Tuesday, August 31, 2010

A Night of Fulfillment.

New life policy: Blog entries need not be deep, philosophical analyses of life as we know it. If I'm actually going to continue to write when a) my husband-to-be is NOT away on a three-week hike, b) I'm on rotations like my current one, when I am allotted 4-6 TOTAL hours of free time per day (which I'd perhaps like to designate to sleeping), c) when I lack motivation to fulfill even the most basic life functions, I can't require myself to invest the amount of cognitive and emotional energy in my posts that I usually do.

I think there's plenty of stuff that just "happens" that I'd do well to capture, to hold onto.

Tonight was my first day of my surgery rotation -- I'm on "night float," covering the emergency surgical services for the next ten days. I work 6pm-9am every day, and my free time is broken up by random, inconvenient lectures. So I really only get to sleep for 4 hours each day, at random hours of daylight. I wasn't stoked.

But tonight was AMAZING. I interviewed patients in the emergency department with confidence, found that my brain was able to work most of the night (except 4am-6am: the end of the shift was unbearable and a complete waste of learning time -- I was just fighting to stay awake!), and had a particularly rewarding encounter:

20-something year old boy presents to the emergency department as if right out of a textbook. Sudden onset periumbilical pain that, over the course of hours, migrated to the right lower quadrant. Accompanied by nausea. Felt worst on bumps on the car ride to the hospital. Extremely tender; positive rebound. Classic appendicitis.

I took the patient's entire history, and spent 20 minutes getting to know him and his family - primary care-style. We talked about their lives, what he's studying in college, what he likes to do with his free time, what his concerns are. An hour later, I was scrubbed in to assist with his appendectomy at 2:45AM. Then, I was at his side in the post-anesthesia recovery unit, assuring him that he was "all fixed."

BAM. Just like that. A completed story, begun and wrapped up all in a few hours.

This almost NEVER happens. So many undetermined details, so much never discovered. Always so much pending. Mostly, that's ok. But this sort of rewarding, feel-good, warm-and-fuzzy connectedness and closure? Awesome.

Monday, August 23, 2010

View from the Top

In my former life (of five months ago), a huge chunk of my world revolved around climbing - literally, and figuratively. Largely, I've carved out my sense of a place in the world through defining the metaphor of committing to uphill terrain, tapping into significantly deep motivating forces to stay the course, and reaping the benefits of conquest. I've defined by concept by expending so much effort to coaching people to do the same.

In my former life, I derived so much comfort and confidence from this construct. Conceptualizing challenges in my world akin to particular stretches of road that I know how to endure and sustain by bike despite discomfort has given me the sense that I really can do anything. But more importantly, it gave me the sense that I really LIKED to climb. Not just because of how awesome it was at the top; it was always moreso that I was proud of the process.

And then, I stopped. I stopped climbing, literally (I avoid my bike - despite three Centuries under my belt and no accidents in a year, I've again begun to fear falling or make other excuses why I don't want to do this "thing" that was very recently my favorite thing ever) and figuratively. I don't seek out adversity in efforts to demonstrate my strength; I avoid it.

My fiance is a third of the way through a 270-mile hike across the entire length of Vermont. With nothing but 35 lbs on his back, he sleeps on wooden planks with mice crawling all over him every night. He, too, likes to demonstrate his ability to survive. But he also does it for the perks along the way -- the epic views from 4000+ feet, the neat wildlife, the breathtaking sunsets.

Tonight, I got my breathtaking sunset.

On the last day of my Ob/Gyn rotation (nearly daily 4:30AM wakeups, total awkwardness all day long because of completely undefined expectations from supervisors, frustratingly useless all day long), I watched my fourth birth: a beautiful baby girl. I cried through my mask. The baby's father bawled, which made me cry more. He stroked his glowing wife's head and snuggled her close. It was one of the most beautiful moments I've ever had the privilege to witness.

