I can finally say that my surgical residency is a thing of the past. As the months of my chief year flew by, I was surprised to find myself dreading the change I had been waiting for so long. For five years, my life was entirely predictable. Every year was divided into 12 blocks of rotations, every rotation made up of 4 weeks of the same cycle of attendings, surgeries, and calls. I didn't have the luxury or responsibility of deciding much, other than performing to the best of my ability as a resident. My precious little free time was spent chasing after my toddler, trying to find balance and make the most of our time together.
As residency wound down, I realized that my 5 years of predictability would also change--not just the structure of my days, weeks, months and years, but also what is expected of me as a mother, wife, daughter, surgeon and human being. What I expect of myself.
In residency, I never liked to blame my schedule for my shortcomings in those important life roles. It was an easy out, one that most of my family (doctors) and friends (doctors) would understand. Everyone knows how hard surgical residents work, although my dad's generation of surgeons would argue vehemently that we don't work hard enough (cue the grumbling, "those millenials..."). My absence at important family events and failure to contribute to the lives of those that I love the most was simply understood all this time. And I don't just mean the 5 years of residency, because the 6 years leading up to it were just as all-consuming in different ways. It takes a LOT of love and support poured into one human being to become a surgeon, and with my family's help I had the world lifting me up.
But even though my family and friends always understood my relative absence in their lives, the gnawing feeling of unfulfilled duty and inability to express my love from afar did not abate. My mind drifts to my beloved grandfather's funeral, which I missed as a junior resident because I was on night float. I came the following weekend, but couldn't help feeling it was too little, too late.
Nor was I there to help my mother and sister care for my father when he suffered a heart attack last year. Again, I did what I could to fulfill my duties as a resident and as a daughter, rearranging the call schedule to be there the next day when he came home from the hospital. By that time, thank God, he was fine--but again, the critical moment of need and togetherness had passed.
I could go on with the stories of things I missed, big and small--these are just two. Sometimes it isn't the big events, but the small ones. I think of those also with a lump in my throat--the moments of bringing my mom tea in bed, philosophizing with my dad in the early mornings, or stroking my sister's hair when she needs an ear or a shoulder as she takes care of the entire world.
I was raised to achieve academic excellence. This was the goal from as far back as I remember. My parents taught me strong values, of course. Charity, honesty and integrity were of utmost importance. But to gain knowledge and degrees were, unmistakably, the measure of one's worth. I internalized this more than I realized.
As I reflect, I find myself now, an MD MPH, not beaming with pride and puffing my chest, but instead with some trepidation as I try to make sense of what I've become, and how to get to where I want to go.
My mentor once told me, frustrated with my self-deprecation, "You never seemed quite settled in residency." It's true, I was always unsettled. I'm still unsettled. Another wise attending told me frequently in the operating room, "You have to know what you don't know". And this is why I'm unsettled. Whatever I have accomplished by the grace of God--that is the known. It doesn't matter much anymore. Perhaps I devalue it too much--I appreciate what I've been so fortunate to be able to do--but it is the past, and there is too much future, too much unknown, too much undone, to feel settled.
Perhaps the biggest surprise, to me, as I finish residency and start this new chapter, is that the unknown is not necessarily another academic achievement. The unknown I set out to discover now is entirely different, though entirely the same. I have taken so much--climbed hungrily on the shoulders of my family, my friends, and my teachers. It is my turn now to give, to be the shoulders on which others climb, to build a foundation upon which others can rise up to reach their dreams.
As I start this new adventure, this is the achievement I strive for, for my family, my friends, my patients, and anyone I encounter. There is no degree, trophy or PubMed ID for it, and it does not go on a resume, but it's more rewarding than anything else I can imagine.
Sunday, July 10, 2016
Saturday, January 3, 2015
It has been ages since I last updated this blog, so it’s time to catch up. Many of the thoughts and concerns that used to fill my head have changed dramatically, but some have not. My tireless drive to be the best doctor and surgeon I can be have not changed, but the demands that temper that drive have.
For one thing, this happened:
And that’s pretty much all it took to turn my world on its side. In a good way, but a sleepy way (note dark circles under eyes during maternity leave aka “vacation”). If I thought I was tired, worn out, hardworking, or efficient as a surgery resident, I was wrong until I added the word mom to that title. Entirely different story.
