One Flew Over

I Worked Damn Hard to Be Called "Doctor"

2011-12-01T22:22:00.000-06:00

Whoa. Am I a snob or what?
Here's the deal.
I am finally, after three decades of education, able to practice medicine without being supervised by someone else. I can write all my own orders, sign all my own notes, see all my own patients, submit all my own bills, do all my own rounds independently. I have my own office (well, okay, I share my office with a colleague, but whatever). My name is on the door. I don't have to ingratiate myself to anyone just for a grade. I don't have to pretend to be interested in areas of medicine that totally and utterly bore me.

I'm a doctor.

I have the $200,000 plus in student loans to prove it. And the forehead wrinkles.

I've spent the past 9 years of my life in medical training, and that was after college.

So, when I walk into a room, and I introduce myself as "Doctor Riegel," and, without a blink, someone says, "Oh, hi, Emily," it raises a bristle on my back.
And not just because I think I'm so super cool and that everyone around me should be calling me "Doctor Riegel."
I don't check the "Dr." box on forms that ask for a Title.
I don't get pissy when I'm checking in at a hotel for a conference and they call me "Ms. Riegel."
I don't have "Emily Riegel, MD" atop my personal checks.

In certain settings, though, it's important to me to be recognized as Doctor Riegel.

You see, contrary to what we've been taught as young children, the masses still see a relatively young woman working in a hospital and assume she must be a nurse. Which means they assume she works for a doctor. Which means they assume that what she says may or may not be the final answer or decision. Which means they sit there, waiting, for the doctor to show up and tell them the diagnosis, tell them what medicine to take or what test to have done.

I have had patients tell me, to my face, after I have seen them for an entire week, "It sure would be nice if a doctor would ever come and see me."

&*%$*@#!

Seriously! People!

Imagine this.
I have taken care of a dying man for several days. Adjusted his medications so that he no longer feel excruciating pain, severe shortness of breath, extreme anxiety. I've made countless phone calls about his ongoing care. Spent hours reading his chart, and writing my own notes. And many more hours counseling his family on the dying process and supporting them through their grief.
All the while putting my years of hard work and education toward this man's benefit.
And, when I walk in the room, overhear someone say, "Oh, Emily just walked in."

When I type it that way, it sounds so petty to even blink an eye at such a comment. Perhaps, some would argue, I should take it as a compliment. Take it as if I have established such rapport with them, and gotten to know them so well, that they feel like I'm a part of their family. No longer a *doctor*. Instead, I'm one of them. I'm *Emily*.

Here's my problem: if my first name were David or Jason or Michael, would they be using it?
Because what I have seen is that no matter how young or old, how good or bad, a male physician is, he is always referred to as "Doctor."

What I really care about isn't that I get called by the appropriate moniker. What I care about is being seen as someone just as, if not more, competent as my male counterparts. What I care about is that my work on their behalf be seen as being just as valuable as if it were done by my male counterparts.

What I care about is that my patients and their families believe in me and the care I can provide them.

So, when I am being called by my first name, I start to wonder if they are one of those patients, sitting there everyday thinking "when am I going to see a doctor."
I start to wonder, "Do they realize that I actually know what I'm talking about, or have they stopped listening to me because I'm not the doctor. I'm just a nurse/aide/custodian. Why should they listen to what I have to say about their disease."

And there's no polite way to ask this. Do I say, "You DO realize I'm your doctor, right?" (okay, so I have had to actually ask that at one point). Do I tell them, "I really prefer you to call me Doctor Riegel."

Admittedly, maybe some of this is my fault. I do cringe when people go throwing around the fact that they are Doctor So-and-So to anyone they encounter. Maybe I do hesitate to clarify my name. When, after introducing myself as Doctor Riegel, someone says, "Now what was your name?" I do frequently say, "Emily Riegel." I get it, that might set a certain precedent.
BUT
I have seen my male colleagues do this same thing, that when they state their name as "John Doe," they still go on to be referred to as "Dr. Doe."

Believe me, I'm not trying to belittle the hard work of nurses or other health care professionals who aren't given the title of "Doctor," but, if you are a patient, can you honestly say that you don't view their roles differently? That you don't have a different kind of expectation?

Harder to take, though, (and, all truths revealed, the impetus for this post) are when male colleagues, who may or may not have more professional experience than me, who may or may not outrank me (Senior faculty>junior faculty [me]>fellows>residents>interns), call me or email me or text me and use my first name, while referring to themselves by their professional title.

Emily,
Can we meet to talk about the patient later today?
Doctor Blowhard

Emily,
Thank you for sending me the information about patient.
Doctor Toocool

Emily, please call Doctor Smartypants at ext 568

If you're going to call me Emily, then go ahead and call yourself Joe. Or whatever your first name might be. It's that simple.

In an age when there are more female medical students than male medical students, when more and more women are physicians, how can we still be facing this kind of gender gap?

Does anyone out there have some wisdom or advice?
Am I just being hyper-sensitive?
Should I grow a pair and start insisting everyone call me Doctor Riegel?

Thoughts?

I have been evicted...

2011-08-01T10:27:00.002-05:00

photo credit http://philip.greenspun.com

We recently had a very dear patient at the Hospice House. One of those old men you look at and still see the charm of his boyhood, twinkling eyes and affection right there on the surface.
He had been an artist, but as he became more ill he was no longer able to hold his pens and lost one of his great joys. In his last month, he wrote this poem:

I Have been Evicted

Evicted from My House

The House of Life

The House I Loved so much

For so long and forever will.

Lately it has been going down

The Shell is breaking

The Structure is cracking

showing its Age!

I Have been Evicted

From My House of Life!

The landlord sent me Notice

Friendly but Unmistakable

Time has been set.

Bring Your House in Order.

You have to Leave.

Take your Memory with you

And take Solace

It has been a lovely comfortable House

But time is Up.

See you all at the new Place

"The Heavenly Chit Chat"

-JB 5/29/2011

By the time I met him, his house was quite decrepit and plans to move out were well underway. He was still there, though, that boyish twinkle. And so very kind and sweet and always trying to lighten the mood and elicit a laugh. He found comfort in having someone just sit with him and hold his hand. Often he would bring the guest's hand to his lips for a gentle kiss.
From what I was able to learn about him from his friends and his medical records, he had every reason not to be sweet and kind. He had reasons to be bitter, angry, dysfunctional. Instead of choosing to rail against the world that had done him wrong, though, he chose to find beauty and joy in it. Even in the small details of flowers on his table, or birds and squirrels in his yard.
The room he was in will always be his room in my mind, the room where the final eviction occurred, and he set off to "The Heavenly Chit Chat."

One lucky man!

2011-06-20T10:52:00.001-05:00

Have you ever wondered what it would be like to be married to a physician? Or, more specifically, to a palliative care physician? Okay, so probably not.
For a moment just try and imagine what it would be like to live with someone who deals with end of life and/or death just about every single day.
"Depressing" might be what you first imagine.
"Weird goth-type person" is what you also might imagine.
I like to think I am neither of those.
I am actually quite certain I am not goth. Although, I am pale...
But I digress.
In general, I would say that the palliative care providers that I know are a generally happy lot. Most seem to have a special sort of joie de vive (yes, I'm busting some french here, tres chic) that may come from seeing daily how fragile and short life is, and that we must enjoy it every chance we have; or maybe its because of this outlook on life that palliative care was an attractive field. Which was the chicken and which the egg, I don't feel qualified to say. So, overall, I don't think living with me is very depressing. For the most part.
Until, while sitting on our front porch, enjoying a late afternoon cocktail while our children nap, I say to you, "So, let's say you were in a horrible wreck and I had to make decisions about what kind of treatment to pursue or not pursue. What are your feelings about what you want form life?"

And the light hearted afternoon comes to a screeching halt.

Why do I feel compelled to break out this line of questioning on a lovely Saturday afternoon, on Father's Day weekend nonetheless? Maybe because over this past year I have seen far too many young people with young families, young spouses experience a tragedy. Either a freak accident or a horrific illness or even if something they brought upon themselves - young people not far in age or life circumstances from myself who ended up hanging by a thread, and with that thread rapidly fraying. I have seen how quickly life can go from perfect to nightmarish. Husbands and wives now making decisions with immense consequences. Left scrambling to figure out what their partner would want.
Honestly, before Saturday, I thought I had a good sense of what my husband would want. Of what kind of quality of life he would find acceptable and what kind he would find intolerable. Of what his values are and what he finds to be worth living for.
Thank goodness we had our talk, though.
While I don't feel compelled to share the details or outcome of this conversation, what I will say is that I am so happy that we had the chance to share our feelings and wishes with each other. Not only do I feel like I would be able to do right by him if her were seriously ill or injured, but I feel like I have a whole new understanding of him and, frankly, new depth of love for him that I didn't know was possible.
So, hard as it may be, and depressing as it may sound to do, if you are in a relationship and haven't had "the talk," I'd encourage you to do so. Yes, it is so sad to even try and imagine my husband incapacitated and me having to speak for him - but, by having this talk with each other I can truly say that we have enhanced our life together.
And, at the end of the day, that's what matters most.

So Long, Farewell.

2011-02-14T21:17:00.000-06:00

Leaving work at the end of the day can be a very strange experience when you work with the dying. You never know if you are saying a casual, friendly "goodbye" or THE "goodbye." The one that means forever. It can put a lot of pressure on what is usually a pretty simple part of daily conversation.
Usually, when there is a chance the patient won't still be alive in the morning, they aren't in a state to really seem to care if I am in their room at the end of the workday, much less what I say to them as I leave it. If the patient is able to tell me goodbye, chances are, I'll see him in the morning. Then one day a patient told me goodbye, and I was pretty sure there was a good chance that he actually wouldn't still be my patient the next day.
I had this feeling because, as I left his room, telling him I hoped his night went better than last night (he'd been anxious and had trouble sleeping and became fairly confused as the night went on by the time of my visit, his thinking was quite clear). He glanced toward me, where I was standing by his door, and stated, plainly, "Oh, I think it will be better. I'm probably going to die tonight, so I doubt I'll see you in the morning."
He didn't say it with drama, or as if he were waiting for some kind of "oh, don't be silly, you're going to be fine" response. He said it as if it were fact. Simple, known, fact.
The sky is blue.
I will die tonight.
You will not see me tomorrow.
It caught me off guard, and made me smile toward this sweet, gently man, who had often said things like, "this isn't living, this is existing" and "I never thought it would end this way for me."
He had become so sad by the fact that he couldn't just will himself to die and that it actually was taking his physical body so long to shut down and release him, that I truly hoped he was right. It was as if this were his last remaining wish, to simply die. To die before he could feel himself growing any weaker, any less vital, less mentally sharp.
The perfect ending to this story would be that I walked into work the next day and was told that the patient had died. That he had fallen asleep peacefully, with his wife at his bedside sleeping on the pull out bed in the room, and that, as they held hands, he had calmly and peacefully taken is last breath.
I'd almost convinced myself that this would be the actual ending.
So when I walked into work the next day, and saw that he was still alive, I felt sad. I wanted the perfect ending, the poetic outcome.
Instead, there were six more days and nights that this man existed through (he definitely wouldn't have liked it to be called "living"). He hardly had the energy to speak, and for his final few days was in a state of being unresponsive to his family. His lovely wife, to whom he had been married for over 50 years, was there with him the whole time. The morning before he died, I walked into his room and she was sitting next to him, holding his hand, crying quietly. His time was clearly drawing close, as was their life together.
Finally, later that afternoon, he did die. His wife and son were there with him. It wasn't the perfect ending he'd wanted, but he was comfortable and peaceful and surrounded by love. And I was happy for him to finally get what he'd wanted.

The World Keeps Spinning

2011-01-05T21:24:00.000-06:00

The Road // La Carretera
Originally uploaded by Dark Botxy

or, Death doesn't take a holiday.

Nowhere is the fact that there is no holiday from illness or death than within the walls of he hospital. There are no holidays from tragedy. The world keeps spinning, life keeps marching forward and death keeps putting a halt to all those best-laid plans.
I recently started back on the inpatient palliative care service. Our first new consult came in fairly early in the day and my attending and I began to scope out the situation.
At first glance, the situation was ugly. A young man, involved in a car crash the day before, transferred to our hospital after a "prolonged extrication" from the vehicle. The trauma surgery team's note laid out injury after injury. Multiple broken bones - jaw, cheek, arm, pelvis, thigh, ribs. Internal injuries - liver damage, bowel damage, ruptured spleen that had been removed. Most dire, though: massive brain injury. Part of his skull had been removed to allow his brain to swell. The skull now tucked safely away inside his abdominal cavity, awaiting the time when (if) his brain would shrink back down to fit within the skull and the portion of bone could be replaced.
It's unusual for the trauma service to consult our service; much less consulting us within the first 24 hours of a patient's admission. This creates a dynamic in which we're never quite sure where we are going to fit into the plan of care or how extensive of involvement we can expect to have. My attending and I arrived in the surgical intensive care unit and "met" the patient for the first time. He was, of course, unresponsive. Machines breathing for him, tubes entering and exiting his battered body, a leg pinned in weighted traction, his head wrapped in gauze.
Taken in isolation, the situation is bad enough.
Then, the story of this man and how he became our patient, and what his family was experiencing adds layer upon layer of sadness.
He and his fiance and their dogs had packed up their car early in the morning heading out for a 1200 mile drive across the country to visit his family for the holidays. They were about an hour into the two day trip when the wreck occurred. Hit head on when another vehicle crossed the median of the interstate. The vehicle rolled over. The dogs were killed. The fiance suffered major injuries, too. Our patient, though, was the worst injured of the humans from either vehicle.
His family, those thousand miles away, got the phone call we all fear. Themselves out visiting friends, they were three hours from their own home when the phone call came to them. They went immediately to the nearest airport, nothing but the clothes on their backs and their wallets, purses and cell phones with them. As quickly as they could and at any monetary cost, they flew here.
We met this family, first at the patient's bedside, and then sitting down with them along with the surgery attending managing his care. It was the first time they had a chance to meet face to face with a physician to be given the list of injury after injury, and the news that, in terms of his brain, this young man couldn't be much closer to death.
Life, hanging in the balance.
Hanging by a thread.
Holiday or no holiday, a young man, a good young man, lays near death. His family, a good, loving family, has their world crashing down around them.
I met with them again this morning, delivering them no good news. I asked them if they had any questions, and concerns - a question I always feel ridiculous posing, since of course there are concerns, and questions, how do I even begin to know how to answer the question most looming, the question of, "why?" But this lovely, gracious family, through their tears and terror, smiled kindly, and thanked me for my time and support. "We don't even know what questions we ought to ask," his mother said.
Medically, I know how grim things look, and I think they understand, too. Of course, they hold onto hope, "we're still hoping for the best" they say.
With his sister sitting in the room, holding on to hope most tightly of all of them, I cross a line that we rarely get to cross in medicine, but often must in palliative care. I speak from my heart. I tell her we are in a situation when my heart makes me need to say what I'm about to say.
I know this must be horrible, I tell her, looking in her eyes. I know you are holding onto hope, and you have to keep doing that. If he were my brother, and I were in your shoes, I would want someone to tell me that this is the time I need to tell my brother I love him, and anything else that is important for him to know. I'm not asking you to let go of your hope, but he may not have another chance to hear these things form you, or for you to say these things to him.
There are tears in my eyes as I finish my sentence.
There are words I'm leaving unsaid. Things I know aren't fair for me to let her know.
That her brother is the same age as my own brother.
Young, healthy men.
My brother, like her brother, a good young man.
As I'm trying to prompt her to tell her brother she loves him, I begin letting the thoughts come too close to home - he could just as easily, just as randomly, just as tragically BE my brother. A flash of my family in a room, surrounding the bed of my brother enters my mind.
Stop. You can't go to that place. Put the wall back up. Quickly.
patient's family. I leave the room, letting them cry together.
Afterward, I make my mind move away from the place too close to my heart and try and keep it a safe distance the rest of the day.
On my way home from work, though, I called my brother and we exchange a few bits of conversation. I tell him, "It's important for me to let you know that I love you, and am so happy you are my brother." I feel my voice cracking. Knowing this rare and random expression of sisterly love probably has my brother freaked out keeps me from getting more emotional lest I totally rock his world. I tell him I have a very sick patient who is his age, that he has a sister, and that I want to make sure he knows how I feel, now, when he can appreciate it fully.
He says,"Ah. Well, I love you, too."
So, this holiday, amidst the usual holiday traditions and chaos, let's all make time to tell our families we love them. That we are proud of them, are better because of them, or whatever it is you would have them know.
I hope this family has a chance to do this now, not only with the patient, but with one another.

Moments We Dread

2010-12-13T08:05:00.000-06:00

I'm breaking away from my use of this blog as more strictly professional to bring in something more personal.
My grandma is dying.

