All things bright and beautiful

This has been a rough week. It has also been an amazing week.

It has been a week that has shown me how the life can be so full of love and within that love come such loss and heartbreak.

In my line of work, I say many times throughout the year, "My patient died." It's part of the weekly, sometimes daily routine of a palliative care physician. To some extent, all of the deaths affect me. Maybe not because I knew the person or their family, or felt sadness or loss from their death, but because in any death I am always reminded of the fragility and splendor in which we exist.

This week, though, I was hardly able to say the words out loud, "my patient died" in speaking about one of them. She was not just a patient. She and her family had come into a place in my heart that only a handful of patients and families have ever been allowed. They inspired me with every interaction I had, and although my medical mind knew the reality of what would eventually happen, I found myself, like them, believing that if anyone was going to have a miraculous healing and beat the odds and live a long, full life, it would be her. We had watched her survive episodes of critical illness that would kill or physically devastate most patients, but weeks after coming through one of these episodes, she was off to DisneyWorld for two weeks with her family, including her young daughter - riding rides, swimming, living life as if there were no illness waiting to overtake. She amazed us.

So when she came back to the hospital days after getting home, critically ill, we all hoped it was another of those episodes. The news wasn't as good this time, though, and when she was able to get to a point where she could get off of life support machines and get home with her family, forces rallied around her to get her home to be with her family. I sat with her before she left the hospital, we held hands, we talked about our hopes, and that even if God's plan for her was not to watch her daughter grow up, that I knew she would still be with her every single day of her life. We both had a few tears. Her family joined our visit, I answered a few logistical questions, and eventually I needed to go - but not after several hugs and a look into my patient's, my friend's eyes, telling her I would think of her every day.

I knew medically that her time at home would likely be short, and my hope was that it would be calm, comfortable, and another chance for her to be a mom, a wife, a daughter if even just for a few days.

From her family, we heard she had just that, for one whole day of being with them at home, before she died in her sleep overnight.

It's one of the rare times, perhaps really the first time I have felt this deeply, "I don't know if I can do this." I don't know how often or how many times in my career I will ever be able to bring someone in this close before it ravages all of my emotional reserve. On the other side of that thought though, is the knowledge that whether or not to let someone in so close is beyond my control, and there are simply going to be people I meet as patients that come to that place in my heart, and as broken as a piece of my heart is left, it also leaves me knowing that this is my place in life, my calling, and is a humbling gift.

This gift was revealed this week in my own life as I spent an evening putting up the Christmas tree with my boys. This is much later in the year that we normally put up the tree, but I wanted it to be something all four of us were able to do together, and I waited. In past years I have waited everyone had gone to bed, or I had a half day off home by myself and I have decorated the tree just so, making sure the styles and sizes and colors of ornaments were evenly distributed. If Henry offered to help I would give him a few ornaments that he could place himself, and if they didn't end up in the right place I would either make him move them or would later relocate them myself. It's a habit I picked up from my mom (sorry mom), and I always remember those red and white checked ornaments that would always end up needing to be moved so we didn't have too many of them too close together. 

This year, Henry showed a new and enthusiastic interest in decorating the tree, and so before we started opening the ornament box, I thought to myself, "just let this happen." And it was so much fun. Henry is old enough now that he remembers acquiring some of our ornaments, he knows he was with me when we picked out some of them at the store, he knows which are his "birthday ornaments" and which are Leo's. He would pull some of them out of the box and marvel at the colors or the details. And he had certain places he wanted them to go, places I would not have chosen aesthetically, but that to him, made sense. Some of the locations were chosen because they made a story or theme together. He put his birthday ornament, and his "H" ornament, and two other of his favorites together near the bottom of the tree. He hung several jingle bells around the bottom like a fringe. He told Leo stories about some of them. We had a fire in the fireplace. The boys drank hot chocolate. For a little while, Tom played the guitar and we made up songs and then Leo started shouting "Jing-Go Bells! Jing-Go Bells!" over and over while he very seriously shook his jingle bells.

And as if that isn't all enough, somewhere in the midst of all this, Henry put his arms around my waist and said, "Thank you, mommy. Thank you for doing this tonight."

I type this now and am both somewhat embarrassed of the overwhelming perfection we had for a couple of hours in our house, and am also wiping tears and snot off my face as I sit here crying. 

It is one of the best nights our family has had. No yelling, no fussing, no bickering. I know that Tom and I, and Henry, will always remember that night. It makes me so happy that Henry has that in his mind now and I hope that if and when he is a father, and while he puts up a tree wit his family, he thinks back to our night when he was six years old. I hope that Leo, though he won't keep details of it, will look at an ornament that I make him take for his own tree, and for some reason feel warm and happy when he looks at it.