I was blissfully unaware of what was in store for me as a mother, despite 10 months of pregnancy to prepare for it. I wasn’t the kind of pregnant person who reads books on parenting or goes to labor classes. I treated my pregnancy as a slight annoyance to my everyday job as a surgery resident, and gave it the least possible attention it deserved to make sure the little alien growing inside was healthy (despite me, really, not because of me). It wasn’t that I was not excited about the baby, or that I was willfully neglectful—I simply didn’t have the time or energy to prioritize both the baby and my job.
Flash forward 3 months after giving birth, and that attitude is a distant luxury. As are the few indulgent things I used to do in my free time before baby—go to the gym (or even belong to the gym), get a pedicure (or cut my nails at all), eat a warm meal instead of two protein bars…and the list goes on. The mommy instinct kicked in full force immediately after Baby K was born, and after a short 6 weeks of leave I found myself with two equally demanding jobs. Neither of which I could shortchange (somehow Baby K’s physical presence in my arms makes him easier to prioritze than his little kicks in my belly). I briefly toyed with the idea of formula feeding to save myself 6 pump sessions per day, but could not reconcile giving Baby anything less than the best unless it was not humanly possible (and isn’t everything humanly possible, at a cost?). I also (very) briefly fantasized about putting off residency to do one important thing at a time, but that wouldn’t work either. The only thing to do was burn the candle at both ends.
5 weeks back at work, I am incredibly thankful to say that I have started to get a bit more sleep, I’m getting back into my groove at work, my milk supply has not diminished, and baby is doing fine. I have not been fired from work for any fatal sleepless mistake or surgical complication, as much as I dreaded that possibility at first. I am a little worse for wear, as the mental, physical and emotional price of mommyhood during surgery residency (or vice versa) is higher than I ever thought possible. Maybe that’s because I’ve had an easy life so far, and not because the burden is great. But either way, I am adapting—I have learned to take pleasure in things like making my lunch every day and how many ounces of milk I pumped, rather than how long I was able to spend at the gym or the nice dinner reservation I have coming up. It is not lost on me that this is an incredibly precious time of my baby’s life, and I intend to savor every minute I am with him despite other demands.
The other demands, however, are no small thing. Residency is long hours and long years—at the age of 32, I still have 1.5 years left of residency and 2 years of fellowship left to become a vascular surgeon. And then I can finally START to establish a career at the ripe old age of 35. During this time, I am supposed to be acquiring as much knowledge and experience as I can in between working 80-100 hours a week in order to become the very best doctor and surgeon I can be. This is the foundation for a lifetime of service to my future patients. A sobering thought, when I now spend so much of that precious time on baby things, whether it’s pumping, feeding, bonding, or playing. And what happens when he gets a bit older and demands even more of my time and energy?
I don’t have a solution to this problem yet. I have never felt so distinctly FEMALE (as a negative thing) as I did when I stepped back into the hospital my first day after maternity leave—figuring out how to pump in between cases, acting as chief resident on half a brain, operating for the first time in weeks, and generally feeling so out of place at work. Over time, the feeling has become less acute, but it manifests itself in different ways—that chapter I wanted to read but didn’t have time for, the manuscript revision I am not actively working on, the academic meeting I can’t attend because I took maternity leave. How much of my insecurity as a new mommy (both in mommyhood and residencyhood) is perceived and how much is real? I don’t know, and I don’t know that it matters. It’s there. I can only hope that I find my footing, and in the process, learn to be the best mommy and surgeon I can be.
For one thing, this happened:
And that’s pretty much all it took to turn my world on its side. In a good way, but a sleepy way (note dark circles under eyes during maternity leave aka “vacation”). If I thought I was tired, worn out, hardworking, or efficient as a surgery resident, I was wrong until I added the word mom to that title. Entirely different story.
I was blissfully unaware of what was in store for me as a mother, despite 10 months of pregnancy to prepare for it. I wasn’t the kind of pregnant person who reads books on parenting or goes to labor classes. I treated my pregnancy as a slight annoyance to my everyday job as a surgery resident, and gave it the least possible attention it deserved to make sure the little alien growing inside was healthy (despite me, really, not because of me). It wasn’t that I was not excited about the baby, or that I was willfully neglectful—I simply didn’t have the time or energy to prioritize both the baby and my job.