That pause was me stopping typing because I couldn't see my keys or the screen.
The tears aren't because I feel sadness about the fact that she will no longer be living in a world marred by her dementia, her rapidly progressing loss of memory of all the people she loves, her inability to care for herself, her existence now as only a shadow of the woman who gave birth to and raised 16 children.
What we cry for is rarely the actual physical death, is it?
More so, I think the fact of loss of personhood, of fading from the world. Whether the fading happens quickly, a sudden and unexpected death, or more slowly, piece by piece as it has for my grandma. The fact is, we fade.
The feeling of helplessness, not being able to stop the inevitable. In my professional world, I have an understanding and acceptance of the dying process. I know it is what we all ultimately face and is the one certainty in life. The helplessness I struggle with today is not being able to be there and doing for her what I have done for strangers. Provide her physical comfort, be a part of a team who escorts her through her last walk of life. I am helpless by not being able to be holding my mother's hand as she watches her own mother slip away. I hold the hands of strangers as they cry. I hold them close to me if they have no one else to hold onto. I try to bring them emotional comfort, or at least the comfort of knowing that all is being done to protect against suffering.
If I knew that my grandma's suffering was minimal, the my family was receiving the right kind of support and care themselves, I might feel a bit better. From 200 miles away, though, I'm afraid that neither can be said to be true. I know there is an effort and attempt, but despite my internal struggle to "not judge," feel myself being disappointed and frustrated and even outraged about some of the care she is receiving - more frustrating because some of this care is being provided by a Hospice group, and I'm finding their interventions frankly medically unsound. From 200 miles away, though, and as one grandchild in a family of 40+ grand and great grand children, in a family with 16 children, each of whom are struggling themselves and floundering along the way - what does the one granddaughter with medical and specialty training for just this kind of patient have to offer?
Or, when what I try to offer is ill-received?
I know the simple answer is this: go there.
I know what I would probably tell someone coming to me with the same questions and concerns: go there.
Travel the 200 miles. Be there.
It makes sense on so many levels, but on so many levels doesn't.
There are the obvious reasons: Work. My own little family needing me here. The fact that my ability to be there wold be so short term, and this a problem whose time frame and longevity is impossible to predict. And the overwhelming feeling that should I go there, I will still be helpless. She will, ultimately, till be made to suffer because I simply will not be able to be there at her bedside or on call until she dies. I will have to leave, and my gut knows that afterward, nothing will have changed.
This defeatist attitude is not typical for me.
I see my family members in various stages of denial. I see them in various stages of grief. I see them in various stages of turning on one another with blame. I see them all claiming that they have my grandma's best interest at heart, and believing they are doing what is best for her - but as we find out with all families in this kind of disarray, there is more beneath the surface. More anguish and hurt than I can expect myself to work through so that everyone can begin to heal and so my grandma is no longer some misplaced pawn.
I can't fix them, either.
Again, defeated.
In the end, one way or another, whether I find an answer to my questions or not, the fact remains.
My grandma is dying.
She is dying and it brings back to mind all of the people I have loved and who have died. The shortness of life. The joy of it all, the pain of it all.
And, selfishly, what I dread most about this is trying to explain it to Henry. My bright little boy. He is old enough and smart enough to realize something is wrong. He knows Grandma Cookie, and I think there is a good chance he will carry memories of her with home throughout his life. So, when she does die, how do I handle it?
You would think someone in my position would have the perfect answer to this question.
Guess what? I do have the perfect answer.
Except, it's a perfect answer for you. Or for a stranger. Or for a room full of people attending a lecture.
The answer is not so perfect when you answer it for yourself.
So, here I am on Monday morning, Facing a week of walking into the lives of strangers bringing them my skills and hoping those skills, in turn, bring them comfort and peace.
I will put on my "Hospice Doctor" name tag and game face and I will fake my way through every encounter, while inside I am calling myself a hypocrite and a faker. I will do unto others as I would have done unto me. Or unto my family. Or unto my grandmother.
And will hope that eventually, it will.

Overflow

2010-11-19T12:03:00.000-06:00

Eight weeks ago was certain I would write at least weekly about my experiences with fellowship. I have a long list of reasons I haven't had a chance to get around to it. I have an even longer list, though, of tales to be told and shared. I have been amazed everyday at the gratitude from families for the care we provide their loved ones. Hardly a day goes by when I'm not hugged, and certainly no day has gone by without verbal expressions of thanks and appreciation. To say I am fulfilled by this work is an understatement.

What occurred to me this week was that, underlying the fulfillment, and often barricaded back by the gratitude, is the fact that this is also very challenging and exhausting work. It means carrying the grief of others and seeing their pain, sadness, and frustration and trying to guide them through the underbrush and dim light to the other side of the forest. I make the trip several times a day, know the way to bring them through some of their fear. I find patients on a dark path, knowing what lies ahead of them won't be easy, and I try to say, "You are not the first to go here, and there is a way through. I will keep you from feeling the thorns and fearing the strange noises and rumbling around us. I will do my best to keep you from suffering on this journey."

The problem is, when you walk that path so many times a day, you can't avoid every thorn yourself. The sense of what is lurking in the darkness can't be avoided. First there are a few tattered bits of cloth caught by a bramble, easy enough to look beyond as you keep leading others through the woods. Then a sleeve gets caught and torn, and as more and more of the outer layers between you and the reality of this dark world become more shredded, eventually you feel a scrape on your skin. At first nothing more than a scratch, but each journey comes closer and closer to drawing blood. Until, eventually, you have wounds as fresh and tender as the wounds on the people you are trying to protect.

So here I am, after eight weeks of trips through the forest, finding myself tattered and exposed, trickles of blood appearing. Raw.

The first blood was drawn Sunday night when, after spending the entire weekend working, standing by families and patients, attending to death, I came home, tired, anxious to cuddle my child and have an evening to recuperate. On my way home I got a call that a new patient had arrived, and the family was very upset that there was no longer a doctor in the facility. Having already kept the babysitter almost 2 hours later than she'd planned, the thought of turning around and going back made me want to cry. I was told the staff there would try and handle the situation, explain that, being a Sunday evening, there was not generally a physician in house. I had left orders for the patient's care, spoken with the nurses about the plan, and me being there was, truly, not necessary. Several phone calls and a couple of hours later, I heard that the family was still livid but had calmed down to a low simmer. They had, though, stated that "whichever doctor didn't care enough to stay here or come back and see our mother has no business taking care of her and we want someone else to see her."

Hearing that, my temper boiled. Me, not caring enough? Hadn't I stayed hours longer than expected that day because I wanted to sit with a family whose mother had died? Hadn't I stayed longer that day to make sure the patient with worsening pain was doing better after I made changes to her medications? Hadn't I sacrificed time with my son to make sure people who are relative strangers to me have the best care possible? And after that, be accused, by someone who has never met me, of NOT caring?

This isn't a career I chose in order to be recognized for my personal sacrifices or be seen as some kind of saint, but eventually, after putting every bit of my heart and mind into what I do I become sensitive to being accused of anything short of that. I tried to work through my anger. Tried to remember this is a grieving family, and grief has many faces. They don't know what they are saying. They misunderstood the information and now had to adjust their view of the situation. Still, I woke up several times overnight and immediately felt my heart begin to race, anger well up. My drive to work that morning was dreadful, knowing I would have to face these people, but maintain my calm and rational demeanor, maintain professionalism.

I didn't have to, though. The patient had died overnight, her family at her bedside. She was not in pain or distress. With some measure of guilt, I thought to myself, "thank God." It meant one less challenge to face that day.

This week has worn on, under the shadow of that rough start. My son and husband, and then eventually me, were all struck by a stomach bug. I was up nearly an entire night caring for my vomiting toddler while my husband retreated to the bathroom not to escape until the morning. I had to go to work the next morning, and since H looked better and his daddy was still a mess, and there wasn't really another option, I took the poor little guy to preschool. I cried when I left- knowing I had chosen work over my child.

The night before everyone got sick, I got news that a dear friend had miscarried her twin babies. What can I do for her? Offer her for comfort or peace? Nothing. Yet all day long I comfort strangers. Those close to me, though, I feel worthless to even try and help.

My grandmother is on a nursing home. Her health is failing, I see her heading down a path that I have watched so many of my patients head down. She is 200 miles away, though, and I can't take care of her or make sure her doctors are doing the best for her. I talk to my mom once or twice a day, hear the strain and grief of seeing her own mother slipping away.

All around me, people I love dearly are caught up in the thorn bushes, crouching away from the sounds in the darkness, searching for a direction on a path. I'm not with them, though. I'm with people I hardly know. People who, while I know they need me and appreciate what I do for them, have never done anything for me. All the while, some of those who have been there for me my entire life and helped me get to this point, are suffering. And I feel powerless to take their hands and show them through the dark path.

So, with my body physically exhausted, my heart emotionally tattered, my spirit powerfully drained, I felt myself collapsing. It started with a tearful display at a meeting Wednesday morning. Continued as I drove home to my sick boys that afternoon. Thursday morning I went back to work, hoping to get in as much as possible before the stomach bug took full hold, but also breaking into tears again when another doctor showed me some kindness and told me I should go home.

So, I did come home. H and I curled up in my bed for a three hour nap. I slept through the night last night, and woke up to a day that I already had off (the benefit of working through the prior weekend). I've spent the morning relaxing with my still-not-100%-toddler. And now I have given voice to my own grief, revealed some of the emotional cuts and bruises that come along with my job.

Lesson One: It's Not Up to Me

2010-10-03T15:22:00.000-05:00

I decided that as I begin the adventure of fellowship training that I'm going to make an effort to actually chart my progress as a developing palliative care physician. It seems the best way to do this is to start right here, at the beginning. Who I am on day one versus who I am on day 365 and on other days in between.
After just one day, after just the very first day of fellowship, I've had to change my perspective about myself as a physician.
Friday, October 1, 2010. The journey begins. It was a bit harried thanks to a debacle at our house over a certain missing key, and my near inability to leave my house thanks to said missing key. Once I finally made it to work, I knew right away that I felt different. Something about actually being able to introduce myself as a "fellow" rather than a resident brings with it a different kind of responsibility and also a different kind of freedom.
Much of the day was spent alongside one of our fabulous palliative care attendings. We visited with patients and their primary care teams, did what we could to help both.
Toward the end of the day, the oncology attending saw us and got our attention. He was preparing to place a consult to us to help discuss goals of care with one of his patients. He felt he and another oncology attending had been very frank and forward with the patient about her prognosis (which is bad) and the need for her to begin getting final affairs in order and preparing for what is likely inevitable - her death. Neither physician was sure the patient really "got it," or that the information was really sinking in - so this is where we are asked to enter the picture.
As we get more information about the patient, the delicacy of the situation becomes more evident. She is in her late 30s and has advanced cancer, which has spread to multiple sites and organs. Her kidneys are minimally functional and not able to clear the toxins and maintain the required balance of electrolytes in the body. She is not a candidate for further chemotherapy or other "curative" treatments. At this point, giving her IV fluids and hoping her kidneys will clear at least some of the fluid and toxins is the only option. This is a temporizing measure, though, as her body is showing signs of not being able to clear the fluids being given to her, so they are building up in her body - something that eventually leads to a variety of other life-threatening issues. Her labs continue to show problems with toxins and electrolytes. She is nearing, literally, the end of what medicine can do to maintain the delicate balance between life and death.
Add to this the fact that she has two children. One in her late teens, another pre-teen.
Add to this the fact that, for the most part, she "feels just fine."
Even though, medically, everything looks horrible and she could be, truly, within days of her death, she feels no worse at this point than she did weeks ago - so how can she really be that sick?
The attending and I prepared to visit with the patient and her mother and brother. Before going into the room, went over possible approaches to the situation, trying to strategize, or get our heads in the game.
Within minutes of our entering the room and beginning the conversation, it starts to become clear: no amount of our talking is going to convince her that she is, really and truly, very sick, very much dying.
She is not ready to "call it quits or say I'm done."
She feels that there must be something more that can be done, and that she will survive this bump in the road.
While the attending is guiding the discussion, inside myself I feel my heart starting to race. In my mind, I hear myself running through all of the arguments to be made in order to convince her that what she thinks simply defies reality. I'm feeling frustrated that she won't hear what we are trying to say and that she won't listen so that we can help her see that she is close to death and that she needs to prepare for it. She needs to get her affairs in order, have the conversations with her children that she may not have much more time to have, needs to accept that if her heart stops, no amount of our interventions and pounding on her chest and sticking needles and tubes in her is going to make her any better than she is at this moment.
I'm fighting the urge to grab her by the shoulders and say, "listen. to. me."
Why won't she just listen? Why won't she let her guard down? Why won't she (and her family) see reality?
If only she knew how much better the end of her life would and could be if she would just see it my way.
After over and hour of discussion, we leave the room.
We have had no more success than the oncology attendings at convincing her that her time is limited.
There was a victor, though. The patient.
By the end of our conversation, we knew what was important to her in her death. She wants to go out fighting. If it means being coded and ending up in the ICU, then so be it. If it means not being able to leave the hospital and get home to see her cats and her beautiful gardens again, so be it. The important thing to her, as she said, is that however she goes, whatever happens, "that was God's will."
As long as she continues to "feel okay" and feel that "there is hope" and "not have the feeling that this is IT," then, though she didn't say it, but what was clearly inferred, then the institution of medicine is just wrong about what we're telling her. She feels that although her labs looks bad, although the fluids are accumulating and although the cancer is spreading, that our predictions just an't be right.
So she will continue to fight and fight and fight.
So, although my judgement of her is that she continues to "deny, deny, deny," there is nothing more I can do to make her see our side - a side I truly feel is just plain right.
Because for the patient, it isn't about numbers and probabilities and what I think is a good death. It isn't about what her oncologist thinks is a good death.
It's about the fact that she doesn't believe she is dying.
And she is my patient.
She is the one I to whom I owe a responsibility to provide care and compassion and all the medical information I possess relevant to her life.
She decides.
And while I may personally disagree with her, the truth is that the way she chooses to live her last days simply aren't up to me, are they? She is the one who must face the consequences of her decisions. Not me. So I owe it to her to respect her perspective and support her in this time, do what I can to make sure she is comfortable - physically, emotionally, spiritually.
This means, for me, to learn how to back down from my innate desire to always try and convince people of my point. To always try and get people "on my side."
My challenge will be to learn how to function in a place of respectful disagreement and not let it compromise the quality of care I provide.
So, in just one day I learned a lesson and discovered what may be the biggest challenge for me in this field. Imagine what the next 364 days will bring.

Where I've Been

2010-09-23T19:40:00.000-05:00

Yikes, I've fallen behind a bit here. My plan was to write a "Pivotal Moments" piece at least every week until I worked my way through them - clearly that hasn't happened. I've been up to stuff, though.
First, studying for pediatric boards, which I take on October 18th. If you have a few extra brain cells that day, you can send their power to me as I submit my own brain cells to 8 hours of multiple choice questions.
Second, the hubs and I took a great vacation with our friends the Drs. Pitts. We had a 5 day jaunt to Cancun where everyone got a chance to relax, nap, sleep in, eat and (for the ones among us non-pregnant), indulge in some tasty (so I heard) cocktails.
Third, the past two weeks I have been hanging out in Little Rock, Arkansas. Why? Turns out, the Arkansas Children's Hospital has a wonderful pediatric palliative care team and they were generous enough to let me come and follow them around for a couple of weeks to learn more about the daily functioning of their team. I've learned a great deal these past two weeks and am so excited about adding the pediatric palliative care service at KU. It's already under the amazing leadership of Kathy Davis, PhD, who provides more support and care to our families than seems humanly possible. I hope to be able to add a little bit to that as a medical provider in the coming years. Many thanks to Dr. Carrie Brown, and Jill Sorrows, the team social worker, for letting me tag along with them!
While I can't promise a major upswing in the blogging until after I take boards, I will be trying to get at least one more pivotal moment up before October 18th. They're brewing in this brain and I'm sure one will be ready sometime soon.
Happy autumn!

Pivotal Moments: Part 1

2010-08-03T11:14:00.002-05:00

Originally uploaded by Em's World

If we're lucky, at some point in life, we will have at least one "A-ha Moment." Some of us are lucky enough to have more than one of these moments - even though we may not realize we've had it until later in life, on reflection of how we ended up just where we are. Hopefully where we all end up is a place that brings us joy and fulfillment. I think that part of getting to these places requires looking for and taking note of the A-ha moments, the pivotal moments when the universe, or your deity, or your subconscious is telling you, "Hey! Look over here, lookey, lookey, here's a clue to your path!"

Not all of the clues are necessarily positive, warm-fuzzy experiences. Some of them hurt, shake us to our core. Some of them anger us, frustrate us, bring us to tears.

I've written about some of my "moments" on this blog over the past 6 years. Some of them, even when I was writing about them, didn't seem to me to be particularly important moments, some of them were just interesting. Looking back on them now, though, I see that some of these actually were key in guiding me.

I know I haven't captured all of them, though, so I'm going to try and embark on a little series for myself to reflect on events that have stuck with me, the ones that play in my head over and over again, the ones that I now know helped get me to this point.

These won't necessarily be in chronological order, or in order of importance. They're just going to be done in whatever order they occur to me, and I feel able to take on.

Part 1.

The spring months of 2007 were strange for so many reasons. I had found out I was (surprise!) pregnant. The weather stayed cold cold cold through mid-May, the trees barren of leaves because of a late spring hard freeze that knocked out any vegetation brave enough to have come out. It was the second half of my intern year. I was becoming exhausted (pregnant + intern = exhaustion).

In April I rotated through the NICU, lucky enough to have two of the best senior residents as my guides through this treacherous month. The three of us got along great and actually remain solid friends.

Two experiences that month stand out from the others.

