Sunday, November 16, 2014

Lows and lows

"Nothing is permanent in this wicked world - not even our troubles."
- Charles Chaplin

It was my last Friday on the wards for this go-round, the last day our current two teams would spend together before all the non-interns switched over. And from noon onward, it turned into an emotional roller coaster I struggled to navigate.

Code Blue, ICU. Code Blue, ICU.
My attending and I were on our way down to the ER to see a new admission when a code was called in the ICU. The ICU staff is the rapid response team, so typically the floor doctors don't descend en masse; a few people headed over there while we two continued our trek downstairs.

Our admission was a very elderly lady with late-stage Alzheimer's who had fallen victim to a vicious infection and recently stopped eating. Her family had made her 'comfort measures only,' and she was being admitted for gentle care until hospice services could be put in place for her to receive care at home.

Spindly fingers. Raspy breaths. Vacant eyes.
Her room was crowded with family and her caretakers. Her presentation, from so many angles (minus the infection), bore strong echoes to my grandfather's last days. My attending spoke to the children as I held her hand, thinking back to when I last saw him, similarly cachectic and lost to the world in all ways except for the air his lungs still pulled in, the blood his heart still labored to pump.

After talking to the family and the ER doctor, we made our way back upstairs. Just as I was settling into my seat to work on her admission orders, a second code was called in the ICU for the same patient. They needed more hands on deck for CPR, and several of us rushed over.

1--2--3--4--5--6--7--8--9--10-- x 2 minutes
The patient's room was the one right next to the room where my patient's harrowing code had occurred one month ago, when I was working in the ICU. Half of the staff was the same that had been present that day. When I was struggling in the aftermath of the code last month, one of my medical school mentors told me, "Events like that tend to stay entrenched in your memory for the rest of your life. You'll always remember the details." It's only been a month, too soon to extrapolate to a lifetime, but I had flashbacks that Friday in a way I never had before. But there was no time to indulge (there rarely is); time to be present.

After some time, the family asked us to stop, and the code was called. Those of us who had come to help trudged back to the wards with a heavy heart, back to the grind of work. My resident had finished the admission orders for me, and I began the admission note. Soon after, my pager went off -- please call radiology.

Peritoneal carcinomatosis. Subcapsular splenic lesions. Periaortic lymph nodes.
They had CT scan results back for another one of my patients, a sweet, feisty elderly lady who had come in with intractable vomiting and unintentional weight loss. The results were grim. She had widespread metastases, likely related to a past cancer for which she had undergone treatment years ago.

I called her primary care doctor to give him the update. He came by the wards within the next hour, and we went to deliver the somber news to our patient. She took it in with her usual stoicism, giving little hint as to how she was feeling, and little room for us to explore that with her.

What was left of the day went toward tying up loose ends and finishing paperwork. And was then followed by the final jarring event of the day -- a celebratory two-team dinner to feast to our time together, which had been scheduled since several days prior.

I wouldn't say I ran the full spectrum of emotions that day, because mostly I wallowed at one end of it, and had to play-act at the polar opposite end for the final few hours of an otherwise exhaustingly mournful day. There were too many echoes in speedy succession -- of my grandfather, of my ICU code, of my first medicine patient I had as a third-year medical student, who happened to be the first patient I had to break the news about cancer to, and the first patient I had transferred to the ICU, only to see him die a slow, sad death there.

Somehow that Chaplin quote seemed to belong with my memories of this particular Friday. When I was an MS-III with my first patient with newly diagnosed cancer, while simultaneously struggling to process my aunt's sudden and tragic death, my intern at the time would say, "This too shall pass." And more recently, as I struggled through that Friday, and some of the days leading up to it, another mentor/friend told me of her dance party with her adorable son to Taylor Swift's "Shake It Off."

How can we build in time to do that? I hadn't fully internalized what a wild, visceral ride I went on that day until over a week later. It was after I transitioned back to an 8a-5p schedule, had caught up on some sleep, and found myself with a two-day weekend to finally try and decompress.

There has to be a better structure for processing, even within the constraints placed upon us by training. How else will we stem that empathy degradation we keep hearing about?

Things to ponder. In the meantime, if you see me jamming to TSwift, all I will say is, don't knock it 'til you try it. 

Tuesday, September 2, 2014

An all-too-common tale

"Let your heart feel for the afflictions and distress of everyone."
-George Washington

Beware, however, of the paralysis that may follow.

