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.

Olé!

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. 

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."

-Phaedrus

(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.)

Identity.

I am a

-daughter

-sister

-cousin

-granddaughter

-friend

-learner

-educator

-mentee, and dare I say, mentor

-reader
-alien

-[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.

-writer

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.) 

80 on 97 at 86.5

 [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.]

“Mr. Maddox is an 86-year-old gentleman with end-stage congestive heart failure, but you won’t believe it when you walk into his room. You’ll see what I mean when you meet him, he looks nothing like a congestive heart failure patient, it’s remarkable!”

A doctor spends her career as a voyeur to her patient's life – births, birthdays, graduations, jobs, marriages, divorces. Tragedies. Deaths. Ultimately, even we are powerless in the face of time and fate. When we accept our impotence, we stop being physicians and become Charon, ferryman of the dead. We bulwark our patients and their families as they pick the next turn. And for the token of their trust, we ease their way across Acheron and Styx.

I spent a recent morning playing voyeur, rounding on the team’s ICU patients – four individuals at different distances down the Styx – with the hospice team attending, Dr. Slate. Two of the ICU patients were in no condition to talk; in fact, they had been unconscious for several days at least. In a twist of fate, perhaps, these were the two youngest patients on the list, in their late 40s to early 50s, the parchment of their life stories prematurely shorn.

Rob was 49, a young professional with an even younger family. He had been expected to die overnight after a terminal extubation, but miraculously pulled through the night. Rob had been in a coma for weeks, missing his daughter's birthday, his wife's promotion. After those weeks of silence and agony, his wife came to the heartbreaking decision to let him go. She brought their little girl in one last time to say good night to her daddy. They kept vigil for hours, watching his breathing peter out. As the sun rose, the shifts changed. When we rounded, his brother was in the room with him, watching over his last seconds…minutes…hours, losing the battle to lung cancer.

 Our other young gentleman, Carl, recently married, had also fallen victim to lung cancer. He had complete white-out of the right lung, maybe complicated by pneumonia, it was hard to tell. He was close to failing respiratory therapy when we checked in on him and had not woken up in days. His wife, sister and mother were coming in the afternoon for the first of many family meetings. There would be questions about his diagnosis, his prognosis. His mother would ask if he was in any pain. His sister would ask what their options were. His wife would ask if he was ever going to wake up.

No decisions would be made today.

These first two patients were non-communicative, obtunded, potentially locked in their own bodies. Dr. Slate told Rob’s brother that even though he appeared asleep, the drugs did not put him to sleep. They merely sedated him enough to dull the pain – he could still hear.

I remember when Barimama, my grandmother, lost her memory after a stroke and became bedridden and aphasic. She could only communicate by singing hymns – we were still granted the gift of her voice, but our voices never reached her again. We had a diagnosis, but no prognosis. If she was in pain, she could not tell us. She was awake, but oblivious to the world. We could only stand by as she drifted farther and farther.

We knew everything, and yet, nothing. No decisions were made.

“He has an ejection fraction of less than 10 percent. He also has a history of pulmonary disease, esophageal cancer status-post resection. His wife of 50 years died two years ago.”

Our other two ICU patients were older, lonelier gentleman, with no families to turn to. Keith, a 90+ year-old partially deaf man with recurrent colon cancer, was cantankerous and jonesing to get out of the hospital. “My doctor on TV there, he told me I can go home today!” he kept eagerly repeating to us. “Get these things offa me and let me walk outta here now!” His daughter was his health care proxy, and she had the clarity of knowing his wishes: no life support, only hospice. So sure enough, we got ‘those things’ off of him and shifted him downstairs to the hospice unit.

Next door was a patient who had inexplicably lapsed into a five-day coma, and even more inexplicably spontaneously woke up a day before the team planned to terminally extubate him. Sidney was a long-term alcoholic who had broken off ties with his family years ago. His wife was long-gone, his children long-estranged. Sidney had no advocate to speak for him – he would become a ward of the state. He was still intubated, with an unclear degree of comprehension and inevitable, significant neurological impairment. Of all our patients, his future was perhaps the most uncertain.