The first was a baby born far too early. She was the second child for her parents, who had a little boy under the age of one already. The mom had become pregnant within weeks of delivering her son, something she and her husband weren't really expecting or prepared for.

She came to hospital in early April having bleeding and abdominal pain. She was admitted for observation of preterm labor, and was a patient on the labor-delivery inpatient service for several days. One evening while she was in the hospital, she went to shower in her hospital room. Before she got in, though, she felt a strong cramp in her abdomen, became dizzy and nauseated. She sat down on the only seat available in the bathroom - the toilet. Moments later, her tiny, premature daughter was born, into the water.

From what I heard, there were screams of panic from her bathroom that brought a nurse running into her room. The mother was sobbing and screaming and in a state of shock. She had to be pried off the seat, and when she was, the nurse saw the baby. Help arrived, and the baby was scooped up into blankets or towels and run down the hall into the NICU.

She was not well. Being born 17 1/2 weeks early just isn't a good idea. Being born into a hospital commode 17 1/2 weeks early is an even worse idea.

At this age, you will find yourself on the brink of "viability" the fancy word we use to try and guess whether or not you can survive outside the uterus.

Your organs are dramatically underdeveloped. Your lungs barely, if at all, functional. Your skin so thin that every one of your blood vessels is visible to the naked eye, just below the surface of your skin. Those blood vessels are so immature that they often rupture and bleed with minimal trauma. Especially the ones in your brain and your eyes.

You don't know how to suck or swallow.

Your digestive system probably can't handle food entering it anyway, and digestion is one of the most taxing things your body could do.

Your immune system is hardly able to ward off infection from bacteria or viruses.

Long story short - don't be born at 22 1/2 weeks gestation. In fact, try really hard not to be born until at least 37 weeks, 40 if possible.

This little baby girl, though, for reasons no one can ever fully explain or know, was on a path to be born very, very early.

So, she was very, very sick.

Complications began soon. She required intubation and being placed on a ventilator for her breathing. She required lots of IVs for medications and fluids.

The attending on service at the time, who is no longer at our facility, had several very frank, very delicate conversations with the parents of our tiny patient. They knew, even before being told, how grim their daughter's days were, in both the immediate future and also long term.

They knew there was no chance their daughter would come home with them.

Her father said, "If God wanted her to come home with us, he wouldn't have had her be born so soon." They felt God was taking her to His home, and they were okay with their baby going there.

After a couple of more days in the NICU, and after the parents were comforted and counseled by members of the nursing staff, the medical staff and others, after they had consulted with their families and one another, and their God, they stated they wanted their daughter taken off life support so she could die peacefully.

Plans and arrangements were made so other family members could come see the baby if they wished. The parents came in the evening, and after the tubes and lines were removed, their daughter was wrapped and they held this tiny little baby, weighing under a pound, barely bigger than her father's hand.

The nurses helped them prepare the memory kit with footprints, handprints, photographs.

Then, eventually, but really after very little time, she seemed to have stopped breathing.

What happened next depends on whose story you believe. The resident who was on that night told us the next morning that she was called by the nurses to come look at the baby after the parent left. The nurses felt that she was breathing, still. The resident looked at the baby, listed with a stethoscope and also thought she heard breathing, a faint heartbeat.

The nurses told her they had seen her arms and legs moving at one point.

The resident called the attending.

He was not pleased.

He was mad that the nurses would "mistake" what they had seen for moving and breathing. He insisted it was part of the death process - firing of neurons now without oxygen.

He was mad that the resident had examined the baby, had listened for signs of breathing or heart beat.

The resident said that he told her, "You're telling me a baby I pronounced dead an hour ago is still alive? Don't you think I know what dead is?"

She said that she and the nurses felt the baby was gasping, that it was not just the small minute changes one can see as the body proceeds through death. She went on, she asked him if it would be okay to give the baby a dose of morphine, for comfort.

This was when all hell apparently broke loose, and the resident was further reamed by the attending, and so were the nurses.

He told her, "What if the parents come back in there and see you examining their baby who is supposed to be dead, or see you giving it medication?" Other harsh criticisms ensued.

No morphine was given.

Eventually, the nurses and the resident on call felt that the baby had stopped showing any signs that might be consistent with life, and the baby was sent to the morgue.

By the morning, emotions were running high in the NICU.

The seniors and I arrived for our day shift, and found a resident clearly upset, frazzled, angered and saddened by what happened the night before. She felt she was in the right, that she had not mistaken anything she witnessed with the baby. So did the nurses.

The staff, who had not been there, continued to disagree with them. He continued to hold fast that the baby had been pronounced dead, by him, and that nothing anyone told him was going to change his mind about the fact that "when I walked out that door last night, I know that baby was not alive."

Later in the day, this attending called aside the two senior residents and myself for a "meeting to discuss what had happened."

He explained to us that he could understand how people might mistake small flinches that a dead body makes for a sign of life. He told us that there is "no reason to examine a patient after they are pronounced dead. Ever."

And, even more, he went on to tell us that the resident's request the night before to give the baby a dose of morphine was almost reprehensible. First of all, why would you medicate a dead patient? Second of all, he told us that there is no place in neonatal medicine for administration of morphine. He said it was tantamount to murder. Said that if we ever gave a neonate morphine that "lawyers would be all over it," and we would be murderers.

Shock.

I was in shock.

First of all, even though I had limited experience in the neonatal ICU, I knew he was just plain wrong about not giving neonates morphine, or any other medication to prevent or treat pain or distress.

My limited experience with palliative care at that time told me that no patient, tiny, huge, old, young, should suffer while dying.

And my mother's heart, even though my baby was still inside me, knew that it would be more traumatic to watch my child die gasping for breath, uncomfortable, anxious, struggling, than to think that a dose of medication given to help keep my baby comfortable might shorten her already ending life. If I knew my child was going to die, and was, in fact, dying before my eyes, I would be demanding medication to keep the child from suffering.

While the attending was worried that a family would sue him because medication was given, I had to bite my tongue, hard, to keep from pointing out that he could just as easily, and likely more successfully be sued, for inflicting pain and suffering on a patient, and the lingering scars that could leave on a family.

This was a moment I knew that pediatric palliative care had a long way to go, and felt myself wanting to start this kind of practice immediately.

I saw the lack of knowledge, and the dangers of lack of knowledge and the dire consequences it might have on a patient and the family.

More, it made me want to specifically go into the realm of perinatal and neonatal palliative care. To provide a service and fill a need that was glaringly void.

Fortunately, I don't think those parents ever had any idea about the drama that ensued after they left their daughter for the last time. For them, their daughter died peacefully in their arms. They said their goodbyes, started to make their peace.

It's the way every family should feel when they have a dying child.

But it's also the way everyone who has cared for that child should be able to feel. That it was a peaceful death, a calm death. A death without suffering - because that's what we go into this field to do - stop suffering. That night, no one involved felt that they had done their job, had fully prevented suffering, and to this day it motivates me, gets me fired up, and reminds me why I have to do what I'm doing.

What IS it you do?

2010-07-29T13:58:00.000-05:00

Being interested in the field of hospice and palliative medicine for a solid 10 years now, there are times when I forget that not everyone knows what I'm talking about when I mention my career. Granted these aren't ever very long times, because what I've found is that, unfortunately, very few people actually DO have an idea of what this field of medicine offers. Usually the immediate question I'm asked when I tell someone what I do is, "what's that?" My immediate instinct is to say, "only the best and coolest field of medicine ever..." But more often I'm able to offer what has almost become my "elevator speech" giving a brief overview of what it means, and what those of us in the field can do for patients, for families, and sometimes as importantly, for other physicians (and all members of health care teams).
Previously I've posted this in an attempt to offer a bit more info.

In a recent issue of The New Yorker, Dr. Atul Gawande, a surgeon and writer, explored the question, "what IS palliative care?" While some of us might argue that he gives a somewhat narrow definition and explanation, still very much focused on the "hospice" side and less so on the ever-developing and expanding true "palliative care" side, at least he gives something.
If you are reading this and have a background in medicine, chances are you realize how amazing it is that a surgeon would even take on this kind of question, much less write an informative and self-reflecting article about our field. More amazing, he provides, via an explanation provided to him by a hospice nurse, the following near-perfect succinct explanation for what we do:

The difference between standard medical care and hospice is not the difference between treating and doing nothing... The difference was in your priorities. In ordinary medicine, the goal is to extend life. We’ll sacrifice the quality of your existence now—by performing surgery, providing chemotherapy, putting you in intensive care—for the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focusing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists aren’t much concerned about whether that makes people’s lives longer or shorter.

Entire article can be viewed here

The article itself provides stories of several patients and their experiences with palliative medicine and hospice, and also of a patient who did not have these services during her battle with cancer. Dr. Gawande paints a picture for us to look at, situations in which we may find ourselves - both as patients and as doctors - and reflect on where we would likely find ourselves in that tableau. I would encourage you to read the article, and consider it for yourself - where would you find yourself in this story? How would you deal with this situation in your own life, your own practice? Why?

Reflecting on these questions is far from easy, even pushing the border of being a scary and painful. The hard and fast fact, though, is that all of us are going to die. Maybe sooner, maybe later. Maybe quickly, maybe slowly. It might be an event we see forming on the horizon like a summer thunderhead, have time to prepare for, time to take cover, time to gather those things precious to us and keep them safer from the storm. It might, literally, hit you like a Mack truck, you never saw it coming.

Although we don't know how each of us will die, we still have control over aspects of our deaths. More importantly, we have control of the life before the death. Years before, months before, days before, hours before. If you take the time to read Dr. Gawande's article, you'll see examples of the many aspects of control individuals can maintain in regard to their deaths. Think about your own for awhile. Write down your thoughts and potential plans and wishes for how you would like to handle these events.
Medical people, think about how you interact with your patients and their families. Is it different from how you would interact with your own family members? Different from how you would hope to have your physician speak to you, shield you, or expose you?

I've done a bit of my own reflecting and the process continues daily. Every time I see a patient or hear about a patient facing a serious diagnosis, the question in my mind, "what would I do?" is present. It is a question being asked of my physician self and also my non-physician self. What would I do as the doctor? What would I do as the patient? I hope I never stop asking this question, to either of my selves.

Again, a link to the original article
http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=4#ixzz0v5hNOtNg

Flickr

2010-07-16T12:41:00.001-05:00

This is a test post from , a fancy photo sharing thing.

Parental Idiosyncrasies

2010-07-15T14:30:00.002-05:00

As I hope any readers of my blog(s) would know by now, I am embarking on my career in hospice and palliative medicine. It is an area I have been interested in for many years, and my particular passion is in the realm of pediatric palliative medicine. No, I'm not crazy.

Given this area of interest, during residency training I tried as much as possible to have exposure to palliative care experiences and to find out more and more about the role of palliative care in pediatrics. During my behavioral and developmental rotation, my academic project and final presentation focused on "Children and Death Concepts." Since kids are not simply "little adults," the way they understand and process the circumstances and events of death and dying - whether it's a pet, a grandparent, a parent, or their own death - depends on the child's age, prior experiences, and what they are simply able to comprehend based on their developmental level.

side note: what I found in my research was that, even though children are supposed to progress through various stages of development and eventually form a "mature" or complete concept and understanding of death, there are many adults I have worked with who are still very much in "immature" phases of their ability to comprehend death and mortality - something I think is an area ripe for discussion on the palliative care world

So, having this knowledge about children and the way they do or do not understand death and dying has recently come into play with something so very unrelated to death and it got me thinking about the effect that my job and my life are going to have on my own child. What are my own parental idiosyncrasies going to do to my kid?

Here's the story.

I have long been very proud of my child's sleeping habits. Maybe a little too proud. I hear other parents tell stories about their 2 year old still waking up in the middle of the night, demanding a drink, a meal, or to climb in bed with mom and dad. Or the kids who refuse to ever sleep anywhere except mom and dad's bed. I admit, I have been judgmental about this and have had little pity for those people when they complain about being tired due to their toddler's inability to adapt to sleep. I have seen it as a parental fault in a way, because I have felt that as a parent it is our job to help teach a kid how to sleep, and that we help them establish lifelong good sleep habits. And who doesn't want good sleep?

Okay, so back to the story. Henry has recently started preschool, which, as a new stress in his life has affected his mood, his eating, and, oh yes, his sleep.

He's been fighting getting into bed. He's been climbing out of his bed, needing us to put him back in several times before he finally passes out. He's been waking overnight, coming into our room, asking to sleep with us.

And, because it's so. much. easier. to let him climb in, snuggle up, and just go back to sleep versus the alternative, which is dealing with him crying and screaming as we order him back to bed.

Another back story: earlier this week, out of nowhere, H told my mom, "If Henry is a bad boy the blue vac will go out with the trash and you can't play with it anymore."

Oh. really? We don't know where he got this idea, but it seems to have the daylights scared out of him...

Therefore at 4am a couple of days ago, when H got out of bed, my husband out him back in - with a warning.

If he didn't stop crying and didn't lay back down and go back to sleep, then the blue vac was going to be put out for the trash guys to come take away.

The child as immediately silent and slept the rest of the night.

Okay, so how do I tie these two seemingly disparate tales together?

Here goes.

Henry is near an age where children develop a "magical thinking" about death. They can believe that it was something they did, they thought, they said that caused the death. They are especially prone to believing that some bad behavior on their part caused the death.

Henry loves all vacuums. If we take away one of these beloved objects because he does something bad, then (this is now becoming my own musing) are we setting him up to believe even more strongly that his bad behavior causes things that are precious to him to be taken away?

If we do this, then if and when there is a death of a person (or, our beloved dog), is he more prone to believe that HE did something to cause the death.

Are we setting up a belief system, a paradigm, for him to be burdened with the wight and guilt of that?

How cruel are we?

What kind of parent would do that?

And am I a total nut job for even having these thoughts and making a jump from a threat that is supposed to help control behavior to something as morbid as death of a loved one and the emotional damage it might inflict on our poor little vacuumless child?

THIS is where parental idiosyncrasies come into play, and how my work, no matter how hard I try, is going to seep into my raising of my child.

Don't you feel sorry for him?

Raring to go!

2010-07-07T09:47:00.002-05:00

How do you spell "raring" anyway? I guess since spellcheck didn't flag it, I must have done it correctly.
Anyway.
Okay, I know I ought to be studying right now. I have the stack of notebooks/binders, study guide, etc sitting next to me at the dining table. The pile of stuff is like a pathetic, ignored dog. "Read us, whimper whimper." Eh. Maybe later.
I'm trying to justify my current study avoidance by at least doing other productive things, like renewing my passport, completing my application for permanent medical licensure in the state of Missouri (a TOTAL pain in the arse), working on other "official" doctorly documentation stuff.
BUT what I really want to do is get on with my life as a hospice and palliative medicine fellow!
Last week I was so excited to get to start the very beginning of the journey. Sort of.
Background check: I took a nice long maternity leave, utilizing the "gift" that is FMLA. I took 12 weeks of time out of residency. Now I have to pay back the time. So, technically, I've done the graduation stuff, but officially am still a resident until September 30.
Back to the story.
Last week on July 1 and 2, the hospice and palliative med (heretofore referred to as HPM) had our orientation days. We went over the perfunctory stuff: schedules, policies, goals of fellowship. And then we got to do some fun stuff: LECTURES!
Yep, I'm a total nerd. I was so pumped about getting to sit through a couple of days of lectures. See, finally I'm getting to a point in my education/training/career where I get to focus so much on what I'm actually, genuinely, truly interested in learning! No more sitting through an hour long lecture about the cell receptors involved in organ transplantation rejection and what some scientist is doing to trick those receptors. Now, I get to listen to people I professionally and personally admire discuss topics that apply to our shared field of interest: HPM. So exciting. I was riveted.
What was so exciting, you ask?
Well, we had a talk about management of nausea/vomiting and constipation. Way more exciting than you'd think. Except, these are symptoms that have huge effects on people's quality of life - not the most glamorous - but probably among the most important.
We talked about management of pain, calculating doses of pain medication, changing medications and therefore adjusting doses. A fun little math game, really, in that "word problem" sense. For example:
Your patient, Ms. B, has taken 6 doses of oxycodone over the past day, totalling 30mg. You wish to change her medication from oxycodone to oral morphine. If 20 mg of oxycodone is equivalent to 30 mg of morphine and you plan to allow doses every 6 hours, how much should each dose be?
I have always loved word problems.
There was a brief discussion about the use of social media in raising awareness of the field of HPM and getting word out to the public.
Hello, I'm obsessed with facebook and I have 2 blogs - okay maybe they aren't always that current - but, of course I'm interested in social media!
We also covered applied ethics and its role in HPM. So cool.
We covered communication skills - probably one of the key skills needed for HPM. How we figure out what someone is saying when they can't find the right words or right way to say it. How to tell them what they are ready to hear, and what they need to hear. So many little nuances and so much to learn here.
Then there was the lecture on prognostication (I hate even using the word "lecture" because these are so not lecture-y). Meaning, how do we arrive at our best estimates on the trajectory of disease and the effect it will have on the quality and duration of a life? Phew. Talk about tough.
And, importantly, we talked about the role of self care in the life of the HPM physician. How do we maintain our sanity when we are working daily in a world with so much stress, emotion, chaos, morbidity?
Can you guess how I might choose to help deal with these? Any takers?
And this is my point today: I'm a writer.
I'm not saying I'm a Writer. I'm saying, when it comes to dealing with my inner world, or how my inner world reacts to the rest of the world, or how the rest of he world looks to be functioning, the way I deal is to write.
For the past few months I have been trying to make myself sit down more often and just write. Just do a blog. You might notice after reading my entries that sometimes it takes me a while (a few sentences to a few paragraphs) to get to the meat of the story. It's because I just sit down and start typing. The story eventually comes through. Yes, there is often some back story to trudge through, but eventually, we get there, don't we? Usually?
It's not always exciting. Or gut wrenching. It has up to now been an effort at discipline.
As part of my self care, I am going to renew my efforts. I want to blog more. I would very much like to say I'll blog a little bit every day - but then I just know I'm setting myself up for failure.
I'm going to try, though.
This may actually require splitting my blog (again). There are some things I wrote that I don't care if everyone sees. At times, though, the line between personal and professional needs to be a bit more distinct. One of my hopes would be that if I am able to blog more regularly (goal = 3 times weekly) throughout my fellowship and maybe beyond, that it can be a record and a guide for those who may want to learn and do more in HPM.
SO: if you come to this blog and find it seems a bit different that's why.
Once I make the final split, I'll figure out how to let people know.
Okay, now I guess I ought to pay attention to some of these books over there...

