all over the place. Then, they slowed.

"She has no carotid pulse!" someone called out.
"That's your indication for ACLS."
"Beginning chest compressions now..."

I watched in horror. The surgeons continued to frantically attempt to stop the gushing blood from her aorta while the anesthesiologist rhythmically moved up and down behind the blue curtain separating her abdomen from the rest of her. I could only imagine how much force was being generated into her chest.

"This is useless - when do we call it?"
"Another 2 minutes..."

Two minutes later, they stopped. I didn't hear anyone call the time of death. I just left.

I felt numb. Kind-of like when I suctioned a demised embryo. I didn't feel anything, except the feeling that I "should" be feeling something.

I left the room. I saw my preceptor in the hallway a few minutes later. He started teaching me about the statistics of AAA ruptures and cardiac arrests and fatalities, and how the present situation had a 90% chance of occuring. I was silent. I realized that this perhaps projected disinterest.

"I'm sorry for being quiet. I've never seen anyone die before."

He asked me if I were ok, was truly kind and supportive. And I truly was ok.

Until an hour later, when I learned that this woman presented to the ED while her husband was being evaluated elsewhere in the hospital by a neurosurgeon for his own brain aneurysm.

When he came out of his appointment, after dealing with his own very scary reality, he would receive news that his wife was dead -- the very last thing he could ever have expected.

Then, I felt something. I felt a cold sweat break out, a deep ache in my stomach. I imagined what that might be like, and I felt like vomiting. I felt like crawling up into a little ball and bawling.

But instead, I cried just where I was.

Monday, September 6, 2010

This is not ok.

The sweltering OR lights dilate the vessels in my head and make me woozy. I alternate between being so overheated that I can barely stand upright, and with freezing chills from my sleep deprivation and the intermittent unbearably cold air conditioner. My face shield is fogged from my breath, my mask perpetually threatening corneal abrasion with its proximity to my fatigued eyeballs. The bottoms of my feet burn mercilessly from standing in place for 4.5 hours. I focus moreso on my duty to flex and extend my knees periodically to prevent venous pooling (and, accordingly, prevent passing out) than my duty to learn anything about surgery.

And then there's the smell of burning flesh, singed from the cauterizer. That, I pay attention to. It's grounding, somehow.

It is 10:30am. My shift was supposed to end at 7am. I've been here overnight, been awake 27 hours, and am scheduled to be back again in 8 hours. Sleep, studying, quality time with my fiance (who's been away for almost a month), and everything else that is supposed to comprise my "balanced" life is all supposed to fit in there. Yet, here I am in the OR, passively observing a 4.5 hour colon resection - with a field of vision more obstructed than the colon itself.

Ironically, this was quite possibly the one operation to which I was most looking forward to seeing on this rotation (I think the gut is amazing, and lots of my patients when I was a GI clinical research coordinator had colon resections by protocols that I only vaguely understood). I'd been able to spend time with the patient pre-operatively, who reminded me very much of a man I took care of in Maine on my medicine rotation (of whom I was very fond, who afforded me opportunities to build confidence and to be truly useful). So here we were, his abdomen sliced open with his oozing loops of bowel spilling out of his body - with so much promise to make him well! Perfect, right?

And yet, here I am: hard-pressed to recall any moments of my life as miserable as this one.

The back of my calf has a strange, sharp, throbbing pain. I am convinced that I have a DVT. I visualize it, ruminate over it. I imagine part of it breaking off and embolizing through my patent foramen ovale (a congenital hole in my heart that I conveniently learned this spring that I have), travel to my lungs and kill me. I try to make a Top 10 list of things about my present "learning opportunity" that are better than this scenario, and I truly can't come up with more than two. I instantly appreciate this as crazy. I become angry that this situation has driven me to think so irrationally.

Four times, I fall asleep while standing up. Once, I nearly fall onto the Mayo stand, the sacred base of sterility where all the instruments are kept. I resort to stepping side to side, or up onto and down from the step stool they've given this 4'11" medical student to be able to see over the surgeons' shoulders. I still can't. All this, and I can't see a thing.

The surgeon and the resident were too tired to teach me anything or engage me in any way. I wasn't being useful, I wasn't learning anything, and all I wanted to do was go home and snuggle my fiance and fall asleep for the rest of my life. And if that couldn't happen, I thought the DVT to pulmonary embolism plan was a good back-up.

The resident, the one with the scalpel in hand carving up segments of bowel, had been awake just as long as I had.

I "get" all the arguments about continuity of care, and how frequent hand-offs make for communication lapses that compromise patient care. But if the man with the scalpel feels half as dysfunctional as I do right now, there's something very wrong.

Thursday, September 2, 2010

A blast of sunshine.

I'm post-call for the third day in a row. I've been awake for the past 20 hours, and have only slept 9 hours since Monday. I only have 4 hours off today before I have to leave for work again (see also: only 4 hours to sleep/study). But I aaaaaaabsolutely have to write before I attempt. (It's pretty nice to genuinely feel motivation to write again).

Since beginning night float, there's a new character in my life: the morning attendant at the hospital parking lot. I've never been LEAVING the parking garage at 9am before, so I've not previously made his acquaintance during my two years here. He looks about 70 years old, wears a big wicker cowboy hat, and always has a huge smile on his face. But that's not all. He doesn't just take your ticket and parking fare; rather, he chats you up about your day and your life outlook, and tells a select relevant anecdote. Literally, one spends 5 minutes at the parking window - even with traffic backed all the way up. And it's, like, the best 5 minutes of the day. You have to remember how many factors exist that drastically reduce the probability of my enjoying ANYTHING at this moment: I'm exhausted. I'm grumpy. I'm hungry. I miss my bed. I miss my fiance. But after this insanely long, totally context-inappropriate encounter with this character, I am glowing. I smile the whole drive home. I smile the whole way from my car to my apartment, and up the stairs. I'm still smiling now.

And the thing is: in my old life in NYC, this would never fly. In my old life, the old me wouldn't even have wanted this to fly. Five minutes to chat with a stranger about a gift his son bought him 20 years ago in Montana, and where he bought it, and how he sent it to him across the country (today's topic, for example) while I've been up 20 hours and haven't eaten in 12, and know that I only have 4 hours off between now and 24 hours from now?

This guy is SO good at his job. He makes every moment count. I'm sure that I'm not the only one whose entire day is brightened by his presence. I may be exhausted and I may be living according to a completely absurd, largely unreasonable life schedule -- but I'm hereby going to do my very best to be this kind of presence to at least one person every day.

My fiance has talked of how content he'd be to work an oft-underappreciated, underpaid job like this. He says he'd be really happy to work in the service industry as a McDonald's cashier or Starbucks bartender, or a school janitor: he's talked specifically of encounters like I've described -- "moments" of unexpected connection, the opportunity to brighten someone's day like none other. The elitist and realist in me, mindful of both of our massive student loans (and their obstructiveness to our having a comfortable life and starting to have children within a few years of getting married) and the discrepancy between societal (and my) expectations of how he'd use his very expensive, private university-earned Master of Business Administration degree, compels me to be vehemently opposed to these thoughts. I feel guilty about that sometimes, even though he's only half-serious to begin with. I suppose it's a good thing that my realism balanced his enlightenment -- but it's still a good reminder, today, to focus on those "moments" that can literally change the course of a human being's existence. At least for the moment.