The aftermath of this ICU morning would leave a little girl without a father, and a new bride without her husband. Meanwhile, two older gentleman with lives fully lived would linger on in hospice care, with the scythe of death precipitously teetering over them, biding its time. It is tempting, and too easy, to try to weigh one life against another. It is even easier to embrace bitterness and cynicism when you find the way the scales fall to be unsatisfactory, "unfair." The key, perhaps, is to leave any sense of justice checked at the doorstep. The hospital has no room for it, only for empathy and care regardless of circumstance.

“He requested to become DNR/DNI on this admission, and is filling out an advanced directive with his daughter this afternoon.”

Our attending described one of the non-ICU patients as a case of “wrongful life.” Jackie was a 90+ year-old lady found passed out face-down on her kitchen floor, to our surprise from drinking too much. “And you think this upstanding little old lady couldn’t possibly be swizzling alcohol,” Dr. Slate said. Unbeknownst to EMS, she had a DNR/DNI order, and yet she had CPR performed, was revived and brought to the hospital. Hence, “wrongful life.” Now she was debilitated and stuck on life support until and unless her family decided otherwise.

Situations like this are not unfamiliar. National news headlines and cable TV themes thrive on showcasing family drama revolving around terminal care. But it isn't drama. It's love. Basic human nature dictates, it is always harder to actively choose to deprive your family member of care than it is to not provide it in the first place.

Dr. Slate told us it is our job to empower our patients' families. "Allow them to think of their role as a protector," he said. "Give them permission to stop us from going overboard and doing more harm than good." And simultaneously, we should not offer any course of action that is medically ineffective. False hope is more poisonous even than inaction.

“He was here at the hospital a couple of weeks ago. Sounds like there was a med mix-up, that’s why he’s back. Oh, and he has a device keeping his heart going since 2010, we might need to check the protocol on it.”

We shifted locations in the afternoon, where we met our new consult, the 86-year-old gentleman with heart failure. The social worker was right – we could not believe our eyes when we walked in the room. The heart failure diagnosis carries with it a certain picture, of an older patient with significantly edematous extremities, large body habitus, considerable baseline dysfunction, lying despondently in bed. But our final patient met none of these descriptions. He looked like a fit, spry old man, sitting up chatting animatedly with his daughter, with no signs of edema, nary an ounce of fat to be found. It was hard to believe this was a man with an ejection fraction almost incompatible with life; if we hadn’t heard that, we easily would have given him another half-decade at the least.

Mr. Maddox was a gentleman at peace with his prognosis; he had been granted the years to achieve that peace. He was content with his life, as long as we could help fix his shortness of breath enough so he could get back to living it. “I just want to get back out there and drive, doc!” he said. “I drive 80 on 97, I’m nothing like those old folk on the road!” Dr. Slate turned to Mr. Maddox's daughter and asked, with a twinkle in his eye, "Would you get in his passenger seat?" "Oh yes!," she exclaimed. "And that, students, is the true test," Dr. Slate said.

 Where did he want to drive to? His destinations were perhaps the most telling. Mr. Maddox loved to cook, and especially loved to cook for his daughter, who worked long shifts. He would drive meals out to her house, 30 miles away, and it gave him great pleasure to do so. Even more importantly, though, he paid weekly visits to the nursing home where his wife spent the terminal five years of her life. “That was our family, doc,” he said. “Most of them have passed on, too, but there’s five or six of them still there. I go sit with them for a few hours every week, and it gives me peace, because it’s where my wife was.”

In many ways, he reminded me of Barepapa, my grandfather – older, balding, his gentle humor laced with a tinge of sass, active and independent. Except Mr. Maddox had managed to retain those traits, while Barepapa progressively lost them in his five-year battle with Alzheimer’s. The similarities interspersed with the stark differences had me holding back tears while I was in the room, but he made it easy to smile with his good-natured acceptance of what was in the pipeline.

I struggled with how my personal experiences overlapped with so many bits and pieces of the patients’ lives throughout the day. Everything I saw and heard went through the filter of my memory – Dr. Slate warned us of it when our day began, yet my emotional vulnerability managed to sneak up on me. Even so, I cannot help but embrace it.

We witness many stages of death in our time on the wards. But the same vulnerability that brings tears to our eyes and a pang to our gut also provides us a lens beyond death to humanity, individuality and conviction. For that, a tender heart is a small price to pay.