There but for...

2010-05-08T22:17:00.002-05:00

Tonight is my (hopefully) last ever 30-hour in-hospital call. It's strange to think that another phase of my training is drawing to a close and that I'm on the brink of being allowed to practice medicine all on my own. The day started off with the usual parade of inpatient tasks: checking in on patients, reviewing lab results and x-rays, rounding with the attending, note writing. It was a calm day. I was in our resident lounge studying, in fact, and had just dozed off on the comfy sofa when my pager went off.
"Of course," I said, maybe just in my head, maybe out loud. I called back the number and that's when things got a little crazy. Sit tight with me for this story, see, I'm still processing what went on and actually thought sitting down to write about it might help me in some way.
So, I returned the call and was made aware that there was a potentially very sick pediatric patient in the emergency room. The call actually came from a nurse in our pediatric ICU, who was checking with me to get more information about a patient they had heard might be getting admitted to the unit. At that point, I actually hadn't heard anything, but told her I'd look into it by calling the ER.
When the clerk answered the phone in the ER and I identified myself as the pediatric resident on call, she laid out a story: a toddler had been brought in by his parents and he had been immediately put in a room and there was a chance he was going to be intubated and possibly coded, and the ER docs thought maybe he had perforated his bowel. She told me he might be going to the operating room, that the surgeons had been notified.
I called back the ICU and gave them the info, then told them I was going to go to the ER myself to see what was happening.
Walking into the 25+ room/bed emergency department, there was no question as to which of the rooms the toddler was in. There was a crowd of people at the door, a flurry of activity coming in and out of the room. I found another resident, who was working in the ER, and she told me a quick story about the patient. By the time I got to his room, he had been intubated and because they had a very difficult time getting IV access on him, they'd had to place IO lines (IO = intraosseous, something we can do for kids where we put a pretty big needle into the bone in the lower leg so we can give vital medications, fluids, etc). An x-ray was being taken to see of the breathing tube was properly positioned, to try and see if there was a problem in the abdominal cavity, and to see if both of his lungs were inflated. The x-ray showed that he'd possibly had one of his lungs collapse, so the ER doctors and surgery resident prepared to place a tube in his chest to evacuate the air. During this time, the boy's heart began to slow down to a rate that requires us to start chest compressions. We were officially in a full blown code blue.
What happened for the next 25 minutes was a demonstration of what physicians and nurses do to work together to save lives. For a few moments every now and then the room would get a little more tense and on edge, but for the most part what I saw happen was a coordinated effort to bring this boy back from the brink, rescue him from death.
Breath was pumped into his lungs, three of us alternated turns to compress his chest to try and pump his heart for him so blood could flow through his body, needles were stuck into his belly, his chest to suck out air that shouldn't be there and might be compressing vital organs, time was watched to let us know when doses of medications could be given, and all the while the boy was motionless on the bed.
At about the midpoint of the efforts the parents were brought into the room. They saw their boy, they saw a room full of doctors and nurses working to save him. They were too upset to stay in the room, and stepped just outside into the hallway, mom sobbing, dad crying.
There was a moment when his heart began beating again. It showed up on the screen, a flicker of activity, a steady rhythm but not the kind that can actually keep someone alive - but just enough that we felt a weak pulse. A shock of electricity was delivered in the hope that it would "reset" the electrical system of the heart so it would beat properly and strongly on its own. For a minute or two, it did, We could take a break from the chest compressions, but several of us had our eyes on that monitor, watching the heart rhythm to make sure it behaved.
Of course, it didn't.
We went back to compressing the chest. More medications were given. More needles placed. I'm sure more prayers or requests for divine intervention were made.
It gets to a point, though, where everyone in the room starts making eye contact with one another. We all begin glancing around, then glancing back up at the clock. In our minds, thinking, "It's been ___ minutes since we started compressions." We start doing the calculations. Start remembering the basic science. "Brain damage sets in after only 3-4 minutes without fresh oxygen." "Chances of meaningful recovery after severe anoxic brain injury are less than 1%." We know. We don't want to know, but we know. We don't want it to be true.
But, it is. It's enough. We've gotten to the point where we say, "this is all we can do." It's enough. But when it's a child, the words "we've done enough" seem inadequate. When a child was playing happily this morning and suddenly fell sick this afternoon, and now we are looking at his little body in front of us, how can we feel that we've done enough?
Through the past four years of training, I have seen plenty of patients die. I have been a part of several code blue situations. I have stuck needles and tubes in people. I have done chest compressions. I have squeezed oxygen into their lungs. I have seen most of those people ultimately pronounced dead - either pronounced dead for the cessation of the code, or dying hours to days later after having been hooked up to life support following the resuscitation efforts. Some of those codes and ultimately those deaths came expectedly. Death creeping up, closer and closer, all of us doctors knowing the end was near, unable to convince the patient or the family that a code would fail. Then when the page comes "Code Blue, room ___," we look at our pagers and think, "Of course." Some codes are expected because of a person's age. Are we really that surprised when a 96 year old's heart stops beating? Is it that shocking when a patient with cancer affecting every part of their body succumbs to infection or organ failure?
What I've never done, though, is gone through a code on a child and seen that child die.
I've been a part of a small handful of pediatric code blues. Fortunately, they rarely happen. There are the resuscitations we do one our patients in the neonatal ICU, those babies born 4 months early, who come into the world needing us to basically replace what their mother's womb was doing for them. Those still fall into that "not surprising" category, though. Just like it isn't surprising when a 96 year old heart stops, so it isn't surprising when a 25 week preemie's lungs aren't working.
I've seen a couple of toddlers come in with near drownings, but they ended up getting intubated and going home, seemingly unscathed, within a week each - although I have to say at least one of those kids shocked the heck out of me to have done so well.
This boy, though, was an out of the blue, totally unpredictable, tragic story. He was a healthy toddler. He was a little under the weather yesterday, threw up a few times. Was drinking Pedialyte okay today.
Then, mom and dad noticed he didn't look right. Noticed his belly seemed to be "getting bigger and bigger" then his breathing started getting fast and shallow and he stopped acting alert. They were driving to the hospital as fast as they could, carried their little boy in, handed him over to the team in the ER.
The ER doctors and nurses, the pediatricians, the surgeons all convened on the room, on the boy.
Help him.
Fix him.
Save him.
We tried.
In the end, it wasn't enough. When we say, "that's enough," we know it isn't the "enough" that got the job done. The enough of "let him go." The enough of "now we need to leave this body alone."
It's the enough of mercy.
We decide we have reached that point. We ask the family to come back in, we keep working. We keep watching the monitors, keep squeezing air into his lungs, keep putting medications into his body. Tonight, I was the one to keep compressing his chest to keep the blood flowing.
The parents come in.
The boy is very sick. He was very sick when you brought him here. You did all you could do. we've done everything we can do. The body has been though a lot. We have been doing all we can do for all this time, are still doing all we can do. We recommend that we stop. We are telling you, "your son is dead."
All that time, while the parents were standing in the room, hearing this news, being told their child's fate was decided, I was pushing on that boys chest. I found myself pushing harder, pushing with all my energy, as if I could elicit the right charge from my body to travel down my arms, into my hands, through his chest and into his heart. Start again, This is your last chance, dammit, if you don't start beating again for us now then you're done. Please, start beating, something. Now...please. Hurry. This is it...
I noticed my vigor increasing, became momentarily singularly focused on trying to get that damn heart to beat again. Then I noticed the hands of the other doctor's and nurses slowing down, drawing back from the boy. Stop the medications. Stop bagging in the oxygen.
Stop compressions.
That's it.
A moment ago, we were keeping you alive. Or at least, "alive."
Now you are dead.
He is dead.
Your son is dead.
Slowly the room cleared out. You don't realize how crowded the room was until people start leaving it.
We removed what we could of medical equipment from his body. Wrapped him in blankets, asked mom and dad if they would like to hold their son.
Mom gathered him in her arms, sobbing over him, rocking him. Saying his name, saying "No."
The other pediatricians and I stayed in the room. Funny how suddenly you look around and everyone who had been so committed to working on keeping him alive leave once there is nothing else medically to be done. We gave them space, tried to comfort them.
It wasn't for about five minutes that when mom looked at her boy in her arms, touched her hand to his forehead and said (in Spanish), "I don't believe it. I can't believe it."
I felt the wave hitting me.
I walked as subtly and quickly as I could out of the room.
The whole time I'd been telling myself, "don't think it. Don't think it."
Then I thought it.
This could be Henry.
Same age.
Same size.
Same thick eyelashes.
If this could be Henry, why wasn't it Henry? How was this boy the one unlucky to be taken from his mother? Or more appropriately, how was this mother chosen as the one to lose her son?
Why not me?
These are thoughts that if you start to let your mind run free with will make you crazy. Make you questions everything "right" and "wrong" in the world. Make you unable to ever let your child or anyone else you love out of your sight. Except these parents didn't let their boy out of their sight, he was with them. He just got really really sick really really fast.
I'm not a religious person, but how many times can you hear the phrase, "there but for the grace of God go I" run through your head? Answer: too many.
So many times that the question becomes nonsensical. Becomes too unbelievable, almost comical.
There but for the "grace" of God go I.
There but for the grace of "God" go I.
(I'm not looking for a religious debate or inspiration here, please)

After the other family members, a chaplain, a social worker all arrived to the ER to the side of the parents, we left. I couldn't get Tommy on the phone fast enough.
"Bring me Henry," I told him. I told him briefly what had happened, told him "I need to hug my boy."
They came to the hospital. I pulled Henry from his car seat. squeezed him tight, tighter. Never tight enough.
There but for the grace of God go I.

Getting to this part of the story, where my work and my life become intersecting with one another makes me eyes well up again. Here I have to put up the mental wall. "You can't let yourself think that way."
So, I have to stop here before my mind goes too close to that wall, before I test those waters and see what happens when the Pandora's box is opened.

Squeeze your babies if you have them. If you don't have them yet, squeeze them every day when you do have them. They are the most overwhelming joyous and heartbreaking thing that will every happen to you. My heart breaks every day with love for Henry, and just when I think it can't break anymore, it does and heals itself a size bigger than it was the day before. It's the scariest most vulnerable kind of love I've ever felt, and knowing it could be taken away, like that - just like that- is too much for me to even keep thinking about right now.

Physician, be thyself

2010-04-27T16:15:00.002-05:00

I'm doing one of those things where I sit down and start writing but don't really have a god sense of where this is going to end up going. One of those times when writing is its most therapeutic for the writer because it gives a chance to explore thoughts, feelings, that maybe the writer didn't even have a full knowledge of even being present, much less any understanding of what they mean. So, here goes.
What got me started on this thought process, or more, brought it to the forefront of my mind again, is one of the patients in the hospital.
This young man woke up those morning with two arms, two hands, two legs and two feet.
By this evening, or maybe even by now already, one of those legs and one of those feet are gone.
His leg has been amputated from a point above his knee in order to save the rest of his body from the cancer in that leg. An aggressive cancer. A cancer that still has a fairly disappointing rate of long term survivorship, even with the most advanced and best care.
For the past several weeks, this young man has endured chemotherapy to try and make the tumor as small as possible, as inactive as possible. One of the goals is to be able to stop the tumor's ability to generate its own blood supply - one of the cruel and clever things these beasts of cancer do is to release hormones that tell the host's body to make a rich supply of blood vessels and to make all those blood vessels become direct food lines to itself. Like a dictator country with no oil of its own forcing the inhabitants of its neighboring and oil rich country to build oil lines into the dictating country. The human body, as amazing as it is, responds vigorously to this hormone signal and does its job - it makes blood vessels, and this is one of the ways a tumor becomes parasitic, opportunistic. Before a surgeon goes into the area of the tumor, a goal is to make sure that this area pumping full of blood has been reduced to a trickle.
Another goal of the chemo is to try and ensure that any small, even microscopically small, metastases from the initial large tumor have been made as inactive as possible. If a patient is giving up a limb, we hope it isn't so that in a few weeks a new tumor, in a part of the body not easily removed or operated on, will enter a growth spurt. Scientists have speculated that another genius of the tumors is that the largest tumor often releases a hormone that acts on other tumor cells in different parts of the body to make them less active. It tries to inhibit its competition, so to speak. Sometimes when a dominant tumor is removed, and that hormone is no longer being made, the previously inactive tumors start to take off. Cancer is a strange, mystifying thing...
So anyway, this young man has gone through weeks of pre-operative chemotherapy, or as we like to say in fancy terms, adjunctive chemotherapy. Last night he had a hospital room full of friends and family members, gathering around him, supporting him, and I'm sure most of them, especially the adults, wishing that they could take his place tomorrow, wishing they could give up their leg, their adolescence and young adulthood so that this boy could go back to his old life, be free of cancer and the anxiety, fear, frustration, pain that it brings.
None of them can do that for him, though, so bright and early this morning he was taken to the operating room, where one of the nation's most skilled and incredible orthopedic surgeons will remove his leg, his cancer, do her part to give him more years of life and happiness.
I don't have an established relationship with this patient like I do with some of our other patients. I didn't have conversations with him about how he has been feeling going into surgery. I can't tell you he was scared, or hopeful, or acting brave, or any of the things I might be able to say if I knew him better. All I can say is the obvious, and that is: it isn't fair.
The other thing I can say is something many doctors have though to themselves when taking care of patients in dire circumstances: I don't know if I could do it.
This isn't just referring to whether or not we feel like we could handle having a bad disease or diagnosis. This isn't about saying we aren't sure if we could put on a brave face, have a good attitude, be a "good patient."
What I mean when I say it is different.
I don't know if I could allow my leg to be removed.
I don't know if I could endure chemotherapy.
I don't know if I could spend days, weeks, months in the hospital going through treatments, trying to "get well."
I don't know if I could sit in a bed every day while nurses, doctors, physical therapists came into my room trying to help me get better, when inside my mind, my highly educated mind, I know that my chances of survival or at least a recovery with any quality of life, might be minuscule.
I don't know if I could take those chances.

And this makes me question so many things about myself.
Does it make me superficial to think that I wouldn't be happy living without a leg, or an arm?
To that end, is there a part of my body I would be willing to live without? And does it come with qualification? Like, I would be willing to live without my arm only if it meant I got to live at least 7 more years? 5 more years? 3 more years? What if it was only one more year? Is there a length of life I'd be willing to give up for that arm?
What about my vision? My hearing? What if I had to have a colostomy? What if I was paralyzed?

Does it make me selfish?
There are times when I have thought that I would rather die and leave Henry without me than to endure some of the treatments I have watched my patients endure. If I KNEW I would live, KNEW I would be able to be a god mother, a good wife, a happy person, then it might change my mind. The fact is, though, in medicine, like all of life, there are no guarantees - and I'm not much of a gambler when it comes to some of this stuff.

Does it make me a hypocrite?
I take care of people going through these treatments, encourage them, try to support them. Sometimes when I'm with them, in my mind I keep thinking,
"I would never put myself through this." And there I am, talking to them about their schedule for chemotherapy, procedures, injections, surgeries.

All of us have our own limitations that only we can fully know or try to understand, and of course none of this knowledge is complete until we actually land in the place.
If I was diagnosed with cancer tomorrow, my whole attitude might (would most likely) change in ways that sitting here today, in the sunshine with the warm spring breeze on my face and my sweet little boy sleeping upstairs, I could never predict.

So why even bother worrying about what my reaction might be?
I think it's something we all have to think about, no matter the specifics of our life. Not just doctors, nurses, health care workers. It's something all of us need to think about at some point (this will be another blog).
For those of us in this field, though, I think it is part of our responsibility to those we take care of to put ourselves not only in their shoes, but in their bed. And not with their family surrounding us, but with our families surrounding us, our friends their giving us support (or not giving us support as the case may be - think about it).
The old adage* is "Physician, heal thyself." To that I like to add, "Physician, know thyself." So, this introspection will go on for me, likely until the end of my life, helping me try and find my place in this world, in this profession, in the hearts of those who love me. Part of the experience of being human, isn't it?