And for this night, I have to thank my patient. If it weren't for her allowing me into her life and to be a part of her journey, I don't know that I would have let myself and my family have our evening. I might have forged ahead and put up the tree at midnight one night when I was too wired to sleep, or have fussed at the kids or rushed them along, or been irritated when Tom started playing his guitar. Instead, my heart was more open to my family and to valuing the time together rather than rushing through it. I didn't even try to make it perfect - which has never worked in the past anyway. I just wanted us to be together, to slow down, and to enjoy. Without her, I might have forgotten about the importance of taking life one day at a time, and loving those we have in our lives more than we love all of the other stuff that distracts us from them.

So, when people tell me, "I don't know how you do your job," or when less kind people say that I do this work because I somehow "like" death, this story is my answer. I can do what I do because what I get from it is an embarrassment of riches. And I do not "like" death, instead, I love life. Death is a fact in this life, and finding the ways to help others live to their best in turn reminds me to do this myself.

In the spirit of this season, my wish is for love and peace in the hearts of my family and friends, for moments here and there that bring you awe and remind you of the fullness of your lives. And for all those I am grateful enough to know as my patients, I say, again, "thank you."

Friday Night Soap Box

"There is no reason children with life threatening illnesses should die in pain and suffering."
Amen.
http://www.littlestars.tv/films/short-film-1/value-every-life-2/
Would you believe that even in our own country, with all our medical system has to offer children, most kids with life limiting or life threatening illnesses never receive palliative care? 
Even where palliative care trained doctors, nurses, social workers and educators are available, patients don't have access because health care providers misunderstand and fear "palliative care" and therefore don't access it for their patients.
If you know a child or a family if a child with a serious illness, make sure they get the best of all healthcare, including palliative care.

Until patients and families begin demanding it for themselves and their families, palliative care for babies, children and young adults will remain tragically under accessed and under utilized, and suffering will remain under controlled, under addressed, and tragically rob these patients and their families of quality of life and quality of time. 

Auld Lang Syne

“Beware the Ides of March.”

 – Soothsayer, Julius Caesar, William Shakespeare

 La Morte di Cesare by Vincenzo Camuccini

“Beware the first of July.” – Everyone associated with academic medicine. Ever.

While most of America recognizes January 1 as the star of the new year, for those in the world of academic medicine, where we train medical students, interns, residents and fellows for their careers as physicians, it is truly July 1 that is seen as the entre to the future.

Every physician has experienced July 1 as a trainee and my guess is that every time the date looms ahead on the calendar, it makes many of us pause and reflect on our own July Firsts. At least, I do.

Each year my remembrance of the first day I walked into a hospital and introduced myself as “Doctor” makes me a little more squeamish, a little more amused, a little more frightened, and from my vantage point as a young** attending, I sigh and shake my head at that young physician who had no idea what would be ahead of her.

July 1 of my intern year was a Saturday. While most industries would think that starting a whole new crop of employees in their new roles on a weekend would be ludicrous, in medicine it matters not on what day of the week July 1 lands. It will be the first day in practice. Deal with it.

That Saturday, I walked into the local VA Hospital, my stomach full of butterflies, my long white coat feeling like a costume, my pockets full of pens and notecards and pocket guides, and my inner voice on a constant loop of “What. The. $%*&.” I was doing my first month in the medical ICU of that VA, working with another intern, a brand new second year resident, and a seasoned attending. From the outside you ask, “how bad does it suck to be on the ICU, where you have the sickest of patients, your very FIRST month of internship?” It does suck. It sucks bad because it is terrifying, but apparently it is some kind of screwed up compliment from the program. They say the only put the “best,” the “most capable” in the ICUs in July. Though I have no idea what scoring tool or measuring system they are using to gauge this, so I think it’s probably just what they tell people to calm them down a bit before they are made the sacrificial offering.

Most of that day, frankly, is a blur. It was composed of getting used to an electronic medical record system, not getting lost to or from the bathroom, trying to remember which of the patients in the ICU were mine and which were to be followed by the other intern, translating the dear attending’s accent and medical-ese into something that made sense in my brain, and constantly trying not to freak out. I survived it, though, and so did my patients – at least in my memory they all were still alive the next day.

Being a new intern is like being a new parent.
You are constantly scared and tired and scared.
Look how terrifying that baby is!