"Anyway: I am not blessed or merciful. I'm just me. I've got a job to do and I do it. Listen: even as we're talking, I'm there for old and young, innocent and guilty, those who die together and those who die alone. I'm in cars and boats and planes, in hospitals and forests and abattoirs. For some folks death is a release and for others death is an abomination, a terrible thing. But in the end, I'm there for all of them."

-Death, Sandman #30: "Façade" (Neil Gaiman)

Moment for life

[Disclaimer: All patients appearing in this are fictitious. Any resemblance to real persons, living or dead, is coincidental.]

No week is ordinary on an inpatient psychiatric ward, but this one stood out.

We received notice of her arrival at morning sign-out from the charge nurse. "Mid-20s female with a history of bipolar disorder with psychotic features, self-reported to the psych ER with suicidal ideation and depressed mood. History of depression, self-reported bipolar-affective disorder, drug abuse." With each of those descriptors I added a mental characterization - unstable, psychotic, jaded, distrustful. Then again, a self-reported history of "the bipolar" in Baltimore frequently means no more than a means to a disability check.

Shantel turned out to fit all those descriptors, yet bore little resemblance to the caricature I had painted.

We sat in the cramped conference room for her initial interview, facing off against her over an unforgiving metal table. Her long, tapered fingers beat a staccato rhythm, a conspicuous, irritable edge to her movements. Faint tear marks tracked down her cheeks, bracketing the false bravado in her tremulous smile. She caved in as we introduced ourselves, folding into the hard chair and desperately trying to keep her pride and personhood from shattering against our white coats.

We asked her questions.

"How have you been?"

"Tell us a little bit about yourself."

She twisted her fingers, played with her hair, wove convoluted sentences - stuffing with nothing holding them together.

"I'm eating like I'm pregnant, but I ain't pregnant."

"They got me, but then I went away and they didn't get me anymore, but I read a book and I knew where to go, until I found some apples."

But ten minutes in, when my resident's patience was thinning and I was leaning down to retrieve my pen, Shantel floored me with a sharp look of tempered fear. Her raspy voice tripped over the words, still pressured but ringing with sincerity. "I committed myself. I gotta be better. For me. For my little girl. For them. Else we all get hurt." She sat a few inches taller than me, but as she spoke, she bent with her words, a sapling valiantly fighting its own youth and fragility.

Her wiry frame quivered with her dreams for the future, simple ones - stay safe, be healthy, raise a family - confined by the boundaries of her paper-thin skin and see-sawing psyche. The confession attenuated her hesitation, but not her paranoia, and the rest of our week was filled with the color of her personality and a litany of complaints, both from our staff and our elusive patient.

Shantel keeps flirting with the young male patients.

They hate me. They're putting stuff in my food. It's yellow!

She started gyrating to Nicki Minaj in the common area this morning.

I'm staying in my room today. They keep glaring at me, I can see the devil in their eyes.

None of the contact numbers she initially gave us worked. One was an anonymous voicemail, one was connected to a construction company, and the last was to a sex hotline - an interesting explanation to human resources…

When I finally tracked down the aunt who had raised her, she had one piece of advice for us. "You keep her locked down, you hear? She runs. That's all she knows to do, and she's damn good at it!"

Shantel's elopement history spoke for itself. She was damn good at it. She had escaped from any number of institutions and programs in a 30-mile radius, sometimes repeatedly - by removing AC units, stealing nurses' keys, scrambling through air vent systems, sneaking out on the food cart.

She acted half her age and looked twice it, no insignificant disparity for a woman in her mid-20s. I could have wrapped my fingers twice around her wrist. Her face was gaunt, her cheeks sunken under the weight of her illness and her struggles.

I checked in on her a few times a day. The first time, she set the tone with a warning, "I have a gift where I can see through what people are saying. I was a crack baby." 

"Hey Shantel, how are things going today?"

"Everything hurts - my legs, my calves, my arms."

"Is anything else hurting you?"

"My feelings."

Her childish innocence repeatedly reared its unforgiving head, as if she was checking whether we were paying attention.

"How are you feeling today?"

"I don't feel the sincerity or the loyalty I should."