*I could have sworn this was a quote from our old friend Billy Shakespeare, but my googling today couldn't help me locate the exact source. Can anyone help me out here?

Because you asked...

2009-08-05T15:14:00.001-05:00

What Is Palliative Medicine?
Palliative medicine is a newly recognized
medical subspecialty that participates in
comprehensive, skilled, interdisciplinary
palliative team services for patients and
families with life-threatening or severe
advanced illness. Palliative care focuses
on alleviating suffering and promoting
quality of life, particularly
• pain and symptom management
• information sharing
• complex decision-making
• advance care planning
• psychosocial and spiritual support
• coordination of care among multiple
disciplines and across multiple settings.

Purple Angel Wings

2009-03-30T16:40:00.005-05:00

I've been away from this for awhile, not for lack of things happening or thoughts to share, more for lack of time to sit down and have five minutes to think quietly and ponder my life.
(Wasn't that something Virginia Woolf warned us women about? Anyway...)
Today one of my dearest patients died.
It wasn't an unexpected death, and truth be told, I think it is largely a relief that she died. Sad yes, but devastating, no.
This patient is 20 years old, and I have been taking part in her care, in some capacity, on and off for four years now. I first met her when I was a medical student, and she had just been diagnosed with leukemia. Since that initial diagnosis, she has been treated and then relapsed several times. She has had blood clots, strokes, major infections that nearly killed her, severe pain, and all of the other horrible side effects of chemotherapy.
Over half of her time the past four years has been in our pediatric ward. She has won over many of our hearts. Before she was ever diagnosed with cancer or dealt with any of the effects, she already had a developmental delay without any official diagnosis. She usually acted and interacted more the way you would expect a 6-10 year old child to, sometimes though, she would show a remarkable maturity and depth beyond even her 20 years.
A couple of months ago, she became ill again and was diagnosed with yet another relapse of her leukemia. She had already had nearly every possible treatment, and the cells that took over her bone marrow were clearly beyond a point of responding. The consensus was that there would be no curing her disease, but there might be medications to give to slow the progression of the disease. Since her bone marrow was full of cancer cells, she was able to make very little of the other essential cells, like red blood cells to carry oxygen, white blood cells to fight infections, or platelets to help the blood clot and keep her from bleeding heavily at the slightest of injuries. This meant daily or every other daily blood and platelet transfusions. She had little appetite and was severely protein deficient and malnourished, which meant a feeding tube had already been put in weeks prior and she was being fed through the feeding tube. Her days and her nights were full of medical interventions, not all of them pretty and some quite painful.
At first, the plan was for everything that could be done, to be done. Give the chemotherapy to slow down the leukemia, draw the blood for labwork, give the blood transfusion,s give the antibiotics, everything everything everything.
It began to seem cruel, since we knew it wouldn't change the ultimate outcome.
One of the best people I have met in life, one of the best people we have on our pediatrics care team, my dear friend Dr. Kathy Davis, began to work with this patient and her family toward determining the appropriate goals of care. It was a slow process, hours long conversations, tears, unhappiness, sometimes the patient just pulling the blanket over her head and saying "I don't want to talk about it."
One Saturday morning, I went in to see her.
The air felt different in her room. I began my usual morning talk with her, but after a few niceties back and forth, I couldn't stop myself from asking her, essentially, "If your heart stops beating, do you want us to push on your chest and do..." She cut me off. "No. Don't do those things to me! If its my time, if Jesus is ready for me, then I'm ready to go." I brought up the questions of the "breathing tube and breathing machine," again, cut off. "No! If Jesus is ready for me, I'm ready, too."
I felt so relieved, in part because she was so certain and peaceful about this decision. In selfish part because the idea of even having to consider doing a full code blue on this girl made me want to cry. Now, she had told me we shouldn't.
Over the next few days, our conversations regarding what she wanted us to keep doing and to stop doing continued. First we stopped waking her up every 6 hours to check her vital signs. We stopped keeping meticulous track of what she ate and what it did to her blood sugars. She was thrilled about no more fingersticks and no more insulin shots. Eventually, we stopped checking her labs, stopped giving her blood and platelets, stopped giving her antibiotic, stopped giving her tube feeds.
It seemed that a girl needing so much everyday, now not being give anything, would be short for this world.
Amazing things were happening, though. She was so happy and so peaceful. She began sleeping through the night, which she hadn't done in months. "I realized I just need to make decisions and stop worrying about things," she told me. She began eating her favorite foods, none of which she had touched for weeks. She was smiling, joking, happy.
Of course there were downsides. Pain became an issue that had to be dealt with, and I hope we did a fine job keeping her comfortable. She worried about how her mom would do after she died. In fact, she said, "The reason I don't want to go on machines is because they won't really help me and then my mom will just have to decide when to stop them, and she can't handle that. It would be too hard."
She told several of us that God has keys to everyone's houses, and she was going to get them from him and come to our houses when we were gone so she could play with our pets. She told us she would be watching over us. She mentioned many times that she would watch over Henry for me when I couldn't be with him. She told her family she would be waiting for them and holding out her hand to them when they were dying, and would show them the way. She was looking forward to taking care of the babies in heaven. She was also very excited about getting purple angel wings, "God waters you and you grow your wings. Mine will be purple."
She was dying, and she knew she was dying. She wasn't afraid, though. She wasn't tormented by the unknown. She had made her peace with things on earth, she was ready to move on to the place she felt she was promised to go.
I don't know how to say that I am sad but not sad for her death today.
I'm sad that she got sick and had to go through four years of pain and suffering, granted, not all bad, but any pain and suffering for her makes me sad.
I'm sad that she didn't get to go to junior college last fall like she had planned, and sad that we won't know what she might have done with more years of life.
At the same time, though, I am so happy for her. She wasn't laying in her bed her last weeks thinking of all she could have done or won't get to do with her life. She was happy with what she had already accomplished, and living each day knowing she was ready to die. I am not sad that she won't have pain anymore, won't have to worry about her mom. I am happy that any of her suffering is over, and that she went quietly, without fear.
I don't know what I believe about the afterlife. I don't know if she is now somewhere with her purple angel wings, rocking babies. I don't know if Jesus reached out his hand to her and brought her "home." I don't know if I should expect my dog to do strange things because some new spirit is here playing with her.
I want to believe she is happy. I want to believe she is watching over me, watching over all of the nurses and doctors and therapists she loved. I want to believe that Henry has a force protecting him from harm (I hear her tell her mom, "She has to go home to Little Henry, her 'Prince Charming.'" When I went to tell her I was leaving for the day.)
What I know is that the last weeks of her life were not lived in vain. They were truly a gift, in so many ways, to so many people. A gift to know she was in a peaceful state, a gift to be given hope that we might be able to bring that peaceful state to all of our patients, a gift to know that even when we, as doctors, can't cure, the we can still heal, still comfort.
I have to thank her, eternally, and know that her spirit is somewhere to feel the gratitude in my heart.

Ascaris Lumbricoides

2007-02-09T09:33:00.002-06:00

I was on call last Friday night and was just beginning to think about going to my call room and trying to get a nap when a nurse came bustling up to me with a slight look of panic on her face. The look of panic on this particular nurse's face was note new, and I am actually beginning to think it has more to do with the alignment of her nose and eyebrows that gives her this look, rather than any voluntary effort at facial expression.
Anyway, she came bustling up to me with what I interpreted at that time to be a look of panic in reaction to an actual panic-inducing situation.
"Dr. Riegel can you please come to room one? There is something on his arm that kind of looks like a worm, but it doesn't look like a normal worm."
"A worm?" I asked.
"Well, I think its a worm, but its really weird."
"On his arm?" I asked.
"Well, yeah, kind of across his arm."
I got up and followed her to the patient's bed.
By the way, this kiddo wasn't a patient I was covering that night. He had undergone a minor surgery earlier in the day and was on the pediatric surgery service, which means the surgery residents are supposed to be alerted to any problems with him. Since I happened to be in the vicinity, I was called to action, despite knowing approximately nothing about the kid.
I walked in to the room and found a chubby toddler laying in his crib, whimpering and looking frightened, as most toddlers would look when a crowd of strangers comes in his room in the middle of his quiet sleep, turns on every light in his room, and none of the faces he sees are him mother's.
Laying on the crib sheet between his arm and his trunk was a curled up fleshy colored worm.
One of the more brave nurses got a tweezers and plucked it up off the sheet, placed it in a specimen collection cup and secured the lid.
"That looks like an intestinal worm..." I said.
The looks that spread across the three nurses faces was one of shock and horror.
"A what?" one of them said.
"You mean like this came from his intestines?" I heard.
"That's really gross. Ew," another said as she quickly left the room.
I put on some gloves (I myself was a little grossed out, too, I have to admit) and started looking the muchkin over.
He looked very miserable and pathetic laying there whimpering.
We took off his diaper and fortunately saw no other worms making their great escape from his anus.
I listed to his belly and heard nothing abnormal, pushed around on his abdomen, which was covered with scars from the burn he suffered when he was 4 months old and had a nasty encounter with a cookstove in Burma.
His lungs sounded clear, no sign that the worms had taken up a home there (as they are apt to do).
He looked well nourished and well hydrated. He was a good height and weight for his age, so no evidence of symptoms of a parasitic infection.
I decided we could wait until the sun came up to alert the surgery team that the had a kid with a wormy belly.
The worm, though, once out of its nice haven of the gastrointestinal tract, was quickly withering away in our specimen cup. I had called our lab and asked how I get an intestinal worm identified. I spoke with three people before any of them knew what to tell me, the last one saying, "Well, microbiology can look at it on a slide tomorrow."
I said, "I don't think this will fit on a slide. It's about 6 inches long."
"Oh goodness." was the response. "I'm not exactly sure what we do with it then."
So I am looking at this worm, withering away in the cup, knowing that if it withers away too much the day team in the lab would have litle to examine to help us identify what was infecting our patient (we lovingly refer to the day time staff as the A Team and night staff as the B Team...I knew the day team would be able to give me a little more help).
I started looking online for pictures of intestinal worms to try and identify just what kind it was. I decided it looked like a roundworm, aka Ascaris Lumbricoides.
So, I decided we needed to feed the worm.
One of the nurses who was intially repulsed by the worm actually started to come around to the little friend and volunteered to find some sucrose (sugar water) to give the worm to see if it would help.
We took the lid off the cup and administered 10 mLs of sucrose, and within a few minutes the worm was plumping back up and wiggling around a little bit.
Admittedly, I also wanted to keep it nice and plump so I had something to show the surgery team that might shock them.
It worked.
The surgery resident the next morning was adequately disgusted by the worm and came to me for advice on treating kids for worms. I gave him the name and dosage of a medicine called Vermex, which I think is a very clever name for a worm-killing medicine.
I also advised that the patient and his five siblings be seen by a doctor ASAP as the siblings likely also have infection, and unless they all get treated they will just keep reinfecting each other with worms. Also, there can be some complications with worms living in your body, so they should get seen for that, too.
Early this week I followed up on the lab results of the worm's identitity, and it was in fact an adult roundworm.
With this patient, though, the mystery remains about how the worm ended up near his armpit. Had it crawled out of his anus, out of the diaper, along his body and nestled into that warm dark place?
Had it crawled out of his nose or mouth as they can sometimes do?
Had it been in one of his diapers that had been changed and somehow fell out of the diaper into the bed?
There really isn't any way of knowing how it got there, and the worm wasn't giving up any info, so we'll never know.
I have since done some more reading about roundworms, and found that abour 25% of the world's population have roundworm infections. That's about 1.4 BILLION people, with about 4 million people in the U.S. having these infections. It is estimated that every year 8,000-100,000 people die from complications of these infections, most of them kids in undeveloped and developing countries.
Now that's something we don't hear about every day...

Six months down

2006-12-20T10:19:00.001-06:00

Yesterday when I walked out of the hospital I offically concluded my first six months of my intern year.
More importantly, I concluded this year's stint with internal medicine. Next week when I go back to work, I will be starting pediatrics, where I will be for the last six months of my intern year.
Doing combined internal medicine and pediatrics means I am going to be living a kind of double life during my training, alternating back and forth between the world of adult medicine and kiddo medicine. This year was split six months of each, and the next three years will have me switching every four months.

Do I have reflections on the first six months?
Here is a tally:

Number of times I got pulled over in the VA Hospital parking lot: 1
Number of times I was accused of "evading police" by not pulling over quickly enough in the VA parking lot: 1
Number of patients I see regularly in my clinic who weigh over 350 pounds: 5
Number of them interested in losing weight: 0
Number of patients I have seen who weight over 650 pounds: 1
Number of people I have pronounced dead: 4
Number of "code blues" I have gone running down stairs and hallways to get to: 7
Number of "code blues" that were called when someone accidentally hit the "code blue alarm": 6
Number of times I have cried in relation to work: 9
Number of times I have laughed in relation to work: too many to count
Number of times I have thought, "I can't believe I get to do this:" roughly 182
Number of times I have been asked by a 3-year old "Are your a doctor or a veterinarian?": 1

Oh, and here is a story about the highlight of my Christmas celebration with Tommy's family.
Our 6 year old niece was telling me about losing her teeth and how she gets a dollar from the too th fairy when she loses a tooth. His 10 year old nephew then asked me how much money I got from the tooth fairy when I was a kid. I told him "A dollar." He looked at me, and with no malicious or smart ass intent, said, "Wow. That was a lot of money back then wasn't it."

Call version 2.0

2006-07-15T21:39:00.001-05:00

So, the first piece I tried to write never really got off the ground and never really got finished. I have really wanted to make myself do a better job of recording my experiences and feelings as I go through this year, but haven't had the discipline to actually do it.
Here I am on my second overnight call. The fact that it has been two weeks since my first overnight call is something amazing. Most interns like me would be having overnight calls every 4th or 5th night for 11 months of this 12 month year.
My program, though, is doing something different this year for the first time ever...no weekday call for interns.
Instead, they have a "night float" system, in which there is one team that covers the patients from 7am until 7 pm and another team that covers the patients from 7pm until 7am every night of the week. Saturday and Sunday nights the "day team" people rotate the overnight coverage in the traditional call system of what has recently been reduced to a 30 hour shift.
This means that I and my fellow interns are a month the luckiest in the country because rather than spending 9 or 10 nights a month in the hospital, we are there for just 2 or 3.
This has its good and bad points. The good is, clearly, the ability to sleep in your own bed, and the actual part about sleeping is a real highlight. It means we are supposed to be less fatigued in our daily activities and this is intended to make everyone safer.
The downside is that there are things you learn how to do on call that you just don't learn how to do anywhere else or at any other time. When you are on call, you are first in line to get to do procedures, and the senior resident backs you up and steps in if you can't do it. You are the person responsible for making decisions ranging from the mundane ("this patient hasn't pooped in three days, can you order him a laxative?" ...something that is clearly urgent at 3am) to the interesting ("this patient's blood pressure is 78/40, what do you want us to do.") There is an element of facing a challenge and solving the problem that belongs to your hours on call that helps shape doctors from know nothings like me into confident men and women who can solve problems even when they are a little drowsy...think of how well it prepares them to think when they are rested.
Anyway, that is my digression about the call system in my program, and all in all I have to say that I would take what we have now over the days of endless shifts and every other night call and walking through the hospital in five feet of snow up hill both ways that our attendings apparently had to endure, because they remind us of it often and readily.
The short of it that I can't really believe all that I've learned in this past two weeks. The MICU I'm working in has been rather slow for business, but I've been getting to see enough to learn, and having just a handful of patients means I have the time and energy to spend learning, rather than just trying to keep my head on straight.
I'm feeling more confident, but waiting for that moment when I flub up horribly, so that keeps me from getting to excited just yet.
I'm not as afraid of nurses anymore.
I'm still worried about getting called to put in an IV because I frankly wouldn't know here to begin.
I'm nervous about being called with a question that I can't answer...although that is just about every question right now.
And I am truly terrified of someone having a CODE BLUE, and me being a central player in that whole crazy mess.
Overall, though, I just can't complain about how things are going so far. I think I prepared myself for the worst and so far my experience has been, dare I say it...enjoyable?
I know I haven't seen the worst of it yet, though, and that things can and often do, go downhill fast. Like the knowledge that my first big screw up could be just the next pager beep away, it keeps me from getting too comfortable.
In general, I think I am a happier person now that I am back to work, back to a schedule, back to doing something that I really enjoy. Not that staying at home with little to do for the past several weeks wasn't enoyable, but I was beginning to get bored with myself and I have to say it was affecting my mood and my outlook... and Tommy will nod his head in agreement here when I say I have been much more pleasant to be around since this all began.

Doctor? Who? Me?

2006-07-04T16:24:00.001-05:00

Well, because it would be sad to let it go to waste, here is something I started writing two weeks ago on my first overnight call (July 2nd, my second day of residency)...it never got finished.

July 1 is a day that should be on everyone's calendar. It should be declared, "Don't Show Up at the Hospital Because If You Do You Might be Taken Care of By Someone Who has Been a Doctor For Exactly One Day," Day.