Flash forward 3 months after giving birth, and that attitude is a distant luxury. As are the few indulgent things I used to do in my free time before baby—go to the gym (or even belong to the gym), get a pedicure (or cut my nails at all), eat a warm meal instead of two protein bars…and the list goes on. The mommy instinct kicked in full force immediately after Baby K was born, and after a short 6 weeks of leave I found myself with two equally demanding jobs. Neither of which I could shortchange (somehow Baby K’s physical presence in my arms makes him easier to prioritze than his little kicks in my belly). I briefly toyed with the idea of formula feeding to save myself 6 pump sessions per day, but could not reconcile giving Baby anything less than the best unless it was not humanly possible (and isn’t everything humanly possible, at a cost?). I also (very) briefly fantasized about putting off residency to do one important thing at a time, but that wouldn’t work either. The only thing to do was burn the candle at both ends.
5 weeks back at work, I am incredibly thankful to say that I have started to get a bit more sleep, I’m getting back into my groove at work, my milk supply has not diminished, and baby is doing fine. I have not been fired from work for any fatal sleepless mistake or surgical complication, as much as I dreaded that possibility at first. I am a little worse for wear, as the mental, physical and emotional price of mommyhood during surgery residency (or vice versa) is higher than I ever thought possible. Maybe that’s because I’ve had an easy life so far, and not because the burden is great. But either way, I am adapting—I have learned to take pleasure in things like making my lunch every day and how many ounces of milk I pumped, rather than how long I was able to spend at the gym or the nice dinner reservation I have coming up. It is not lost on me that this is an incredibly precious time of my baby’s life, and I intend to savor every minute I am with him despite other demands.
The other demands, however, are no small thing. Residency is long hours and long years—at the age of 32, I still have 1.5 years left of residency and 2 years of fellowship left to become a vascular surgeon. And then I can finally START to establish a career at the ripe old age of 35. During this time, I am supposed to be acquiring as much knowledge and experience as I can in between working 80-100 hours a week in order to become the very best doctor and surgeon I can be. This is the foundation for a lifetime of service to my future patients. A sobering thought, when I now spend so much of that precious time on baby things, whether it’s pumping, feeding, bonding, or playing. And what happens when he gets a bit older and demands even more of my time and energy?
I don’t have a solution to this problem yet. I have never felt so distinctly FEMALE (as a negative thing) as I did when I stepped back into the hospital my first day after maternity leave—figuring out how to pump in between cases, acting as chief resident on half a brain, operating for the first time in weeks, and generally feeling so out of place at work. Over time, the feeling has become less acute, but it manifests itself in different ways—that chapter I wanted to read but didn’t have time for, the manuscript revision I am not actively working on, the academic meeting I can’t attend because I took maternity leave. How much of my insecurity as a new mommy (both in mommyhood and residencyhood) is perceived and how much is real? I don’t know, and I don’t know that it matters. It’s there. I can only hope that I find my footing, and in the process, learn to be the best mommy and surgeon I can be.
Sunday, June 8, 2014
Work in progress
As we come to the end of another academic year, I find myself two weeks away from my first chief call as a surgery resident. 40% prepared and 60% terrified, I am excited about the new level of responsibility but concerned about making the right decision for critically ill patients in the middle of the night. Of course, I won't be alone, but the decision to call for attending help will rest on my judgment.
Preparing for the transition, I recall our chief academic officer's introductory speech on my first day of residency as a fresh intern. "Welcome to residency!" he said. "It's gonna go by really fast, in a slow kind of way." So true--wasn't i just that fresh intern bumbling around? Another truth: "Don't expect to be comfortable. In fact, I hope you are never comfortable in residency." At the time, I didn't know exactly what he meant, but I have come to realize that despite the wretched feeling of inadequacy it brings, this is what I love about medicine in general, surgery in particular, and the vascular specialty specifically.