I started my third year clerkships with nephrology, where the goal was to situate people on either a road to dialysis or to death. Often, their end destinations were reached. It was depressing and awful, and I instantly decided that I hated hospitals - just because stuff like this actually happened. Turns out, this was largely an artifact of being on the service that takes care of the body's most important organ at a tertiary hospital that cares for the sickest of the sick for the whole state (and a lot of the state next door). Even so, the majority of my third year has been more about preventing imminent death than promoting health and wellness.

On Internal Medicine, none of the people I helped take care of are actually going to get better. Their hearts were failing; their livers and lungs were not far behind. On Gyn, I helped surgically reduce cancer loads from uteri, ovaries, and pelvic walls of women for whom the cancers would largely grow right back. On Ob even, I saw more suction dilation & curettage procedures for spontaneous abortions (miscarriages) than I saw live births. I even performed the suction of an embryo myself. I felt nothing. It was like cutting off a human head in gross lab all over again: just another day in the life.

That just shouldn't be.

It's hard not to get caught up in all the suffering and sadness without the energizing balance of primary care preventive health efforts. Even obstetrics is a chaotic, scary world where so much can go wrong in an instant. A shoulder can get stuck. An umbilical cord can rupture. An amniotic fluid embolism can launch, flying straight to the lungs or the brain. You never know that someone is going to be ok, until they're ok.

But then there's a clearing. Through the wet, mucky branches, we glimpse a moment of perfection -- a tiny new life entering the world. She is peaceful and perfect, the reward of intense dedication and commitment. Not mine, of course. But the fact that I have the opportunity to be present for the most special day in people's lives -- for a moment, to share the greatest joy they will ever know...

In an instant, it all becomes worth it.

Friday, August 20, 2010


Sometimes you make choices that you're not particularly proud of.

My choice to not make time to write about any of the incredibly formative life experiences I've had over the past four months? Not my finest.

When I started this blog, it was to serve as a forum for self-reflection: to process, in real time, the subtleties of the thoughts, experiences and exposures that shape my world for better or for worse; to evaluate my choices along the way. Most of the time when I don't write, it's because I'm satisfied with the way I superficially process it as it's happening or, more frequently, because I'm too emotionally exhausted after telling my now-fiancé about a particular event that writing a "second processing" feels forced and chore-esque as opposed to cathartic.

But there's also something about the environment of medical training that makes me want to detach from thoughts and emotions alike. Something that makes me want to stick it in my back pocket, be glad it's done, and move on. Something that makes me just a little bit afraid of owning it, lest that give me the opportunity to regret it.

I did make some good choices recently, though.

On my psychiatry rotation in May, I chose to intervene in a child custody case. I chose to advocate for my patient, despite her history of severe mental illness and substance-induced violence, and chose to personally drive her and her mentally ill boyfriend an hour each way in my car to a hearing (after the hospital and child protective services refused to pay for a cab) that single-handedly enabled her to be able to keep her newborn son out of foster care and have a chance at supervised, safe recovery. I didn't necessarily think that she would be Mother of the Year; I didn't say that I did. My medical assessment of her psychiatric state, however, was that she was no more likely to make a bad parenting decision than hundreds of thousands of people who don't automatically get their kids put in child care -- and that she should at least have the opportunity to advocate for herself. My dramatic action (to seek the permission of legal services, my supervisor, and her supervisor to transport two homeless strangers, one of whom I was moderately fearful, in my own car) was the only thing that could have afforded her that. When I spontaneously offered, I didn't want to do it. I just felt that I had to. I couldn't not. It was the one thing, in that moment, that I could do to be useful, to contribute. It was my job.