Walking into the MICU on Saturday Morning was an odd thing. I had no idea where to go, and frankly no idea what to do once I got there. I entered the unit and spotted a nurse, and said, "Hi, I'm Emily and today is my very first day as an intern and I don't know where I'm supposed to go."
She could have been really mean or really rude. Actually, though, she was very nice. All of the nurses were nice that morning. I admit I'd been expecting the worst. I was expecting to be welcomed less than warmly by the people who will have to deal with me and the rest of my intern class as we learn the ropes and figure out to do this doctor thing. They are the ones who have to scramble to draw blood when we forget to order a lab test, or have to call us when we forget to write a standing order for a pain medication. They have to do what we ask when they have been doing their job just fine for many many years and we have been on the job for just the blink of an eye. In some ways, I don't blame them for having a bad attitude toward us, but I never knew what a huge difference it would make to get to work with nurses who are actually kind and warm and who, at midnight when they are ordering Chinese food, are actually nice enough to ask you if you'd like to order something, too.
Anyway, that is how I feel about the nurses here at the VA MICU.
So day 1 arrived and I felt both excited and incompetent. The exciting part was that I was finally starting to work, and I know that this next year is going to be the time when I learn more than I've ever learned before. Incompetent because, well, I am going to spend this year learning more than I've ever learned before, but I'm going to be responsible for all of those things I have yet to learn.
As the first day on any new job goes, there was a lot of having to ask where things are, how to et places, the protocol for addressing certain issues. And the most important part of any first day---finding the nearest restroom.
Overall the day went well. The strangest part of the day was when the attending introduced me to one of my patient's families as," Dr. Riegel," and informed them that I'd be "primarily responsible for Mr.R's care." I hate to admit it, but tears came to my eyes when he said that.

We really want to be your doctors.

2006-06-28T22:29:00.000-05:00

Alas, they have not yet given us the "Everything You Need to KNow to Be a Doctor" microchip implant. Hmm.
L to R:
Dr. Dave Kolhoff, urologist
Dr. Jen "Adventuresome" Goldman, pediatrician
Me, internal medicine and pediatrics
Dr. Eliza Bennett, ob-gyn
Dr. Abby Snavely, psychiatrist

On The Brink

2006-06-28T22:23:00.001-05:00

I have the four extra years of education.
I have the diploma.
I have a new stethoscope.
I have the knee-length white coats.

In two days I am going to walk into a patient's room and introduce myself as "Emily Riegel, your doctor."

Like I mentioned for the photo above, there was no microchip slipped into our rbains at any point during the graduation week events, nor since then at the endlessly boring days of orientation I've been attending. In fact, I am really starting to think there will be no microchip.

What I am looking at instead is a huge shelf of books, filled with details of anatomy, biochemistry, physiology, all the secrets of the inner workings of the human organism. I think at some point, much of that information was supposed to become lodged in my brain, at a place readily accessible for future use.

The problem is, I'm not so sure where exactly it is in my brain, nor if it was ever actually firmly lodged there in the first place.

Come Saturday, though, I'm being entrusted with people's well being...or as well as their being is while they are in the medical ICU at the Kansas City VA.

Of course I've been given the "help is never more than a phone call away," and "you won't be allowed to do anything unless you are comfortable doing it," and even better, "you're just the intern, no one expects much of you the first few months."

Despite all the reassurances and good advice we've all been given, there are worries in my mind that just can't be addressed until I am in the situations that I actually worry about. Whether it's how I'm going to stay awake to drive home after being up all night at the hospital, or what I'm going to tell the nurse to do when she tells me that my patient has a fever, or how I'll react when I have a patient die for the first time...you just have to get through those things yourself in order to know how you'll handle them. Even then, you know the next time will be different, or better, or worse.

This is going to be a whole new adventure.

2005-08-27T17:17:00.000-05:00

Windmill somewhere in Kansas.

Back in McPherson

2005-08-17T19:38:00.001-05:00

I am rounding out my third week back in McPherson, Kansas. This is the small Kansas town where I spent January of this year doing 4 weeks of my surgery rotation. During our 4th year of school, we are required to spend 4 weeks in a rural location for our "Rural Health Month." Knowing this would be a requirement, and knowing how great a time I had in McP earlier this year, I quickly asked to be reassigned to this quiet little town.
I have been with the surgeons again since I got here, but this time we have had quite a bit more action. We have had unscheduled surgeries on the past 14 of 18 days. This has meant being in the operating room well into the evening most nights, even well into the next day on a couple of occasions.
Of note, I got to see my first amputation. It was bloody and bony and physically demanding on everyone involved. My job was holding the thigh up while the surgeon cut off the leg below the knee.
There have, of course, been plenty of colonoscopies. We also had a run on appendicitis and and gallstones, getting to take out at least one of the two every day in the past week.
Yesterday I worked with an Ob-Gyn who comes to McPherson once a week. She was helping out a little old lady whose vagina had decided to fall out, bringing along the uterus and part of the bladder and rectum with it. It was to the point that she had to wear a catheter because she wasn't able to go pee. Since this little old lady was quite frail, it was thought she wouldn't be able to tolerate general anesthesia or a long procedure. So, the ob-gyn did something that is rarely done in the age of hysterectomies...she got an epidural. and then, after tucking everything back into place, the vagina got sewn shut.
This may sound like a great idea for some people...many of the nurses invovled in the case asked when they could have theirs done.
What I thought about, though, was that somewhere in the past, some poor woman had to be the first to endure this. And she probably did it with little in the way of sedation or analgesia.
In fact, when I thought about it, I realized that most surgeries are fairly barbaric, specifically gynecologic surgeries. And what is most frightening is that sometime, someone had to INVENT these procedures.
I have tried to rationalize that most of these things were probably first done on animals in barns and fields in order to meet the demands of necessity.
You have a cow and her vagina is falling out? Well, just stuff it back in there and sew the damn hole shut. Problem solved.
None of these rationalizations give me a great deal of peace, though. It just makes me really grateful to live in a time of really nice drugs that can make us fall asleep and other really nice drugs that can help take away pain.
My time with surgery is drawing to an end, though, for my last week I will be working with a family practice doctor. I don't think we'll sewing any holes shut in her office.

Three Down...

2005-06-23T18:49:00.001-05:00

I am only 16 hours from completing my third year of medical school. That means just one more year to go, or 332 days until the official graduation day, or 372 days until I begin my residency training.
Has the last year gone quite fast for you, too?
It hit me this afternoon while riding the elevtaor at the Barnes & Noble on the Plaza, heading up to the Starbucks Cafe where I sometimes go to study when I am going out of my skin in my own house. Actually, I haven't been there for over a year, since I had my last afternoon of studying for Step One of the boards on June 14 of last year. Riding the escalator, I kept thinking, "Has it been a year since I last took this ride?" It seems like it might have been just last week or maybe last month, but to think that it has been an entire year, and that I have just one more year left to go, feels a bit strange.
This time last summer, there were so mant things I was dreading about my upcoming semesters. I was dreading finding out of I passed or failed Step One. I was dreading the idea of spending the night in the hospital on call. I was dreading the eight weeks of my surgery rotation. I had so much trepidation mixed with so much anticipation. Having come through this year, a part of me looks back and thinks, "Who was that person?"
All of the things I feared or worried about now look like the molehill rather than the mountain I saw at first. It seems that what I feel most of all is a sense of being able to trust myself.
For a long time, whenever I was nervous about a new situation, I would remind myself that I figured out how to master the subway system in Paris, and it would help calm me down. That is how I am starting to feel about the last 12 months.
It is my latest Parisian Metro.
So, which route am I going to take?
I have looked at the map for a long time now, and I have had a chance to ride on each of the lines trying to find the one that suits me best. Certain of them I expected to love, but turned out to find the ride a bit bumpy. With others I expected an unpleasant ride and ended up having a smooth trip. Each of them eventually brought me to a point that I thought I could be happy staying at for my life.
Now, though, finally, I think I might be able to say which direction I'm going to head.
It is kind of a surprise to me, as it wasn't a direction I ever expected to choose to head, but in my gut I have a feeling it is the right way.
Ready?
Want to hear?
This really is a big deal to be making this type of "announcement," having danced aorund the issue for so long and having actually gotten a bit comfortable with the words, "I don't know what I'm going to do."
So, I better just say it.
I am going to pursue a combined residency in the areas of internal medicine and pediatrics, aka, med-peds.
One of the beauties of this choice is that it still allows me not to choose just one area, but instead I get to have two.
The reason this choice surprises me is that at the beginning of this year, I had no desire to become neither an internist nor a pediatrician.
And here it looks like they are just what I am going to be.
I am going to get to treat adults and kids, but not deliver babies. I will be able to spend all of my time working as a hospitalist or I will be able to have the traditional doctor's office. I can stay general, or I can do a fellowship after residency. In short, I am setting myself up here to have a lot more options.
Do I still have an affinity for women's health? Yes, absolutely. The thought of becoming an ob-gyn still lingers in my mind, and I will add the disclaimer that it may still happen.
I feel pretty confident in med-peds, though. I have been saying, "I am going to do med-peds" in my mind now for several weeks, and something about it just feels right. Today one of my classmates said, "I think you just have to kind of try something on and see if it fits and feels comfortable," and I feel like that is what I have been doing here lately.
Phew.
So, there it is, in public, on the record. Like the first time wearing a new dress out, thinking it looks and feels good, but still feeling nervous about putting it on display.

Exit Stage

2005-05-25T21:31:00.001-05:00

A thought occurred to me today that I know has been hashed out by cultures, religions, and societies for thousands of years, but that for the first time really made sense on a practical level. Death is almost exactly like birth, but instead is the opposite.
This month on the oncology service has been among the most remarkable thus far. In a way, it has been so remarkable that I have had a difficult time remarking on it. I have seen how precariously life can hang in the balance, how fiercely it can be fought for, and how easily it can be let to fade away. All of the patients I have seen this month are sick. This sounds a bit silly, given that I have been seeing sick people for almost a year now, but this month the patients are sick. They do not simply have a sickness. They, in a sense, are their sickness, because cancer, no matter how valiantly it is fought, will, at a minimum, take over a life, and when fulminant will simply take the life.
The patients that we see range from those who are admitted for "routine" chemotherapy to those whose bodies are losing their last battle. For the most part, every patient we have seen has been nothing but wonderfully kind and thoughtful and a true joy to know. We don't just get to know the patients, we get to know their families, and we get to know their stories. This makes it all the more difficult when they leave the hospital, all of us knowing that they are going home to die. This event of dying is one that I have feared witnessing. Every doctor has their story of their first patient that died. It is just one of those touchstones along our path. I haven't yet made that part of my journey, but today I came very close.
We have a lovely older woman in her late 70s who has widely metastatic breast cancer, including metastases to her liver, lungs, and brain. She came to us having seizures and extreme shortness of breath. For the past two weeks, we have been working on getting her to a point of having her pain managed well enough for her to be able to leave the hospital. Her family has decided that she should receive only comfort care, and that we should not make attempts to resuscitate her or intubate her should her heart stop or should she stop breathing (doctor lingo: do not resuscitate, do not intubate, or DNR/DNI). She has made steady improvement, but there have been several setbacks along the way, including her becoming delirious and needing to be sedated because she was taking swings at every one who came into her room, and a run in with pneumonia. Over the last few days she has seemed to become a bit more coherent, but still confused, and plans were in the works for her to go home with her family on Friday.
This morning the other medical student on service with me commented that this patient seemed a bit more confused and lethargic. Later in the morning, our senior resident rushed into the resident room where we all do our work, asking, "Mrs. E is a DNR/DNI, right?"
"Yes," several of us said in unison.
"Okay. She's dying."
The three of us who were in the room jumped up from our chairs and walked across the hall, following our senior resident into the patient's room. Her nurse and the nurse's aide were with her. Her eyes were closed, she was breathing very rapidly, her heart rate was less than half the normal, and she was unresponsive to us, but seemed to be trying to utter something. The four of us who had just entered the room gathered around her bed, and watched.
The thought kept going through my head, "This is death. This is the last battle for her." It felt like some kind of out of body experience, just too surreal to actually be taking place in front of me, with all of us just standing around watching it happen. There were questions flying around the room about calling her daughters to let them know what was going on, paging our attending and updating him, running checks of her vital signs to see if this would somehow pass, theories about what might be happening other than simply death. At that point, the four of us all had a task to accomplish to make sure things went smoothly and that all the proper people were called.
We left the room, did our tasks, and by the time we got back, she seemed to be improving. Her breathing was slowing, but still irregular. Her heart rate was approaching normal, and her blood oxygen level had started to creep back up from the depths. Then she started whimpering, "It hurts. It hurts." Again, a flurry of activity. When was her last chest x-ray and what did it show? Could she have just had another seizure? Is this something that actually could be easily treated? So again, we left the room.
After a few more gatherings around the bed, we drifted back into our resident room, and waited. We soon realized that she had, indeed, faked us out, and that although her death would likely be soon, it was not imminent.
It all reminded me so much of the nights on the labor and delivery floor, the waiting, the checking, the watching, the progressing of labor and the failure to progress. The knowledge that a life changing event was about to take place, and that it could be neither hurried nor delayed. Life, it seems, comes and goes as it pleases despite our best efforts to command it.
In experiencing these moments, I have noticed the division beginning to develop within me. There is the side that must think, "What do I do now with my knowledge and my skills to help this person medically," and the side that thinks, "Given my lack of real knowledge or experience, what can I do to make up for my lack of skills?" This is the same side that wonders, "Do I pray now?" and "Do I try and say something soothing or calming."
Not exactly being a churchly person, ahem ahem, I find the idea of actually praying a bit awkward, but for some reason, I find myself hardly being able to keep myself from simply thinking, "God please help this person and help us help them." Not having ever been in the position of having my legs in stirrups with all my goods showing while a small human is ejected from my body, I have an equally hard time mustering up the courage to say something as ridiculous as, "Keep pushing." Or even being able to imagine the feeling of hearing that first cry, that first breath.
And, not having ever been in the process of dying, it seems grotesquely inadequate to try and think of anything at all to comfort someone who is about to breathe their last, or to their families watching the last breath be drawn.
In both of these moments, I feel so small.

Four More Weeks

2005-05-24T21:45:00.002-05:00

after this week, i will have only four more weeks left of my third year of medical school.
i still do not know what i want to go into after all this is over, and i have really just stopped trying to figure it out.
as has now happened 6 times previous, i am finding that i unexpectedly enjoy this rotation. i had really convinced myself that i would hate everything about internal medicine, from the hours to the patient population to the subject matter. i kept thinking," this rotation is going to make me learn about all that stuff i hate, like the kidneys." when i shared this thought aloud, the reactions i got were along the lines of, "well, i hope a doctor would know something about the kidneys..."
um, true.
so, here i am, finally actually understanding material that has evaded me for so long. i am not sure if it is because i can think, "oh, mr. so and so has kidney failure, and this is what happened to him, let me read about it so i understand more." maybe it is because my brain just needs to read about kidney failure 28 times in three years to finally get it, in which case, i will be about 78 before i am able to understand every organ in the body.
the other thing i feel i need to share right now is actually an answer to a question that has recently been asked of me several times.
the question is, "have you been watching that new show 'grey's anatomy?'"
answer: no.
i was intitally intrigued by it, and i watched a short part of maybe the second episode. it had to do with some guy dying and the interns deciding to try and get his organs or something. what i remember most are things like, " we're doctors, aren't we supposed to save lives?" delivered with such emotion that i nearly gagged on the puke welling up in my throat.
i have been warned that any form of entertainment involoving the medical world would one day be ruined for, and i think it now finally is. the thought, "that could never actually happen," has gone through my head several times, each time annoying me because i do not want to be "that girl" who always says things like, "oh, that would never really happen because blah blah blah," thereby ruining the show or movie for all the other people who are just trying to be entertained. so, i have now started avoiding any medico-fiction-drama in order not to have to see myself as "that girl."
and, since i am married to an attorney who has a very difficult time watching any legal fiction-drama, and since 90% of television shows have something to do with medicine or law, we have no choice BUT to watch intellectually stimulating shows like "America's Next Top Model" and "Showdog Moms and Dads." i suppose the one exception to my rule is "dr. 90210," a show on E! that i fond very amusing because, unfortunately, it is a pretty accurate portrayal of the kinds of personalities that flock to surgery as a career.
thank you for excusing the lack of proper capitalization.

Two Months?

2005-04-01T13:47:00.001-06:00

Has it really been two months since I have written anything for this. Yikes.
I do have a lovely set of excuses prepared, though...

1. Upon my return from McPherson, I was assigned to the neurosurgery service at KU Med. Although I enjoyed parts of it, the hours did begin to suck my will to live. Although I often thought about writing about seeing a skull sawed open, or drilling pieces of skull back together, it just never happened.
2. For some reason my computer stopped letting me log into my account, so I wasn't able to post anything even if I'd had the time to sit down and write it. Last night I did some computer wizardry, though, and ta-da, here I am again.
3. Now that I have had a bit of experience with the psychiatry, I have a label for the constant worrying and thinking and talking about what to do with my future. Perseverating. I have been spending all my free time perseverating about what the heck I am going to do for the next 30 years.

So, now that the excuses are all there, and now that I can access my account, and now that I am about to do a 4 week stint on the inpatient psych ward, I ought to have plenty to share. I think.