"We heard from the staff that you wanted to stay in your room today, is everything okay?"

"They act like they're scared or disgusted. They treat me like I'm strange or different, and I don't like that."

"Do you want to hurt yourself or anyone else?"

"I don't know if I want to live or die."

"What do you like to do?"

"I like to write poems, and collect knives."

"Why?"

"Someone hurt me a lot, when I was little. Beat me up. Had sex with me. The poems help my head, and the knives help my body."

The inherent power imbalance in our relationship, she was well aware of. But she never learned the extent to which we had managed to even the scales of knowledge of her past. What we knew of it, we learned from the one call to her aunt, or from the three-inch stack of past records painstakingly obtained from her array of psychiatric visits to dozens of individuals and institutions, a novel in its own right.

But even though we had thousands of scraps of her timeline, they were constantly overlapping, never lining up. The sad truth about inpatient psychiatry, it is a layover toward a final destination. We never had the chance to walk through her past with her. We would have had just enough time to break down her defenses, with none to spare toward building a safety net for the released demons.

In her case, the destination we sought, and her social worker managed to secure, was a housing program for patients requiring psychiatric support. Given her penchant for running, the social worker even ensured door-to-door service. A representative from the program came to accompany Shantel from the locked entrance of the inpatient unit to the watchful eye of the house caretaker.

Three weeks later, our team's social worker flagged me down from the opposite end of a long hallway. The distance felt interminable, watching her face transform from exaggerated attention-seeking to apologetic and pitying. She rarely flagged me down, and even more rarely for good news. I was not hardened enough yet for the news she was about to hesitatingly deliver to me - news I had unknowingly brought upon myself.

"They IDed a Jane Doe on one of the autopsy tables at the morgue yesterday."

She paused. I wonder what my face gave away. Shock? Grief? Resignation? The last one seared through me, an unforgivable burn. I forced myself to prompt her for the name, fingers crossed behind my back and toes crossed inside my shoes. Perhaps hearing it would be my absolution for so readily losing faith.

"Shantel. She ran away."

Her autopsy results were not due back until after my time on the ward completed. But the superficial cause of death was somewhat irrelevant. Ultimately, the driving force would be irreversibly tangled with her mental illness, her drug habit and her naïve immaturity.

I only felt increasingly powerless as the weeks carried forward. Nothing I wanted to take from this experience was helpful to my patients during their fleeting sojourns with us, or so I felt. I still did not have the time to build a meaningful therapeutic relationship with them, did not have the breadth of resources to hold their hands through a torturous walk down memory lane.

What I did learn, albeit indirectly and over a painful month of second-guessing, was the power of the psych ER and the inpatient ward as a front line of defense. For all that it felt like we were failing our patients, we served another purpose - tracking them to the long-term therapy that would help rehabilitate them. Maybe we gave Shantel a few extra weeks she may not have had otherwise. Maybe in the time she spent with us, we validated her experiences and her sense of self.

Our profession finds mileage in the weightlessness of hope. Perhaps even more so in a field where the damages born are invisible and the wounds take years to scar. 

Noose of suspicion

“I prefer credulity to skepticism and cynicism for there is more promise in almost anything than in nothing at all." - Ralph Perry

Friday afternoon of Grand Prix weekend. The city mayor has issued a decree - all persons found prone on the streets of the city are to be transported by ambo to the nearest hospital within two miles headed away from the racing streets. The rule seemed laughable at the time. Prone persons in the city streets? The ERs would be flooded.

Our patient lucked out, thanks to the decree. The circumstances of her pick-up and arrival were unclear, but since she was nearly full-term in pregnancy, she wound up in L&D's triage, completely unconscious and unarousable. Paramedics must have found an ID, because we had a name, leading to scant records in the system from a past ER visit or two, but little else. No prenatal records, because she didn't see any of our hospital-affiliated OB's for care. No significant demographic or psychosocial information. A mystery heightened by her incapacitated state.

Concern was mounting, however, because her baby was as unresponsive on its heart monitor as she was, and so the debates began. How long did we wait for the baby to wake up before we took her for an emergency c-section? How long did we wait for the mother to wake up and face our inquisition? Should we attempt an overdose-reversing therapy in the interim?