It has never been my personality to be cocky or arrogant. I am not bragging about my own humility--I have seen how far a little swagger can take you in life but I just don't have it. What brings me the most satisfaction is figuring out how to do something better than I'm currently doing it. This started with my junior tennis career, and a brilliant coach who would videotape each of my strokes and then painstakingly review the mechanics of my serve, forehand, and backhand to see how we could improve them. The lesson there was to keep perfecting my technique--not just to beat someone else (although that was the ultimate goal) but to be MY very best. It was a loftier goal than being #1 on the circuit, and something truly worth achieving. Of course, it can be painful and humiliating to learn your own shortcomings, and I learn them on a daily basis, but it is also most rewarding when you can tackle those shortcomings head on and come to a better place. That process is built into the career of surgery. Uncomfortable? Yes, but I never thought I was perfect anyway, and am far more content to see myself as a work in progress.
One of the greatest joys in my life is that I was able to continue this journey of perfecting my technique in the far more rewarding career (for me) of medicine. I wish I had a mentor like my tennis coach who cared enough about my technique on femoral exposures and vascular anastomoses to criticize every poor move. Isn't the whole point to be technically perfect? Of course, the onus is on me to learn my own best practices, but as a third year resident, I am still an apprentice. And the mechanics of a aortofemoral bypass anastomosis are surely far more important than the mechanics of my forehand, right?
Another turning point as third year comes to an end is the choice of a specialty. Vascular surgery has been my passion since I started residency, yet the acuity, lifestyle and lack of mentorship have made me question this choice. Until recently, I have strived to be on the academic fast track of publishing papers, presenting at meetings, and building my resume. But the realization of missing eight years of my family's life (it will be twelve once I'm done with fellowship) and a baby on the way have made me truly question my choice to become a vascular surgeon. What is the point of being a fancy surgeon when you haven't shared in the joys and trials of your family's life? When you cannot answer your sister's calls in the middle of the day, or help your mom plan her trip to Spain? Or even be emotionally present enough after work to enjoy an evening with your husband? And so many other things that fall by the wayside when you work 80-100 hours a week.
I have thought carefully about what I have given up, and what I will continue to give up in my life, for this career. While surgery will never surpass my faith and family in importance, it will, for a time, take up a lot of my time. But I figure I owe it to my patients to do what I truly love, what I can stay up all night reading about to help them, what I literally ache to do. Maybe there are people who can walk away from a career they truly love in order to be more available to their families--and maybe those people are just better people than me. But this is right for me. I need a career that challenges me, makes me uncomfortable, makes me look at myself twice and think about how to be my best and do my best for the patient in front of me. That career is vascular surgery. The list of priorities is the same, and I have faith that I will mold my career to reflect those priorities better than I am able to now.
I'm still a work in progress, for sure, but for the moment, it feels good to have this little bit figured out. And as the years pass, I'm getting ever so slightly comfortable with being uncomfortable.
Preparing for the transition, I recall our chief academic officer's introductory speech on my first day of residency as a fresh intern. "Welcome to residency!" he said. "It's gonna go by really fast, in a slow kind of way." So true--wasn't i just that fresh intern bumbling around? Another truth: "Don't expect to be comfortable. In fact, I hope you are never comfortable in residency." At the time, I didn't know exactly what he meant, but I have come to realize that despite the wretched feeling of inadequacy it brings, this is what I love about medicine in general, surgery in particular, and the vascular specialty specifically.
It has never been my personality to be cocky or arrogant. I am not bragging about my own humility--I have seen how far a little swagger can take you in life but I just don't have it. What brings me the most satisfaction is figuring out how to do something better than I'm currently doing it. This started with my junior tennis career, and a brilliant coach who would videotape each of my strokes and then painstakingly review the mechanics of my serve, forehand, and backhand to see how we could improve them. The lesson there was to keep perfecting my technique--not just to beat someone else (although that was the ultimate goal) but to be MY very best. It was a loftier goal than being #1 on the circuit, and something truly worth achieving. Of course, it can be painful and humiliating to learn your own shortcomings, and I learn them on a daily basis, but it is also most rewarding when you can tackle those shortcomings head on and come to a better place. That process is built into the career of surgery. Uncomfortable? Yes, but I never thought I was perfect anyway, and am far more content to see myself as a work in progress.
