One lucky man!

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.

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.

There but for...

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.

Six months down

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

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?

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.

On The Brink

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.