She had no autonomy of decision, because she was asleep and had no advocates, no one we could track down. She had a nurse who was increasingly concerned for the baby. She had a resident who was convinced she was a druggie, intent on getting a high even if it meant screwing her baby over along the way. She had another resident with a cool head, patience and an iota of faith. And all this before she awoke and had a chance to speak even a word in her own defense - not that it made a difference even when she did.

Resident #1 kept evolving her own opinions without ever meeting the patient. Meanwhile, the nurse, resident #2 and I spent 45 minutes trying to stimulate the infant on the monitor and on ultrasound. We managed to engage the patient in spurts of awareness, and piece together haphazard segments of her last 12 hours. Her urine toxicology came back positive for a handful of things, some of which she fessed up to and others that elicited a palpable, visceral shock.

Her grip came to bear on my wrist as tightly as the fetal heart monitor snapped around her abdomen, almost cutting off circulation. What was wrong with her baby? What had she done? In the months of her struggle with psychiatric issues, staying off medication to avoid harm to her baby; in the months of abandonment by her family; in the months of terror, tears and confusion; she had lost her way, more helpless than willfully destructive. And here in the hospital, where she should have been able to expect support and unbiased care, she had to fight not only against her psyche, but also against the ill-informed preconceptions of her own caretakers.

Even as mom woke up and became increasingly aware of her situation, the baby insisted on sleeping in, and eventually dragged its mom into the OR for an emergency c-section. Medically speaking, the situation ended as positively as one could hope - the c-section proceeded without any complications, and the baby came out looking fantastically healthy and alert. Now mom was left to deal with the fall-out, with the questions from social work and CPS.

Everyone was predisposed to believe the worst. Clearly she was a drug-addled woman, unfit to be a mother, callous to her baby's needs, constantly on the prowl for the next high. Never mind that she was scared to death of the possible harm she had caused her kid. Never mind that she was terrified of losing her baby to the system. Never mind that she felt demeaned because no one had the courtesy to treat her like a person and keep her informed - the most basic of courtesies, one could argue, when we hold all the cards and she holds none.

Who will advocate for her? The nurse who is annoyed by the barrage of questions from a perceived irresponsible mother? The staff who discount her incisional pain as the lure of a drug seeker?

I only have unfounded theories about what fosters this unshakable suspicion. Some have probably been burned countless times in the past for giving the benefit of the doubt, and having patients take advantage of their empathy. Some have lost their integrity of faith, maybe had it beaten out of them by the job or job culture. Some are just predisposed to cynicism from the beginning, and they are perhaps the ones we can never sway. I keep hoping I can find the necrosed root and chop it off, even while recognizing it's an impossible feat. At the least, I hope nothing can quash my idealism, however naïve it may prove to be.

Never have I felt this frustration more keenly. We have all, since starting med school, dreamed of the day when we are capable of assisting the nurses, putting in orders, answering patients' queries, and have constantly felt the pang of disappointment when we cannot fulfill any of those. But for the first time this weekend, I felt the hollow sink of failure, confusion from standing alone in my opinion of my patient's needs.

Was I a sucker for empathizing with her helplessness, for believing in her commitment to love and nurture her child? Honestly, the answer to that question is irrelevant.

This job is not easy. Of all the patients we will meet who struggle with addiction, probably 80 percent of them will attempt to exploit us for pain killers. To some degree, they cannot help it, nor can they recognize their helplessness; that task falls to us. Of that 80 percent, maybe 60 percent will claim they want to quit, they need help. And of that 60 percent, maybe 10 percent will mean it. It might start with 2 days clean, then 2 weeks, and for a handful of them, maybe it will graduate to 2 years, or even 20.

But we have no way of knowing who that handful will be, and who are we to project a perceived fate onto anyone? That falls outside of our purview.

We should be the torchbearers of faith, believing that any person walking through our doors could be among the handful. And if we nurture them as such, maybe that handful will grow. If we lose faith in them, who will they hang their dreams on? 

Sworn in

Yesterday, I received my stethoscope in the mail. Today marks the two-week point since our White Coat Ceremony (shout-out to Dr. Lovering!). And this got me thinking.