One of the greatest joys in my life is that I was able to continue this journey of perfecting my technique in the far more rewarding career (for me) of medicine. I wish I had a mentor like my tennis coach who cared enough about my technique on femoral exposures and vascular anastomoses to criticize every poor move. Isn't the whole point to be technically perfect? Of course, the onus is on me to learn my own best practices, but as a third year resident, I am still an apprentice. And the mechanics of a aortofemoral bypass anastomosis are surely far more important than the mechanics of my forehand, right?
Another turning point as third year comes to an end is the choice of a specialty. Vascular surgery has been my passion since I started residency, yet the acuity, lifestyle and lack of mentorship have made me question this choice. Until recently, I have strived to be on the academic fast track of publishing papers, presenting at meetings, and building my resume. But the realization of missing eight years of my family's life (it will be twelve once I'm done with fellowship) and a baby on the way have made me truly question my choice to become a vascular surgeon. What is the point of being a fancy surgeon when you haven't shared in the joys and trials of your family's life? When you cannot answer your sister's calls in the middle of the day, or help your mom plan her trip to Spain? Or even be emotionally present enough after work to enjoy an evening with your husband? And so many other things that fall by the wayside when you work 80-100 hours a week.
I have thought carefully about what I have given up, and what I will continue to give up in my life, for this career. While surgery will never surpass my faith and family in importance, it will, for a time, take up a lot of my time. But I figure I owe it to my patients to do what I truly love, what I can stay up all night reading about to help them, what I literally ache to do. Maybe there are people who can walk away from a career they truly love in order to be more available to their families--and maybe those people are just better people than me. But this is right for me. I need a career that challenges me, makes me uncomfortable, makes me look at myself twice and think about how to be my best and do my best for the patient in front of me. That career is vascular surgery. The list of priorities is the same, and I have faith that I will mold my career to reflect those priorities better than I am able to now.
I'm still a work in progress, for sure, but for the moment, it feels good to have this little bit figured out. And as the years pass, I'm getting ever so slightly comfortable with being uncomfortable.
Saturday, November 2, 2013
Rage against the machine
It’s my third year of surgery residency. I enter Starbucks in a flurry, a carefully timed practice designed to enter the store just after it opens and to exit just in time to be at work 3 minutes early. I grab the coffee, letting the piping hot liquid splash onto my hand a little as I use the other hand to snatch two sugars. As I tear open the packets and pour, the other hand reaches for a stirrer. Stirring with one hand, the other grabs the sippy top and I am back in my car 4 minutes later, racing down Broad to the hospital. One-handed, of course.
Surgeons are naturally impatient people, and the business demands of health care only encourage a sense of urgency. Amidst the piles of dictations and paperwork every doctor battles, surgeons must also spend a great deal of life in a sterile bubble where multi-tasking is impossible. Being efficient becomes even more vital, and benign tasks become unnecessarily stressful. The sense of urgency transfers to everyone and everything involved, both inside and outside the hospital.
Efficiency is key. No matter how efficient you are, you can always be more efficient. My mentors often remind me in the operating room that I have two hands, and they should both be doing something useful at any given point in the case. This dogma is not limited to the operating room, hence the coffee routine.
On morning rounds, for instance, seeing fifteen surgical patients and dressing their wounds in an hour is a perfectly calculated science. A quick squirt of hand sanitizer is followed by flipping the lights on, apologizing for the light, and making a beeline for the surgical wound/abdomen. One hand opens the gauze while the other rips off the patient’s previous dressing. Fresh gauze replaces the soiled one as the other hand reaches for tape. Pulling tape is, alas, a two-hand job, so for the moment both hands reluctantly work in tandem. This frenzied orchestra occurs amidst a rushed conversation with the patient during which time an attempt is made to display true concern for his/her well-being under five minutes while trying to extract three distinct pieces of information: 1) whether diet is tolerated, 2) whether gas or poop has exited the rectum and 3) whether pain is controlled. This process is repeated over the course of 60 minutes. Hand sanitizer, lights on, gloves, feel belly, change dressing, extract information, lights off, gloves off, hand sanitizer. Next.