Freaking Me Out

2005-02-03T14:11:00.002-06:00

The powers that be at my school held a class meeting today to freak me and the rest of my classmates out.
Phrases like "graduation," and "getting your lives together," and "plan ahead," were uttered several times.
Apparently, we are reaching that time in medical school when we actually have to face the reality of being shoved out of the shelter of school and into the real world. with our third year barely halfway over, it is time for us to start planning and scheduling our fourth year.
The beauty of the fourth year of school is that it is basically a "do it yourself" year. We get to choose the rotations we want to do, and to a certain extent we choose when and where we want to do them. There are three rotations and one class that we are required to complete, but they exist in the sense of categories, meaning that we have to do a months of Critical Care, but it can be in the medical intensive care unit, the neonatal intensive care unit, the surgical intensive care unit, the emergency room, or some other types of intensive care units.
The problem is that the rotations we choose and when we do them and where we do them are actually going to be of importance. No longer can I say, "oh, that sounds cool." Instead, I have to actually think in terms of "oh, that sounds cool, AND it is something I am interested in doing for the rest of my life, and therefore I need to take that rotation in Septmeber because I want to impress these doctors and be able to get a letter of recommendation for residency, and those are due in October."

Somehow I ended up with this afternoon off, so ever since the meeting I have been looking through the catalog of electives, looking at the possible schedules, making lists, drawing arrows, circling things, crossing things out, and in general, the longer I do this,
the
more
I
freak
out.

People have started asking me when I have to decide what kind of doctor I will be, and when I say "in the next 8 months," the response has been, "Oh, well that is plenty of time."
Uh.
No.
Not for me.
I have spent the last 26 years avoiding deciding on a specific profession. I have carefully shrouded myself in the dream world of academia and school. And now they want me to dacide on one thing to do for the rest of my working life?

As Tommy will attest, even the daily decision of what to have for dinner is gut wrenching for me. "Do I really want spaghetti tonight? Maybe I would have spaghetti tomorrow night, and should have grilled cheese tonight. But if I have grilled cheese tonight, then I might not want to have pizze tomorrow, and pizza might be the only decent thing available in the cafeteria at lunch tomorrow. I did just have spaghetti two days ago, though, maybe I should have pizza tonight..."

I have started trying to look for signs as to what I should go into. I have tried to close my eyes and imagine myself as a doctor, and what kind of doctor I see in my mind's eye. I have tried to find things that I know I definitely would never want to do with my life. The only things I can rule out for sure are anything that has to do with poop and most things that would have to do with the penis. I like kids. I like old people. I like being in outpatient clinics, and I like being on the inpatient service. I like the medicine side and I like the surgery side.
So, here I sit, writing this in order to both avoid actually making any decisions and hoping that by getting my thoughts on the screen, I will maybe see some kind of clue. Then I glance to my left and sitting on the table is the calendar they gave us, and my own notes and scratch marks and highlighting and general insanity.

The only things I know for sure are that I am going to New Zealand in February of 2006 and that I graduate on May 20, 2006.

Other than that, I am clueless.

Privilege

2005-01-26T20:41:00.001-06:00

A mantra that I have heard over and over again these last three years has been to always remember the privilege it is to be a physician because of the role you will play in people's lives, and to never take it for granted.
I had seen glimpses of the true meaning of this over the past years, particularly in the past eight months. I have been present at the births of babies, mine being the first hands to ever hold them as they enter the world. I have had patient's tell me things that they have never dared tell another human being, placing trust in me despite only knowing for a few minutes. I have looked into orifices, I have dealt with secretions, I have breathed in odors.
In the past week, though, this idea of privilege has become truly ingrained, and as I spend my last few days here in McPherson, I am feeling a new weight.
This entry is a compilation of several stories, so it is pretty long.

Mrs. S
Last Friday, we took one of our patients to the operating room to perform what is know as a split-thickness skin graft. This patient is dying of metastatic colon cancer. The doctor I am working with said that when he first met her, he would have given her six months to live, and that was nearly three years ago. She is married to a real cowboy: a man who gets on a horse and drives cattle across the range. She has had rheumatoid arthritis for several years, which has twisted nearly every joint in her body to a form that looks barely usable. She has managed to continue her life as a cowboy's wife, though, raising a garden, canning vegetables and fruits, baking pies, tending to children. In December, her husband noticed a small sore on her ankle, at a spot where a shoe or boot rubbed against her skin. Quickly, what began as a pindot progressed to a 3 inch round ulceration, clear through to the tendons and bone beneath her skin.
She was admitted to the hospital for management of this ghastly wound the first week I was here. We were attempting to get the wound to heal with aid from various bandages, ointments, cleansings, and the like, even as the cancer in her body sequesters every nuttient for its own deadly growth.
Last week, it became clear that this wound was not going to heal on its own, and she and her family have realized that what remaining functional time she has left should not be spent in the hospital nursing a leg wound.
Fortunately, we have been able to encourage a certain amount of recovery in the would, enough to creat a bed of blood and soft tissue that could support a skin graft. So, Monday, we took her to the operating room for the procedure. It involved using what I can only describe as the world's most high tech cheese slicer to slice a millimeters thin section of skin from the front of her thigh to be transplanted and sewn into place over the wound on her ankle.
Since the procedure, she cannot stop talking about how much better she feels, how much better she is sleeping, and how much she is looking forward to going home again. What has touched me most, though, is the way she has welcomed me into the circle of her care. She has learned my name. She greets me every time I see her, and thanks me every time I leave her room. I am touched to my core that in the limited time she has left, she has allowed me into her life and treats me as someone she cares about seeing.

KP
Last Thursday we were asked to see a patient about a 1 or 2 inch mass growing on his outer thigh. This man admitted himself to the hospital for alcohol detox, and his doctor thought it might make sense to have this mass taken care of while he was here drying out.
On Friday, after we were relatively certain he had reached a steady level of sobriety, we had KP come over the clinic, which is a part of the hospital, se we could remove the mass and send it for biopsy.
For most people, the weird lumps and bumps we feel floating beneath our skin are about as dangerous as a tulip. There are some oddly occuring cancers, though, that can show up as just another odd lump that just keeps growing.
The doctor told me that I would be doing most of the work of this procedure, and that he would be talking and guiding me through it. I was extremely excited, as anyone who knows how much I love to extract ingrowns hairs can certainly imagine.
We has him lay down on his side, and once the area was nicely numbed, I proceeded to cut into his flesh until the skin opened enough and the nature of the mass revealed itself. It was gray or blue, enclosed in layers of clear, tough fascia. It sat just atop his muscle, and took anly a few minutes to fully remove. Even with my limited experience, I could tell it wasn't going to be one of those innocent little lumps. It had a sinister look to it, but I kept the thought to myself and only later asked the docotr what he thought it might be. "I think it's a sarcoma," he said.
Sarcoma is a nasty kind of cancer that likes to invade and proliferate and use a body like its personal playground. Treatment can sometimes require amputation of the entire limb.
When the pathology report was faxed to us on Monday, it confirmed that this was, indeed, a sarcoma.
The problem for KP is more than just this sarcoma, though. KP is homeless. KP is an alcoholic. KP has no phone number, no address. KP has no medical insurance.
When closing his incision, we purposely used non-absorbable sutures so that he would have to return to the office to have them removed, so we knew we would be seeing him again (unless he decided to remove them himself). This way, the doctor knew he would be able to let him know the results of the biopsy, and try to make some kind of plans for KP to receive treatment.
Sarcomas are difficult and costly to treat. In general, there will be one oncologic orthopedic surgeon in a multiple state are who specializes in the treatment of these kinds of cancers. For KP, this will Dr. Kim Templeton at KU Medical Center in Kansas City, an amazing physician whom I have gotten to know and whom I deeply admire.
Today, KP showed up to clinic. It wasn't time to take his sutures out yet, and he didn't have an appointment, but the doctor knew this may be a key moment in KP's treatment.
Until today, I have never witnessed anyone being told that they have cancer. I have never observed the way the news seems to travel like a wave from the doctor's mouth, to the patient's ears; the way it takes time for the wave to settle into the mind and be understood; the way it eventually runs down to the heart, and then as tears from the eyes.
He heard the news, but it took several minutes for it to really be felt, and then his soulders began to shudder, his hands went to his face, and he cried.
To think of dealing with a deadly disease is one thing, but to consider the obstacles KP faces in getting the treatment he needs to, very literally, save his life, almost seems to much to face.

Mr. E
On Friday, an 82 year old gentlemen came to the ER by ambulance because he could hardly breathe and was having terrible chest pain. This had been going on for over 24 hours, and Mr. E though he would be able to tough it out, but finally let his wife call the ambulance.
He was suffering from a partial collapse of the right lung, because he had essentially blown a hole in the bottom of the lung, allowing air to leak out into the space between his lung and his ribcage, which then compressed that lung to only half its normal size.
You'd have a hard time, breathing, too.
So, the doctor placed a very small tube between two of the ribs, into this now air-filled space, to get the air out and allow the lung to re expand. We admitted the patient to the hospital to make sure recovered okay and that the air leak in the lung healed. This meant that I was going to see him at least two or three times a day, and it somehow happens that everytime I go see him, he has just started a meal. It has become a bit of a joke with us, and the two of us have hit it off quite well.
Over the weekend and beginning of the week, it was starting to look as if the tube we placed in the chest just wasn't doing the job of sucking all that leaked air out, and this morning it was decided that we would put in a bigger tube with more suction power.
Obviously, this can be very painful (imagine sticking a garden hose between two ribs), so we were going to give him some sedation so he could fall asleep and not have to be aware of what was going on.
Once he was snoring away and in the right position, the doctor directed me to a site and told me to make a half-inch incision. He then had me pick up an instrument that I would insert into the incision, and use to begin separating the muscle tissue beneath it. I was essentially making a tunnel through the muscle between the ribs to gain access to the lung cavity. I would insert the instrument with its prings together, and then open it like a scissors, stretching and prying apart muscle fibers as it opened. I did this for several minutes, with the doctor assuring me that I was making progress. I inserted the instrument as I had before, prying it open with all my hand's might, when I suddenly felt a total loss of resistance and a gush of air. I nearly jumped onto the ceiling, thiking I had done something gravely wrong. "Oh my God!" I yelled, my eyes three times their normal size and my heart skipping a beat. I thought for certain this was a huge mistake and that it would lead to his death. "You're okay," the doctor said, "You did exactly what you need to do."
"Holy crap," was all I could say, and everyone started laughing.
"Now put your finger in and feel the space, you can even feel the lung," the doctor instructed.
I took my finger and placed in the tunnel I had created, which was still whistling like a punctured balloon. I out my finger in a little farther, and then, sliding over my fingertip, was his actual, breathing lung. With each breath, it slid smoothly over my glove, up and down, up and down.
I looked at the doctor again and uttered, "Oh my God! That is too awesome."
Once I collected myself, we finished up by inserting the tube into the cavity, allowing it to suck out the leaking air, placed a few sutures to keep it stable, and added lots of gauzed and tape to keep it secure.
All I could think was "I touched his lung." When we went to see him this evening for rounds, I wanted to say, "Guess what, Mr. E, I touched your lung today!"
Instead, when we went to see him, and he was, of course, just starting to eat his dinner, he asked if he could change from his "sexy hospital gown," into his own pajamas.

Lessons Learned: Week Two

2005-01-18T21:30:00.001-06:00

I have been trying to recall any of the itneresting or amusing things that took place last week, but, sadly, i have been drawing blanks. I am just going to start typing and see if it can dredge up anything worth while.
Much of the time in procedures last week was tied up with colonoscopy after colonoscopy. The doctor let me actually "run" it a couple of times, which involves holding the control device for the camera and light that are on the end of the tube that has been rammed up the butt. As we watch a television screen to see the inside of the colon, it is similar at times to a video game...a video game gone very wrong. There is one wheel on the control device for moving the camer up and down, and another for moving it left and right. Inevitably, when the doctor directed me to look up, I would look down, and when he would ask to look right, I would look left. Fortunately, he is possibly among the most relaxed and laid back surgeons in the world, and he has quite a bit of patience with me.
Another procedure I have gotten to see several times now is called "hemorrhoid stapling." It is designed to both treat hemorrhoids and also remove about 2 centimeters of the rectum. I am going to try and acquire a pciture of the device used to achive this, but for now imagine a miniature version of Apollo 13. It gets stuck into the blessed behind, and once a few stitches are placed, the device is fired, causing it to clamp down. this simultaneously removes the 2 cm of rectal tissue, while placing miniature staples to hole to newly created ends together. These staples remain there forever. No, I do not know if they set off metal detectors, but in my reading about the procedure, I have learned that the main cause for concern after the procedure is anal sex. Not for the recipient, but for the giver, as he is likely to feel the staples, and may suffer some scraping of his unit.
There was another interesting and disgusting run in with some veritably flying feces. One of the patients had taken the oral enema, but somehow managed to resist all urge to expel due to the severe pain he would expereince. So, when the doctor inserted the anoscope, all hell, literally, broke loose, as all of the fecal matter the guy had held in was subsequently released as a flood of shit. A flood of loose, watery, slimy shit.
What better closing image could there be?

Lessons Learned: Week One

2005-01-08T14:55:00.001-06:00

It is now Saturday afternoon of my first week in McPherson. I am on call, so I find myself tied to staying here at the hospital, in case some dire emergency or large disaster necessitates my "assistance." Rather than reading any mroe about the colon, I decided to go ahead and reflect on the lessons I have learned so far.

Lesson One: Do Not Swallow Toothpicks
Tuesday morning brought an interesting case to the Emergency Room. A man was complaining of intense abdominal pain and fever since the night before. An emergency exploratory surgery was arranged, and the list of possible diagnoses was long. It could be appendicitis, diverticulitis, gall stones, and the list went on.
Shortly after opening up the fellow, it became clear that the problem was in his small intestine. This became clear as about half a toothpick was poking through the intestinal wall, into the gut cavity.
The surgeon removed about 5 inches of the small intestine around the toothpick, placed the segment on a tray, and we began to examine it. He made a lengthwise cut, and opened it up, to find the other half of the toothpick. It was perfectly intact, sticking there like some kind of strange cocktail weenie gone bad. There was much speculation as to how this could have happened. Did the guy know he had swallowed a toothpick and was just to embarassed to admit it, even under the threat of major invasive surgery? Had he fallen asleep with it in his mouth and just forgotten?
Turns out, when it was explained to him after the operation, the man was just as puzzled as every one else. He continues to claim that he doesn't even use toothpicks, and that he can't think of anything he might have eaten that could have possibly contained a toothpick. So, the mystery continues as he heals from his incision.

Lesson Two: Stand Clear the Line of Fire
Wednesday morning I got to see the first of what I know will be many colonoscopies. The colonoscopy is that treat that everyone is supposed to have at the age of 50...a 5 foot long hose stuck up your butt to examine the health of your colon.
At this hospital, they very kindly give patients IV sedatives, essentially knocking them out for the procedure.
In order to get a good look at the walls of the colon, the patients have to "prepare" the colon by only taking clear liquids the day before, and also ingesting certain drinks that essentially cause a lot of diarrhea. During the actual colonoscopy, something that I can really only decrsibe as a small hose with a camera on the end of it, is inserted into the anus and advanced the length of the colon. Since it is empty, the colon is kind of like an empty ballon, which we need to slightly inflate. This is done by blowing air from the end of the hose ahead of the camera's path. Needless to say, quite a bit of air get blown up their asses.
Usually after a colonoscopy, the patient is brought to a recovery area, and allowed to deflate.
This patient, though, was also set to have a hemorrhoid removal after the colonoscopy, which made it all the more interesting.
After the camera/hose was removed, the nursing staff got the patient into the proper position for the next procedure. This means having her lay face down on a bed, with pillows beneath her lower abdomen to prop up that part of the body we are again going to invade. The bed is then tilted so the head goes down, which means that the butt goes up. Everything except the patient's butt is covered with sheets and drapes, so there is, essentially, an ass flaoting in the middle of the room.
For our little old lady, this turned out to be the perfect position for deflation.
As soon as she was flipped over, she began expelling large quantities of air, to the effect of someone having sat on a whoopie cushion.
Now, I realize that at my age and with my planned profession, I should not find anything amusing or remotely interesting about farts. Fortunately, I was wearing a surgical mask, so my facial expressions were mostly disguised. Soon, though, even the nursing staff could not hold it together, and we all giggled a bit at the next 30 second expulsion of air.
It was all fun and games until more than air began flying out of the butt. Soon enough, bits of lovely, watery stool began flying with enough propulsion to send them 6 feet from their exit. Everyone was a bit taken aback.
Except, it seems, me. Despite the "warning shots" that were sent in my direction, I did not take it upon myself to move even slightly to the left or right, and at the next expulsion, found it difficult to dodge the barrage headed my way. Despite my efforts, I was hit.
It was a small hit, and it only landed on the outside of my scrub top. It was a hit nonetheless. I was totally grossed out, wondering how I was going to remove the top, which can only come off by being pulled over the head, without getting any of the "material" onto any other parts of my body. Somehow, I managed to squirm out of it though.
I am happy to say that roughly 7 showers with lots of soap later, I am feeling almost clean again.

Hmmm. I thought I had more lessons to share, but my mind has suddenly gone blank.
So, I am going to have to leave everyone with these tales to ponder for a few days while I try to learn a few more lessons and come up with a few more interesting tales.