One of my absolute favorite ICM sessions to date was the one a week before our ceremony, when we read through and discussed the various medical oaths that have come down through the centuries. Our profession is infused with a rich, inspiring history that brings with it the heavy weight of responsibility -- that day, we got a chance to touch on a small fraction of it.

I marked up my copies of the passages, but I just wanted to put down my thoughts on the parts that resonated the most. So, chronological order.

Hippocrates' Oath

Hippocrates, in the late 5th century B.C., set down many of the most basic tenets of medicine that we now take for granted. He swore his responsibility holding the Greek gods as witnesses. He stressed the familial/brotherhood aspect of medicine, and the importance of passing knowledge down to the next generation of disciples. His oath implied a separation between the art of medicine and the art of surgery. The oath introduced the concept of patient confidentiality. But most interestingly, in my opinion, was his very last sentence:

"If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

He didn't settle for, oh, if I do right, I'll do okay in life, but also stressed, should I do wrong, I should suffer the consequences of the violation of my responsibility. I think that idea, while not completely lost in the revisions and versions that came later, wasn't stressed quite as much as it was here, in Hippocrates' writing.

Oath of Maimonides

Maimonides, a Jewish physician and philosopher, also invoked his faith in his oath, written in the 12th century. He brought in another crucially important idea in practicing medicine: "May I never see in the patient anything but a fellow creature in pain." I can't speak from extensive personal experience, but from what I've heard and what little I have seen, this idea sometimes is forgotten in our over-eagerness to 'fix what's wrong' with our patient, and is often difficult to face. Another stigmatized idea Maimonides made mention of is admitting that yes, even doctors make mistakes. We can't afford to freeze up in face of them, but must learn, internalize, and carry forward.

Nightingale Pledge

A pledge first taken by nurses in 1893, named after Florence Nightingale, it made mention of something I don't think was quite as explicitly mentioned in any of the other oaths. Hippocrates did make mention of not administering deadly drugs to one's patients. This pledge, however, stressed neither taking nor giving any harmful drugs, acknowledging a medical practitioner's responsibility to both self and patient. It was strange to see that the pledge didn't make explicit mention of the 'art of nursing,' so to speak, the warmth that is often associated with it.

Declaration of Geneva

The Declaration of Geneva was first written and adopted by the World Medical Association in 1948. I suppose because it was an obviously international document, it more explicitly acknowledged issues of discrimination across many lines -- religion, race, nationality, political affiliation, social status, none should come between the doctor and his/her patient. This was also the second of our selection of oaths that included anti-abortion sentiments, after Hippocrates', which I suppose given the timeframes makes sense. 

Oath of Louis Lasagna

This one was by far my favorite of the oaths. Louis Lasagna put out a revision of the Hippocratic Oath in 1964, and injected a bit of quiet humor and poetry into his comprehensive breakdown. He acknowledged ongoing research in medicine and stressed avoiding the "twin traps of overtreatment and therapeutic nihilism." Lasagna wrote of the art and science of medicine, of speaking to patients regarding matters of life and death, taking care not to play God with a patient's life, remembering that you are treating a sick human being, that prevention is preferable to curing, and that we now are joining the ranks of a society that carries many an obligation. But most important, I think, is his hope to never lose the "joy of healing."

Student Oath

The student oath we read at our White Coat Ceremony was an amalgamation of many of these oaths, and incorporated almost all of the elements I most admired in the other oaths we read through. Wearing my shiny new white coat, I stood holding a sheet of paper full of words that grew heavier in the air as I breathed life into them anew, along with the rest of my class. As I reached the end of the oath, I felt the weight of those words settle from the air onto my shoulders, woven into the seams as tightly as they were into my psyche.

And it feels simultaneously humbling and thrilling.

Origins and Orientation

Until I've caught up on the first 1.5 weeks of orientation and 4.5 weeks of medical school, this will still seem too disorganized to me. Thankfully, probably no one other than me will care. So, as the saying goes: Let's take it from the top!

ORIENTATION (8/12/10 - 8/20/10)

The very first lecture I had in med school has easily been the most inspiring one so far: "What does it mean to be a physician/healer?" given by Dr. Richard Colgan. He spoke to us about the history of medicine, the art of healing, and a slew of thoughts for me to come back to for the rest of my career. It sounds cheesy and exaggerated, but it isn't at all.