On my internal medicine rotation in June, I chose to intervene in a patient's cancer evaluation. After I heard how pompously and jargon-esquely an oncologist explained my 93 year old patient's options to her, I chose to acknowledge that she understood 0% of her situation (including her option to do nothing). I chose how to re-present it to her, neutrally, and was fortunately able to find words that meant something to her. I asked her questions that helped elicit her underlying priorities and life values. Surrounded by 25 family members all crowded in the hospital room, I helped her frame the choice at hand (whether or not she wanted to know if she had cancer, based on whether or not she would do anything to treat it). My words found their place for each person in the room. There were tears and sighs and questions, so many questions. I patiently backed myself out of the equation, enough for her to make her choice clearly. I chose to hold her for the next hour as she sobbed on my shoulder. That was my job, too.

On my gynecology rotation, I didn't have a job. My role is ill-defined, and the circumstances of my environment contributed very little to any motivation to define it for myself. And I find that this very directly shapes the choices I make, new choices that I don't think I would have made before.

Calling upon my framework for evaluating new phenomenon: Where did this come from?

It comes from 4:15AM wakeups, 15-hour days where conscious patient interactions are limited to waking them up at 5AM (while they're supposed to be recovering from surgery), inquiring about their bowel movements, and forcing them to painfully contort their bodies to participate in a cursory exam that will be repeated an hour later by somebody else once I return with the rest of my overwhelming "flock" of white coats. It comes from how badly my feet burn after 9 hours a day standing in a freezing operating room, both temperature-wise and temperament-wise. It comes from the sterile, hostile surgical environment where the people entrusted with my development are more interested in advancing the tradition of 'education by humiliation' (which is actually preferable to hearing them mock and disrespect their patients' body habitus). It comes from being surrounded by overworked, exhausted residents who complain, talk dismissively of their patients, and are systematically forced to prioritize getting people out of the hospital over even attempting to connect with them. It comes from, from the minute I wake up, already wanting to go home.

Do I like it? Not one bit.

So on this rotation, I experienced almost the exact same situation as the previous one I described. But the players were different: a resident who in no way empowered me to take ownership of any of my experiences. The motivation was different: I didn't empower myself to do so either. The hours, the stressors. The excuses.

My resident explained my patient's options to her for evaluation of an ovarian mass that was causing her unbearable pain, which may or may not have been cancer: 1) do nothing, 2) drain it, which might be a temporary fix, or 3) have surgery, which would be a permanent fix. The trouble was that she had severe congestive heart failure, diabetes, hypertension (a significant risk factor for stroke), and severe lung disease. Surgery, for her, was a huge risk for death.

"Well, the thing about surgery is that you might not be able to get extubated... you might have to go on a ventilator for a little while," explained the resident.

Ventilator for a little while?! A little while, until her family may or may not have decided to take her off of it. A little while before death. That's a pretty important qualifier to include.

"Oh, no problem! A little while on the ventilator doesn't sound that bad," said my patient. "I'll go for surgery!"

"Ok, think about it some more - we'll come back this afternoon. See you later!" She and the rest of the team left, returning to the rest of their lives.

My heart sunk. My patient, who had no independent mechanism for evaluating her risk, was about to make what might be an irreversible choice. It would be her choice, of course, but based on things that we as her treatment team had a responsibility for communicating effectively. We failed.

I stayed behind.

"Mrs. W," I began. "You realize that you don't have to choose one vs. the other. You can try the low-risk option, the draining, and see if you get better. Then this way, you might not have to go through the dangerous risk of surgery."

I was leading her. I detected my own agenda, and I stopped. I didn't underscore the risks of surgery. I didn't underscore my concerns about all the reasons that she was more likely to die than not. I was a mere third year medical student; I didn't feel that I had the right to have an agenda. It wasn't my place to scare her. It wasn't my place to sit down and assume control over her life. The words I chose had powerful direction; however I chose to frame it and explain it, that's the way she would understand it. If I wanted to scare her, I could. If I wanted to make her understand, I could.

This profound responsibility, which should humble and thrill me, now frustrated me. I was tired. I was hungry. I was discouraged.

The optimistic smile on my patient's face brought tears to my eyes. And right there, I chose to check out. This wasn't my job.

But it should have been.