Welcome to BFE

2005-01-03T19:27:00.000-06:00

After a much needed two week break from the world of learning, during which time I entered the world of drinking alcohol in order to kill off a few extra brain cells, and spending many hours staring at my extra large television to further numb the few brain cells that remained, I now find myself back in the full swing of things.
For the next 8 weeks, I will be on my surgery clerkship, which, in my mind, is just a little preview of Hell.
In order to dodge the excessive competitiveness of the surgery rotation at the KU Hospital in Kansas City, I decided to take a 4 week detour to BFE.
For the next 26 days, I will be in McPherson, Kansas.
McPherson, Kansas?
Yes, McPherson, Kansas.
If you want to know where McPherson is, just pull up a map of Kansas and try to put your finger in the dead center of the state.
I arrived at the hospital about an hour ago, unloaded my bags (yes, I brought way too many), unpacked my clothes (yes, I wondered why I thought I would need 43 t-shirts), and sat on the bed in my 6x10 piece of heaven here in McPherson, wondering what I should do first.
Should I try to get ahead on my studying?
Should I take a walk over to the hospital fitness center and get in a little work out?
Should I make sure I have everything I need ready to go for when I get up in the morning?
While all of those things might have been a good idea, I decided instead to begin chronicling my time here, and let everyone know where I am and why I will be difficult to reach for the next 4 weeks.
The only thing I really have to chronicle up to this point is my 4 hour drive out here to the middle of Kansas.
You may or may not know that I have no CD player or even tape deck in my car.Just a good old radio. So, the biggest part of my drive was spent trying to find a radio station that did not play Christian rock, Jesus babble, or country music.
I made exactly three pit stops.
The first was somwhere past Topeka off of I-70, at a questionable gas station. I went pee and got a bottle of water. I also filled my gas tank.
The second stop was in Salina. I has just driven past what is quite possibly the nation's largest trailer park, and hence ought to be taken out any summer now by a tornado, and I realized I was getting quite sleepy, and had to pee again.
I stopped at a brightly lit gas station just off the highway. I peed. Then I got a cup of FrenchVanilla cappucino.
My third stop was just after I entered the town of McPherson. In order to get acquainted with the place, I went right to its cultural center: WalMart. I had forgotten a couple of items, and wanted to make sure I got them while my time was still under my control. From the outside, it looked like any other WalMart Supercenter, but when I walked it it became apparent that this town has the most awesome WalMart ever.
It is the biggest WalMart I have ever been in, and I almost became overwhelmed with awe.
I found the items I needed, resisting the temptation to wander and find things that I need, but just don't know it yet.
So, that has been my day so far.
I have to go now because the other student who is staying this month just arrived and I should probably help her get her things.
I hope to be able to write a little bit at least once a week. I am sure there will be some kind opf amusing tales involving me, a surgery, and my clumsiness.
Post me questions or messages!

Get Some

2004-09-16T23:40:00.000-05:00

All I knew before going in to see my fourth patient of the day was that she "desires change in birth control," and that she has been receiving Depo-Provera shots since she gave birth in 2003. The following dialogue (or one close to it) ensued:
Me: Good morning, my name is Emily, I am the student working in the clinic today.
Patient: I seen you before. (She had, in fact, six weeks ago at a pediatrician's office whre she had taken her older child for a kindergarten physical. At that time she informed me that she didn't like students, and that she didn't really care for her children, either).
Me: Oh, yes, hello. So, you want to switch from the Depo shot to another form of birth control, right?
Patient: Hell yes.
Me: What is it about the Depo shot that makes you want to switch?
Patient: I be bleedin' all the damn time, girl, and I can't get no ass when I be bleedin'. I ain't gonna got his whole winter without no ass.
Me: So you are bleeding in between periods?
Patient: Damn straight.
(We continue the conversation to get more info about the nature of the bleeding)
Me: Have you been having any weight gain or mood changes since you've been on Depo?
Patient: No weight gain. I maybe been in a bad mood, though, but probably because I can't get no head and no ass and that make me crabby.
Me: What kind of birth control do you think you would like to switch to?
Patient: Whatever don't make me bleed, but I ain't puttin' nothin' in my coochie.
Me: So you wouldn't be interested in the Nuva Ring? You just insert it in the vagine once a month and leave it there, then you don't have to take a pill every day, and you only have to think about it every four weeks.
Patient: Hell no, ain't nothin' goin' in my coochie. You know how it be when a man got a big ol' dick and you don't know how it be rockin' around in there movin' shit around.
Me: Do you want to try oral birth control pills?
Patient: Yeah, I'll do those. I been on 'em before, but this time I'll remember to take them everyday because before I forgot and that's how I ended up with him (pointing to her 13 month old running around the room).
Me: So you know how important it is to take it every day at the same time?
Patient: Every morning when he wakes me up at 7:30 the first thing I'm gonna do is take that pill. Also, can you look down there and check everything out and make sure I don't got no infections or diseases? It been a few months since a doctor checked me.
(We wrap things up and I go to wait for my attending to come in so we cn complete the physical exam and counseling. Before we go in, I let the doctor know about the patient's concern over her lack of ability to get any ass or head)
Doctor: So, Emily has been talking to you about some birth control and I hear you aren't happy with the Depo and want to try the Pill again?
Patient: Doctor, like I told her, I be bleedin' all the time and can't any. I got a birthday comin' up and the holidays and you know how we be, I don't wanna go without.
(Most of the conversation I just had with the patient is then repeated with the doctor. I am then instructed by the doctor to do the genital exam, which I am really looking forward to connsidering the lovely things I may be about to find.)
Me: Have you had any increase in discharge? (There is a plentiful amount.)
Patient: There been a little more discharge. I think it stinks, too.
(As I am in the prime location, I can verify the odor)
Me: How long have you had the increased discharge and odor?
Patient: I don't know. I just think it smell like a dead racoon.
(I have heard those "female odors" compared to many things, but this is the first time road kill has been used as a descriptor. I do the pap smear and then take specimens I need for the STD testing. That concludes the physical exam.)
Once the doctor and I finish the exam, write the prescription for a drug to treat the bacterial vaginosis (source of dead racoon smell), and give her a sample of Seasonale (the Pill you take for three months in a row without any placebo weeks so you only have you period once every three months), and a prescription to have the birth control refilled (please please please let her get this prescription refilled and use it, daily, for a very long time), we send our lovely patient on her way, off to merrily begin her pursuit of ass.

Yuzpe

2004-09-13T22:39:00.000-05:00

I am sure there is something borderline illegal about my dispensing of medical advice on the internet, but there are just some things I need to share with people. Also, I was recently told by one of my attendings that he thinks all sexually active women need to know the following info, and that if they don't know it, the medical community has failed them.
Since I don't want to contribute to that failure, today I will share a recipe for emergency contraception, known as the Yutzpe Method.
This recipe uses your basic birth control pills to prevent pregnancy after unprotected or unplanned sex.
There are just a few rules you need to follow:
1. You have to do this within 72 hours of sex to have the best effect
2. You have to take the second dose promptly 12 hours after the first dose for maximum effect.
So, here you go.
Each dose is either:
2 pills of Ovral or Ogestrel, OR
4 pills of Cryselle, Levlen, Levora, Lo/Ovral, Nordette, Tri-Levlen, Tri-Phasil, Trivora, Lo-Ogestrel, OR
5 pills of Alesse, Aviane, Lessina, or Levlite.
Take the first dose ASAP after the sex. Then take the second dose (identical in quantity to the first) 12 hours later.
The most likely side effect will be nausea and vomiting (due to all the estrogen you just swallowed).
If you throw up, take something for nausea (dramamine is available over the counter) and then repeat the dose an hour after taking the anti-nausea meds.

Of course, there are some other handy products, such as Plan B, that are "available," but that lots of chain drug stores have decided not to carry, so they may be hard to find. If you can get it, though, then the advantage is that you only take one pill in each dose, and the pills have no estrogen, so you won't get nauseated. For more info, go to www.go2planb.com

These methods are 80-90% effective in preventing pregnancy. They will NOT end an already established pregnancy, and if you happen to have conceived from the unplanned sex, then this won't affect that, either. This is why you want to take the pills as soon as possible.

Also, my attending recommended that we ask all our patients if they would like a prescription for PLan B so they can get it filled and have it around for the "just in case." If your doc hasn't offered it, and you are interested, then demand your Plan B, ladies! If you can't find Plan B in your area pharmacies, then ask to have an extra pack of pills so you can do the Yutzpe (your doc can also prescribe you a more powerful medicine to prevent the nausea that might come from taking the regular birth control pills).

Let me know if you have any questions!

INFP

2004-08-26T00:06:00.000-05:00

When I was a sophomore in high school, I took my very first Myers-Briggs Personality test, and at that time was an INFP (introverted, intuituve, feeling, perceiving).
When I was given the test again toward the end of my first year of medical school, things had changed and I tested as more of an INTJ (introverted, intuituve, thinking, judging).
Happily, I can now report that I am back to my more INFP ways.
This may just sound like a bunch of blah blah blah, but it is cool to ttake the test and then to see what other "famous" people share your personality type.
So, I am pleased to say that as an INFP, I now join the ranks of none other than:
Mary, the Virgin Mother of Jesus.

To take you own Myers-Briggs test, go to:
http://similarminds.com/myers-briggs-jung.html
enter your gender, and on the box for mbti type, select "unknown"
This is a real test that is used by psychologists, counselors, and lots of other people who try to figure other people out, so it isn't just a hoax.

Again, I repeat, I am just like the Virgin Mary.
The question is: how did they manage to give Mary this personality test?

Slippery When Born

2004-08-25T23:45:00.000-05:00

Yes, it has been some time.
For the past three weeks, I have been on my obstetrics rotation, which means I have been seeing lots of 7 pound humans coming out of lots of 10 centimeter holes. Tomorrow being the last day I have in this rotation, I thought I could soend some time reflecting on what I have seen and learned this month.

1. We all start off slippery
I don't think i have ever held anything more slippery than a brand new human being. Last Monday, I had the distinct honor of actually catching a baby (Sidebar: We say "catch" now instead of "deliver," which I think is a change for the better because when that baby comes shooting out of its mom, you just have to grab it an hold on tight). I could write pages about that experience, but suffice it to say that it was once of the coolest and scariest things I have ever been a part of. I am not sure of there is anywhere in nature or made by man a more slippery substance than that stuff that covers babies when they are born. It makes sense: you want the watermelon well-lubed before you send it down the pipes. If small town fairs wanted to have real entertainment, they would skip the greased pig contest, and instead oil up some babies and start tossing them back and forth, like a water balloon contest.

2. Wear Disposable Shoes
Birth is a beautiful thing. Birth is also one of the bloodiest, gunkiest, poopiest, water-shooting-out-of-orifices-est things that happens. No, I will go ahead and say it is THE bloodiest, gunkiest, poopiest, water-shooting-out-of-orifices-est thing that happens on this planet. Since each birth is different, you never know just what is going to come flying out, or just what is going to land on the floor. So, always put on the prtective gown and mask, always cover your shoes with the throw-away booties, and never wear a apair of shoes you wouldn't be willing to throw away in case you don't have time to put the dispoable booties on over your shoes.

3. Placenta is Gross
Ys it is responsible for noursishing the baby for its 9 months in the womb, but once that thing has served its purpose, it is nothing but a big old nast bloody mess that no woman needs to witness being expelled from her body. Ew.

4. No Matter How Mature You Think You Are...
It is still weird to be within 6 inches of someone else's vagina when you only met them 10 minutes ago.

5. Moms Rule
Anyone who gives birth is my hero. I don't think there is a grown man alive who would endure what every mother has gone through to birth her children. They just couldn't handle it. I have been shocked and awed time and time again at the strength that women have, and their amazing ability to love the little crying creature that just caused them hours of agonizing pain.

Snip Snip

2004-07-27T23:52:00.000-05:00

Circumcision.
Today I learned all I ever need to know about cicumcision, as it was my job to assist with four of them. This week I am in the newborn nursery at the hospital, and one of the fun things we do every day is to remove foreskin.
My official job was to use a dropper to give the babies sugar water right before and then during the procedure. The baby would be strapped onto a special board, legs tied down in spread eagle position, and then I would begin giving them drops of sugar (it was probably the first time these new little humans had ever expereience the sensation of sweetness, and the look of delight on their faces when the drops hit their lips was undeniably adorable). We give them sugar water because it makes the babies release endorphins, the body's "feel good" chemical. After a few drops of sugar and once they get a little of the feeling good, the nurse starts injecting lidocaine into the base of their penises to get them numb. During the rest of the procedure, my job was just to keep giving baby the drops of sugar.
I also liked to say reassuring things like, "Better now than later," and " Don't worry, we won't take off too much," or, "I promise this is the meanest thing two women will ever do to you." I think it made the babies feel better, but it also made the nurse performing the circumcision start to laugh, and I thought the babies would like a steady hand rather than the humor.
The nurse who did the job was so quick and efficient that I barely had time to ever really figure out exactly how the skin got taken off. By the fourth job of the day, though, I was able to adequately aim the dropper at the baby's mouth and watch the entire procedure from start to finish. Does it look rather barbaric? Yes. Does the baby seem to be in pain? Not really. Is there a lot of blood? There can be. What happens to the 1/2 inch of skin that gets snipped of the baby's wiener? That I never found out.
So, as you fall asleep tonight, just think that somewhere in this world, there are babies without their foreskins, and there are foreskins without their babies.
Good night.

Where to Begin?

2004-07-24T19:54:00.000-05:00

Now that I have this blog thing, I have been racking my brain about exactly which part of the story to jump into first. "The story" being how I went from a creative writing major with no idea about what to do with her life to a frenzied medical student with a few definite goals and one chaotic schedule, and how this right-brained lady deals with the left-brained world of science and medicine.
There are two question I hate being asked. The first is "What brought you to Kansas City?" (in reality I still haven't exactly pinned down the answer, but I know that roughly 89% of it had to do with a shaggy-haired fellow named Tommy whose life goals included becoming either a rock star or a ninja, who since has become nearly bald, my husband and an attorney...)
The second question is, "Have you always wanted to be a doctor?" The true answer to this question is NO, I have not always wanted to be a doctor. You tell people in the medical profession this, though, and they look at you as if they are just now noticing your second head poking out from your neck. For some reason, the majority of my classmates, established physicians, etc, just can't seem to fathom not having the desire to be a physicians since the moment the exited the womb.
Perhaps this has actually been some of the source of my struggle over the past two years . I didn't have that sense with in me that I was finally doing what I had always dreamed of doing, and that there was no obstacle great enough that I wouldn't be willing to overcome it to get to my dream. I lack a certain element of resolve that you can practically see dripping from some medical students. They are like those people we all know who dedicate their lives to a sport, who dream of one day playing college or professional basketball, baseball, or soccer, and who are willing to endure early morning practices, bruised and swollen body parts, and being yelled at to go faster and play harder. They think that kind of thing is fun. I think that kind of thing is torture.
And I tend to think that the people who put up with this are a little bit crazy.
Anyway, the same dedication that sends some people to the gym or field at 5am also runs through the veins of students who are capable of sitting still, reading books, memorizing lists of info for 12 hours at a time, barely taking a break to eat or drink (which is probably why they never have to break to pee or poop).
Long story short...compared to most of my class, I am a slacker.
So how does this apply to the big picture story of how I ended up in medical school, dealing with these over-achieving people on a daily basis?
Good question.
I don't have a solid answer, except to say that in the past four weeks, I have actually started to feel as if I AM doing what I was always meant to do.
For four weeks now, I have officially been a third year medical student. This means that I no longer sit on my butt in lectures 5 hours a day and then go home and sit on my butt for several more hours. Instead, it means I spend an average of 10 hours a day with real, live patients instead of real, dead books.
Right away, during the first week of this new phase of my education, I started to feel something strange stirring inside me. Yes, much of it had to do with what seems to be recent-onset lactose intolerance, but in addition to the weird things going on in my gut, there was also something weird going on in my head and my heart.
I was having fun.
I was learning.
I was learning and having fun.
And then, before you know it...I was getting up at 5am to be at the hospital by 6:20.
More than that, I was getting up at 5am everyday, and managing to be a pleasant person.
Then one day the thought came into my mind as I was on my way to examine a patient, "I can't believe I actually get to do this everyday."
I stopped in my tracks for a brief second, and it occurred to me that even though I haven't always wanted to be a doctor, that suddenly I am doing exactly what I think I was meant to do, but just never knew that I was meant to do it.
HOLY CRAP.
And so, I guess that gets us pretty much caught up.
Summary:
I spent 25 years wondering what the hell I was supposed to be doing with my life, and within the last 4 weeks realized that even without having a definite goal or any reasonable plan, I somehow ended up exactly where I think I am supposed to be.

This feels better than a bubble bath.

Ta-Da

2004-07-23T18:06:00.000-05:00

So it begins...
If you made it here, that means you have recently gotten an email from me, had a conversation with me, or have been stalking me. No matter the reason or method, I suppose I am flattered that you have come to read my little takes on the world. Hopefully most of what I have to share will be happy and lighthearted, but I am sure there will also be an ample amount of bitching and perhaps a tad bit of moaning. I will try to keep the bitching and moaning to a minimum, though.

And now, please raise your trays to their original upright position, fasten your safety belts, and prepare for take off...