Last week, I found out that one of the patients I had cared for while she was admitted to the hospital died within a couple of weeks of going home.

I suppose, depending on the expectations and theories one associates with being hospitalized, this could come as an expected eventual outcome. While I'm not feeling particularly profound or philosophical, I suppose it's worth conceding that the eventual outcome is always death. Except this sweet, unfortunate, confused lady was not here for any acute health issues, but rather, a worsening of many chronic ones. And her true cause of admission? A complex constellation of social symptoms. Her "eventual" death came too soon.

Her true illness was joblessness, near homelessness. No health insurance. No resources. Limited supports. A language barrier. A profound degree of not just health illiteracy, but illiteracy, period. The overwhelming combination eventually brought her path to intersect mine for a brief interlude. In theory, I cared for her and made her feel better. But I had no remedies, none at all, for the true causes of her multiple diseases. My prescription pad was useless in more ways than one -- not only could I not write her for a home, or a paycheck, or a family, but the few medications I could write her for, she would be unable to take due to lack of comprehension.

We try, with incredible efforts from our social workers and case managers, to set up safe discharge plans for our patients, but in so many ways, our hands are tied. She left our hospital bed and returned to her familiar ground. Within a few short weeks, she died -- ostensibly of medical causes, but actually of so many social ones. And since then, I've wondered what more I could have done to prevent this, and what more I can do for the next incarnation of her confluence of social issues who crosses my path. I've yet to come up with any answers, and am left feeling miserably inadequate.

This is not meant as a social commentary, though the situation deserves one. I have no groundbreaking insight or ideas on how to remedy this story and the multitudes like it, at least not just yet.

This is an outpouring of grief and regret. Of failure.
I'm sorry. 

Monday, July 14, 2014

BAU to the Rescue

"Things are not always what they seem; the first appearance deceives many; the intelligence of a few perceives what has been carefully hidden."
(spoken by Hotch in "Paradise," 4x04, Criminal Minds)

Most who know me know I am a loyal Criminal Minds fan. Every episode is book-ended by quotes. I don't believe they have ever repeated a quotee (apparently this is actually word) within or between episodes, but don't quote (ha) me on that. But I digress. 

In senior year of college, I began to struggle with blogging, especially as difficult things were going on at home, combined with the encroaching sadness of leaving college behind and separating from a lovely, if insular-to-college, community. So, I turned to my favorite TV show for inspiration -- I picked an arbitrary quote from one of the openings/closings to help me focus my thoughts whenever I struggled to write. And it worked!

When I started my med school blog, I felt I was 'better' than that. I could manage my own inspiration! I was in such an inspiration-rich environment, what could possibly be lacking? Quite a bit, apparently, the most significant of which was focus.

I changed blogs from college to medical school because I thought carrying the same one forward would encumber the process of identity growth. But I'm keeping the same blog for this transition, from medical school to residency, at least for now. Why?
a) I never quite gave it a fighting chance, and feel responsible for giving it another go.
b) Transition and growth is a gradual incline, not a stepwise leap from one standpoint to another.
c) Let's face it, it's kind of an awesome name. (That's not arrogance speaking -- I didn't come up with it!)

But I think it will take a different form. I hope it will.

In medical school, I shied away from expressing too much of myself or my opinions. My friends will probably scoff at this. I should clarify -- this was mostly true in public environments/forums, maybe not as much one-on-one. I don't think this was a new trend; I'm a somewhat conflict-averse person, though I've been known to pick my battles.

I also somehow became of the opinion that I was only worth taking seriously if I processed my experiences into story-form prose. I'm still struggling with this, but I'm starting to consider that to be false. And the duality of self gets tiring to maintain. The intention to maintain it here began to translate into maintaining it in person. And that really gets tiring.

It seems kind of goofy to think that writing this will somehow affect a significant change in behavior. But maybe I will at times be more successful in holding myself accountable. And hey, I'm kind of goofy at baseline -- who knew? (Spoiler: My sister definitely knows. Better than any other human being alive. This will probably make her feel validated in some way. Just for you, M.)

I am a
-mentee, and dare I say, mentor
-[select] TV show junkie
-coffee addict
-Bollywood fan (though the 90s make me cringe)
-PJ extraordinaire
---> Some will think this stands for pajamas. Others will say poor jokes. They would all be correct.