Efficiency is not limited to the hospital. Coming home is also a premeditated sequence. My parking lot, located three short blocks from my apartment building, is a daily waste of time. I usually jog the distance--not because I need the exercise, but because it is faster than walking. Meanwhile, I survey the streets hoping no one I know is witnessing my exhausted lunatic shuffle. Once in the elevator, I shake off my white coat, poised to exit and walk down the hallway to my apartment (I have the decency to walk when others are in such close proximity). Entering the door is followed swiftly by hurling my bag, jacket and shoes to their designated corner. Conversations with my husband generally occur from a distance, because I can only prepare something to eat, wash up, or check emails if I’m not spending time with a face-to-face interaction. Sitting on the couch with him is similarly avoided as it carries the hazard of hearing about his day or sharing the details of mine, both of which are low-yield as the events have already been digested independently.
The day is filled with similar repetitive motions that are boiled down to a number of steps directed toward accomplishing mundane tasks. There is nothing mundane about surgery, but despite the excitement and variability of each patient, the algorithm remains the same. I am forever trying to get ahead of myself, trying to check the next thing off on the to-do list, striving to save up a pocket of time to breathe. Yet when the pocket of time arrives, I'm still jogging. The ridiculousness of this approach lies in its lack of humanity. When did I forget that the whole point of being a doctor was to get to know people’s suffering, to really get to know it, to reach into the bowels of it (no pun intended) with the intent to remove it forever? As idealistic as that dream was, there was some dignity to it, and what do we have to stand on if not the dignity of bright-eyed idealism?
Everyone in medical school urged me not to go into surgery because it would change me. I told them (and still do) that was impossible. During my first year of surgery residency, when colleagues found me nice, again they pleaded with me not to change. Two years later, I am still the same person (just last week, a medical student observing our veritable zoo of personalities urged me to "never change."). But in so many ways I have succumbed to what I was so fervently warned me about and what I myself so intently dislike. When did I forget that walking a few blocks was the perfect amount of time to stop and breathe fresh air? When did people become less important to me than tasks? Weren’t the tasks in place to serve the people? I love my patients. I love their faces, their personalities, their suffering, their disease process and their healing process. I can’t wait to one day have patients of my own, who I see in my office and hold hands with through the hardship of surgical disease. A cloying sentiment, surely, and certainly not an efficient one. So maybe there’s hope for me yet.
Surgeons are naturally impatient people, and the business demands of health care only encourage a sense of urgency. Amidst the piles of dictations and paperwork every doctor battles, surgeons must also spend a great deal of life in a sterile bubble where multi-tasking is impossible. Being efficient becomes even more vital, and benign tasks become unnecessarily stressful. The sense of urgency transfers to everyone and everything involved, both inside and outside the hospital.
Efficiency is key. No matter how efficient you are, you can always be more efficient. My mentors often remind me in the operating room that I have two hands, and they should both be doing something useful at any given point in the case. This dogma is not limited to the operating room, hence the coffee routine.
On morning rounds, for instance, seeing fifteen surgical patients and dressing their wounds in an hour is a perfectly calculated science. A quick squirt of hand sanitizer is followed by flipping the lights on, apologizing for the light, and making a beeline for the surgical wound/abdomen. One hand opens the gauze while the other rips off the patient’s previous dressing. Fresh gauze replaces the soiled one as the other hand reaches for tape. Pulling tape is, alas, a two-hand job, so for the moment both hands reluctantly work in tandem. This frenzied orchestra occurs amidst a rushed conversation with the patient during which time an attempt is made to display true concern for his/her well-being under five minutes while trying to extract three distinct pieces of information: 1) whether diet is tolerated, 2) whether gas or poop has exited the rectum and 3) whether pain is controlled. This process is repeated over the course of 60 minutes. Hand sanitizer, lights on, gloves, feel belly, change dressing, extract information, lights off, gloves off, hand sanitizer. Next.
Efficiency is not limited to the hospital. Coming home is also a premeditated sequence. My parking lot, located three short blocks from my apartment building, is a daily waste of time. I usually jog the distance--not because I need the exercise, but because it is faster than walking. Meanwhile, I survey the streets hoping no one I know is witnessing my exhausted lunatic shuffle. Once in the elevator, I shake off my white coat, poised to exit and walk down the hallway to my apartment (I have the decency to walk when others are in such close proximity). Entering the door is followed swiftly by hurling my bag, jacket and shoes to their designated corner. Conversations with my husband generally occur from a distance, because I can only prepare something to eat, wash up, or check emails if I’m not spending time with a face-to-face interaction. Sitting on the couch with him is similarly avoided as it carries the hazard of hearing about his day or sharing the details of mine, both of which are low-yield as the events have already been digested independently.