We learned about many medical greats, most of whom I admit I hadn't heard of before, but I haven't been interested in history until now, so I suppose that comes as no surprise.

Hippocrates: First do no harm

Sir William Ostler: Equanimity and imperturbability

Francis Well Peabody: 'For the secret of the care of a patient is in caring for the patient'

William Carlos Williams: One of the best trainings you can have as a writer is to be a physician - people will tell you the most intimate details of their lives that they may never have told anyone else before and won't tell anyone else again

Theodore Woodward: 'Don't be a slip doctor'

Dr. Kalia (sp?): 'When you're not sure what to do, remember: focus on the patient'

Dr. Colgan: 'What does it mean to be a healer? Smart. Philosopher. Loved and hated. Case worker. Patient's advocate. Respect and disdain. Accountable. Challenged.'

I only wrote up tidbits from a handful (the ones I managed to scribble down legible quotes for), but the talk, the history, was inspiring in its entirety. The rest of the talks were well and good, but nothing quite stood out the same way, with the same relevance and gravity.

A couple of days later, we were introduced to the wonders of the MASTRI center, which is the simulation lab on the UMB campus. The traditional saying in medicine, especially regarding surgery, goes: "See one, do one, teach one." As the MASTRI tech put it, "See one, simulate many, do one, simulate some more, and then maybe you can hopefully teach one." After watching a couple of fellow classmates take a shot at simulated gall bladder removal, all I can say is, I'm definitely hoping.

Next up, medical ethics. This is an area I've always been very interested in, but my undergraduate schedule conspired against me whenever I tried to take a class in it. It focused more on breadth than depth, but even the brief overviews gave plenty of food for thought.

Four approaches:

1. Utilitarian philosophy - end justifies the means
2. "Rules" - No matter what good you might do by breaking the rules, you must always follow the rules
3. Virtue ethics - do you act virtuously?

4. Case-based decision-making - can you do each case on an individual basis?

Four principles:

1. Beneficence - doing good
   Nonmalificence - or at least, do no harm
   Should this be put above all else?

2. Autonomy - patient has a right to drive their own info, make their decisions, etc.
3. Justice/equity - should be some rough justice with how patients are treated

4. Integrity - of us individually and of the system

Of course, the complications arise in how you apply these approaches and principles. What happens if they conflict? What if you and your superiors don't see eye to eye? Or you and the family? You and the patient? Where do you draw the line at determining whether a patient is of danger to him/herself? How much responsibility can you assume in the doctor-patient relationship? There are so many more questions, but I have no basis to evaluate them on right now, so this will definitely be revisited.

Also, Dr. Mallott is a fantastic speaker. Just for kicks: "One day, my kids asked me, 'What do you do?' This is when I was in the in-patient psych ward at the hospital. 'Mostly I deprive people of their civil rights.'" -Dr. Mallott

Sometime after, we had career counseling with Dr. Martinez, another fantastic speaker, super-cool guy, and his presentation was simultaneously informative, nerve-inducing, and reassuring. Don't ask me how he pulled all of those off together, but he did. He threw a bunch of career ideas and summer opportunities at us, then promptly forbade us from thinking on it until after the first exam. Mostly, he left us with: "Learn to be comfortable with being uncomfortable." Yessir!

There were a few other highlights, too. The fashion show was entertaining, though I was heartbroken to learn I could no longer take my exams in my wallowing sweatpants. Also, tragedy of all tragedies, I don't have a sewing machine. Dr. Dolan held a talk on study tips and academic counseling with Dr. Keller, which gave us some vague ideas on how to kick our first week off right.

I think that closes out orientation week. Somewhere in the midst of all that, on the 15th, I made my first foray into having a 'thought of the day' (which I subsequently abandoned for a week). Here it is again:

 It's finally starting to hit me, the weight of responsibility that promises to grow heavier with each passing day, every ounce of knowledge. The idea is too much to wrap my head around.

It occurs to me that it might come across as defeatist, which was entirely NOT the idea behind it. In fact, that very weight and enormity is incredibly galvanizing, almost uplifting, and I hope it remains to be so.