And it was the next day that would test my mettle as a newbie physician. For, on July 2 and 3, I was to be on call. For 30 hours (give or take, but let’s go with 30 for the sake of what the rules limited us to at that time). I came to the hospital around 6am on Sunday morning, carrying a backpack full of food to get me through the next 30 hours (the VA was not in a good neighborhood for take-out and the only food items available were from the vending machine), a few toiletries, some caffeinated beverages, and probably a book I thought I might get a chance to read.

My team made rounds through the morning and early afternoon. My co-intern and I did our notes while our senior resident stayed near us and answered questions about how to place orders, delete notes we started on the wrong patient, find lab results – all of which she had shown us the day before, but had not quite stuck.

Then it happened. The other interns, who were not on call, started paging me and wanting to give me checkout on their patients.  It was time. My call coverage was starting. The other interns flocked to me, armed with their printed off patient lists that seemed to be hundreds of pages long, rattling off the demographics, the diagnoses, the problems to watch out for, the labs to follow, the plans in case of disaster. After hearing “Mr. Jones is a 72 year old guy who came in with COPD and chest pain and is on {fill in antibiotics} and {add in ant-hypertensives} and has labs at 8 o’clock tonight…” and “Mr. Johnson is a 67 year old guy with CHF and shortness of breath who came in for a COPD exacerbation versus CHF and is on {fill in diuretics} and {fill in breathing treatments} and has labs at 7:30 tonight…” and “Mr. James is a 76 year old guy with COPD and CHF who came in with nausea and diarrhea and is …” over and over again (say, 50 times because that’s how many patients you are going to be in charge of tonight), these wonderful vets become a big old medical soup of CHF, COPD, CAP, C diff, AMI, AMS, VRE that has no chance of being able to distinguish one clearly from another.

I suspect I almost cried. Or at least had some “stomach issues.”

For a couple more hours, though, my co-intern and my senior were still close by, since we had a lot to get finished before they could go home. The scariest moment, though, was when that dear, sweet, lovely, patient senior resident picked up her backpack and told me “See you tomorrow. Good luck!”

I felt abandoned. Vulnerable. Inadequate. Like I had been kicked in the stomach and then dropped at sea.

There was, of course, another senior resident on call with me and another intern that night. It was a senior I knew well. And it was his first night on call as a senior resident. His first time in charge of the interns. His first night running the show and making sure the interns didn’t screw up too badly. And he was well qualified to do this, since just 48 hours prior, he had been an intern. But, from June 30 to July 2 he had been given that mystical power that all interns assume will be granted upon them and was now “the senior.”

The night was, as you may have predicted, horrible.  New admissions. Sick guys**. With blood pressures in the 80s. Admitted to the ICU with guardian angels of ICU nurses there to say things like, “Doctor, you want to order another bolus now, don’t you?” and “Doctor, you’re getting ready to start antibiotics, right?” and “Doctor, which pressor are you thinking of starting now. I’ll go get it from the Pyxis…maybe some dopamine?” Here is where I will say it: nurses kept patients alive that night. Sure my name and my seniors name were on the orders and the notes, but the nurses are the ones who had the experience to see when patients were on the brink of disaster. They are the ones who had the sixth sense about patients preparing to crump. And it didn’t take me long to realize that I needed them desperately.

The flip side to this, is that the nurses know we aren’t to be trusted, and they know they need to initiate the fresh interns. If you are a nurse and you deny this, I will take back the last three sentences in that prior paragraph. I’m giving you all huge credit for keeping patients alive the first week in July. However, you guys know that you get a little thrill out of paging at 2am and asking for orders for a bowel regimen for the patient who “hasn’t pooped in 2 days. Can you order a laxative?” And you all are good at sensing that moment when we have finally gotten all orders in, patients relatively stable, and can steal about 30 minutes for a cat nap. Just as the brain goes fuzzy and sleep sets in, “BEEEEEP BEEEEP BEEEEEEP.” The pager goes off. And the patient who is soundly asleep despite not having pooped since Friday is granted an order for some milk of magnesia…that he will take when he wakes up…in five hours. It usually takes interns until about mid-September to realize the ridiculosity**in this, though.

Back to the night of July 2, and morning of July 3. Around 5:45 the sky begins to lighten. Pagers start going crazy as the nurses preparing to hand over their patients to the day crew request new orders or draw your attention to the labs starting to come in. This is when, as a sleep deprived, stressed, and hungry intern (seriously, those 5 granola bars and the PB&J I packed were NOT enough food) I began to get a little snippy despite my best efforts.