The day is filled with similar repetitive motions that are boiled down to a number of steps directed toward accomplishing mundane tasks. There is nothing mundane about surgery, but despite the excitement and variability of each patient, the algorithm remains the same. I am forever trying to get ahead of myself, trying to check the next thing off on the to-do list, striving to save up a pocket of time to breathe. Yet when the pocket of time arrives, I'm still jogging. The ridiculousness of this approach lies in its lack of humanity. When did I forget that the whole point of being a doctor was to get to know people’s suffering, to really get to know it, to reach into the bowels of it (no pun intended) with the intent to remove it forever? As idealistic as that dream was, there was some dignity to it, and what do we have to stand on if not the dignity of bright-eyed idealism?
Everyone in medical school urged me not to go into surgery because it would change me. I told them (and still do) that was impossible. During my first year of surgery residency, when colleagues found me nice, again they pleaded with me not to change. Two years later, I am still the same person (just last week, a medical student observing our veritable zoo of personalities urged me to "never change."). But in so many ways I have succumbed to what I was so fervently warned me about and what I myself so intently dislike. When did I forget that walking a few blocks was the perfect amount of time to stop and breathe fresh air? When did people become less important to me than tasks? Weren’t the tasks in place to serve the people? I love my patients. I love their faces, their personalities, their suffering, their disease process and their healing process. I can’t wait to one day have patients of my own, who I see in my office and hold hands with through the hardship of surgical disease. A cloying sentiment, surely, and certainly not an efficient one. So maybe there’s hope for me yet.
Friday, October 19, 2012
Life and Death Decisions
It’s 4:45 am on a Monday. I wake up five minutes before my alarm, as usual. Since residency began, I have never overslept it. I lie still for another five minutes, checking the clock in between to assure my mind that I have a few minutes of luxury left. And then I surrender my bed to the inevitable day.
I arrive to the ICU, bracing myself for the day’s admissions. There is a Whipple, a thoracotomy, and a craniectomy on the OR schedule. They will all come to the SICU after surgery. Since it's Monday, there will also almost certainly be at least one emergent admission from the floor, perhaps a gastrectomy with CHF whose fluid status was mismanaged or neglected over the weekend.
I get a quick signout from night float on last night’s events. I meet the new trauma patients: a drunk head bleed from a pistol whipping, a gunshot to the abdomen with a liver lac and a bowel injury. They are both totally stable, and I plan to move them out as soon as possible. After seeing all the patients, I check all their boxes—make sure their electrolytes are balanced, sugars are controlled, and fluid status is appropriate. I lower their ventilatory support to work their respiratory muscles and make a mental list of who can be extubated.
I round with my attending, trying to keep my presentations crisp. We discuss a sea of numbers, CT scans and xrays. Satisfied that every patient has a plan to advance their care, I turn my attention to the only really sick patient in the unit. Everyone in the unit is sick, of course, but Mrs. Riley is DNR after the family meeting over the weekend, and there is nothing to do for Mr. Ellis after his catastrophic intraparenchymal hemorrhage but schedule a tracheostomy and PEG. Mr. Turner, however, is actively dying—he has a chance, but his window is closing.
I first met Mr Turner a week ago, after a routine sigmoid colectomy. He had suffered repeated episodes of bleeding per rectum and after a colonoscopy tattooed an oozing mass, was offered a partial colectomy to remove the offending lesion. The surgery was uncomplicated, but because of his COPD, recent heart attack and renal failure, the patient was admitted to the ICU for postoperative resuscitation. He was moved to the general floor after two days to make room in the unit. He was almost ready for discharge until his nurse found him collapsed on the bathroom floor in a small pool of dark blood. He was confused, combative, and diaphoretic. The overnight team pumped him with fluids and blood, intubated him, took him to the operating room to remove the bleeding colon, and brought him to the ICU. He had a rising lactate, a pH incompatible with bodily protein function, and multiorgan dysfunction. He was actively dying.