The list is both incomplete and in continuous flux. Now I am also a psychiatry resident, resolving to work harder to find a truer me even as I help patients do the same. And all this with the hope that I will come out a better care provider and individual for the effort.

(Leave more identities in the comments! Yours or mine. The more absurd the better, of course.) 

Sunday, January 26, 2014

Dialects of love

[Disclaimer: Names and all sorts of details have been changed to maintain confidentiality. As such, any resemblance to real persons, living or dead, is coincidental.]

7:30 a.m., reporting for duty to the intensive care unit. I was just two months shy of finishing third year, and thought myself immune to the beeps and alarms that passed for signs of life in the hospital.

My fellow took a break from pre-rounding to assign me a patient. No new admissions had come in for quite some time, so she instead assigned me a young gentleman, Coby, who had been in the ICU for almost two months.

I hurriedly jotted down an abbreviated clinical introduction – student, sudden collapse, intracranial bleed, herniation, not arousable – and an even more abbreviated social introduction – dedicated family.

Dedicated family. Close-knit. One could mistakenly think we minimize their depth of commitment with our sparse words. But the fellow’s words were accompanied by a note of grief, a glance toward Coby’s room to reassure herself the family was okay, not flagging someone down in a panic. But the glance was reflexive – his room was around the corner, out of sight. She said, “Talk to them, and answer their questions if you can. But never assume.”

I steeled myself to approach Coby and his family, not out of apprehension in interacting with them but because I could not predict their response to me and my own response to the situation. As a medical student, I had little exposure to the trials of the ICU, abode to some of the sickest patients in the hospital. What comfort could I, an inexperienced physician-in-training possibly offer a tortured family? I was young enough to be their child. Would they view me as insolent? Presumptuous? The stark white walls of the hallway to his room offered no solace, as if mocking my supposed “immunity” to the sounds they channeled to my ears.

My apprehensions were unrealized, at least for that first entry into his room. He was alone, harsh vent-supported breaths rippling from his trach collar, even as the cardiac monitor beeped at a deceptively regular rhythm. But before I saw Coby, I saw the walls of his room, plastered floor-to-ceiling with posters, cards, sports logos, a fraternity sweatshirt. His friends told him to hurry up so they could get back to their soccer tourney. His niece was waiting to show him her newest toy. There were colored pencil drawings of mountain ranges and rainbows, a cup of coffee, a rainy day. In his silence, the colors on the walls screamed their love.

Expressions of love lurk in many nooks and crannies of the hospital, not always with bright colors and words of sentiment. Down the hall from Coby’s room, an elderly lady’s daughters posted an austere sign on the IV pole by her bedside: “Say ‘Hi’ to me…I cannot see.” Anytime someone entered the lady’s room, she strained her neck in indecision, unsure which direction to turn her head. Some staff were cognizant and lent her the thread of their voice. Others remained painfully invisible, dismissive of the sign and silent in their breach of social contract.

Two floors below on another ward, the headboard above a comatose patient’s bed is carpeted in words of faith, in stark black and gray and white. Some are methodically stenciled in pencil. Others are sketched in permanent marker, as if to impart endurance. John 10:10. Exodus 15:26. Luke 1:37. Jehovah-Rapha: I am the Lord your physician.

When I graduated from college, my best friend’s mother gifted me a shivling, representing the infinity of creation, the cycle of life. “May it guide your healing hands,” she said. I wear it as my own token from a loved one, in the hospital where balloons and stuffed animals offer affection in proxy. 

I spent several minutes more than I had been granted standing by Coby’s bedside. The sobering faith adorning his walls sank under my skin. His wrist felt clammy under my one hand, as my other hand reached up to grip my pendant. The smooth, dry surface was at odds with the dampness hanging heavily in the room – from his skin, from his vent. 

His family returned to the room. Their lips moved interminably in silent prayer, loath to break their cadence of insistent hope for a green stranger. His aunt adjusted the temperature on his heated blanket, and meticulously jotted numbers in her pocket notebook. His mother stood by his pillows with a wash towel in hand, gently wiping the drool he could no longer control. His father stood watch at the foot of the bed, doggedness in his spine and weariness in his shoulders. 

And I found myself backing into the corner, head bent, eyes closed. The colors from his walls danced behind my eyelids as I yearned for the solace I had sought to provide. I did not disturb their vigil with empty words, for I had no answers, only questions.


Please share your stories/thoughts/comments/criticism below.