Then I had to go through the process of handing back over the patients to the bright eyed, well rested, clean smelling, breakfasted group of interns coming back in for the day. And those interns were probably asking really annoying questions like “what was the K last night?” and “how many doses of Tylenol did he use?” and I probably felt really guilty inside for not knowing those answers, but at the same time, probably thought to myself, “DUDE! I had 50(!!!) patients under my watch last night. I don’t know all this shit! Look it up yourself!” and “Just wait, my friend, you have no idea what you are in for when you have your first call.” But I got the patients back under the care of their primary team intern, and then started to pre-round on my own ICU patients and then rounded with my ICU team.

Up to that point in my life, I never knew what it was like to have been awake for 27 hours. And it isn’t just the physical strain of being awake that long. It’s the emotional and mental strain as well. It’s the kind of strain that causes atypically articulate, quick-witted person to not be able to find the right term and instead fumble around saying, “we got results of that test. The one that tells about the number of cells…in the blood…like the red ones and the white ones and the platelets…” Until the attending looks with confusion and says, “Do you mean a CBC?!?”

“Uh, yes, I meant a CBC…”

Then, a few hours later, after rounds are finished and notes are in and it’s finally time to go home “post call,” that physical, mental, emotional fatigue is what made me collapse into a puddle of tears as I turned on my car. That’s the thing about me. I know I’m exhausted when I start crying. I had called my husband to let him know I was on my way home, and when I heard his voice, I started bawling. All of the fear and anxiety and worry and self-doubt came out right then.

“What the hell have I gotten myself into?”

“How am I qualified to take care of people?”

“When am I going to know what I’m supposed to do if…”

“How am I going to drive all the way home like this?”

It was a mash up of emotion all the way home. When I got home, I was greeted by my sweet dog and my husband, who had some food for me and let me cry some more on the couch. I told him, “this isn’t right. This isn’t how people should be treated.”  I lamented the state of residency training for a few minutes before I crashed for the next 17 hours.

Then I woke up, got dressed, and went back for more.

I was in one of the last residency classes (I did a four year med-peds residency) that still had 30 hour shifts. New rules went into effect the year after I graduated residency, and now the maximum shift for an intern is 16 hours. It is a rule change fraught with controversy and new problems – how do you learn as much when you are so much more limited in your exposure to clinical patient care? What do we do with all those extra hand-offs? In ways I envy their limited shifts, but mostly I don’t. In the moment, it was terrible. I left that first 30 hour shift thinking that it was going to be a brutal four years of training and that it was seriously flawed. Yet in hindsight, I know that those 30 hour shifts over those four years were likely among my most educational. They forced me to begin taking charge of patient care, making decisions on my own, interacting with families and answering questions and, yes, getting beaten down at times. Did I make mistakes along the way? I’m sure I did. Did they cause harm to any patients? I truly don’t know. And I can see that side of the argument for restricting work hours and trying to modify resident training, absolutely.

Through the rose colored glasses of hindsight, it is only that first 30 hour shift that stands out for being torture to me. There were other bad shifts, but not like that one. No other that, simply for their existence, brought me to tears. That young intern in my memory is like a child to me, in fact, I see her much as I see my 13 year old self embarking into high school, or my five year old self embarking into kindergarten – so very much to learn about the world and about herself.

This was taken at my 8th grade graduation. Look, it was the very
early 90s and floral prints were all the rage, so stop mocking.
After all "Everyone's a Star!"

It’s probably that perspective of the young intern me that has kept me in academic medicine, now seeing that there will always be learning to do, always be teaching, always be those fresh young minds to try and help shape into excellent, compassionate people and physicians. It gives me a chance to make resolutions, which I no longer do for January 1. Now I do it on July 1: I will teach better and more, I will be more patient with learners, I will set an example for them, etc.

So, to everyone out there, Happy July. May we all embrace our own past, thank the patients, nurses, and physicians from whom we have learned, and may we continue to grow and learn ourselves.

**”young” is a relative term. I am still in my first 5 years as an attending, but am in my mid-30s as a human. Thanks to the wrinkles and dark circles that come as a perk from this job, though, you might mistake me for someone a few years older.

** patients in the VA, at least in the Midwest in the mid ‘00s, were almost all male. Like, we fought over who would get to take the 1 in 1000 female patient who got admitted because she might be more interesting.

** yes, ridiculosity is not a real word. Neither is "ridiculopathy" which is a nerdy word that nerds like me prefer. I would explain it but it would be way, way too nerdy.

I Worked Damn Hard to Be Called "Doctor"

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...

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!

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.

Windmill somewhere in Kansas. 

Back in McPherson

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...

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

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

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?

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

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.