I’m only in my second year of surgical residency, but I can already see where this is going. I put him on a bicarbonate drip to counteract his body’s acidity. I’d like to use a different drug but we are “out of stock” of the proton scavenger that works better than bicarb. He is difficult to ventilate, with oxygen levels barely compatible with life despite maximizing his ventilator settings, putting him at high risk for barotrauma. I’m working his lungs hard, trying to blow off carbon dioxide to reduce his acidity, but I’m running into myself because the bicarb I’m using for the same reason creates more CO2 to blow off. It starts to look futile. I try him on bilevel, thinking he’s in ARDS, but he is already on CRRT because his kidneys shut down and his potassium shot up—his T waves on the monitor are like tall spikes. The bilevel causes his pressure to drop more, because the extra pressure in his lungs prevents the vena cava from filling. Again, running into myself. I add another pressor. We are maxed on three. Options are running out. He has no gag or corneal reflex. I call his wife and have a candid discussion. She says she's on her way.
His belly continues to blow up, with all the fluids we’ve pumped into him. It’s tight as a drum, so we check an abdominal pressure. 30: intraabdominal hypertension. Another reason for hypotension and difficult ventilation. The only option becomes surgery—his abdomen needs to be cut open to relieve the pressure. We rush him to the operating room and cut him stem to sternum. We examine his bowels and organs. Everything looks dusky but there is no evidence of bleeding, necrosis or infection. I almost hope there is something catastrophic to explain his dire clinical status, something to fix so we don’t return to the hopeless 3-pressor, hypoxemic, acidotic state of the morning. We place a plastic bag over the belly and attach it to a specialized vacuum to maintain sterility and drain extra fluid, We now know how this will end.
Wheeling him back to the ICU, I pass several family members gathered outside the ICU door. There are at least fifteen people in the waiting room. A tearful young woman, an elderly lady in a wheelchair. Probably his sister and mother. I get Mr. Turner settled and return to the family, gathering them into the family meeting room. I stare directly at his wife and inform her that her husband is dying, his organs are shutting down, and there's very little chance he will survive for more than 24 hours. This is not the first time I have had this discussion but my mind cringes, expecting a horrific reaction to such unspeakable news. My professional stare does not waver as I move on to discuss options, including withdrawal of care. We offer them time to think, but they don’t need it—-they want everything done. They want him to fight, and they want us to fight for him. We tell them there are limits, that we are out of options, that we are prolonging his suffering. This seems to pain them, but it does not change their minds.
They hover by his door as we discuss how to proceed. There is no sense adding another pressor, as there are only so many receptors in the body to constrict to increase blood pressure. We get a bedside echocardiogram to see if we can improve his heart function, but unfortunately his heart function is adequate. We draw labs to see if his hemoglobin is low—maybe we can give him blood—but his blood levels are sufficient from all the products he has already received. My attending goes home and tells me to call the on-call surgeon for future updates on Mr. Turner—he knows this is a futile case.
The patient hangs on for several hours. Late in the evening, his pressure continues to dip, and then his heart rate. I have no choice but to code him. We drop the bed down and press on his chest. Abdominal fluid seeps through the plastic bag covering his organs—the vacuum seal has been violated. We give boluses of epinephrine, atropine, bicarbonate, calcium and magnesium. We do three rounds because the family refuses to leave his room. If they were not present, we would do less. I call time of death. We clean the patient and finally allow the family to attend to him. I text my attending that he has passed, and receive no answer.
The rest of the night passes uneventfully. Mrs. Riley dies peacefully in the early hours of the next morning, with her four children at bedside, on a dilaudid drip.
Tuesday, March 13, 2012
Having heart
It was 5:45 in the morning on a Monday after a full weekend of call. Thoroughly exhausted, I shuffled into the elevator and was met by the stench of stale clothing mixed with cigarette smoke. A painfully thin teenager exited, looking lost. I allowed him to wander out, grateful to be spared his odor. I was apathetic, overtaken by a weariness I vowed as a medical student never to have.
Morning rounds passed without incident. All our CABG patients were more or less stable. I collected each patient’s overnight events, vital signs, laboratory values, daily chest xray, ekg, fluid balance and wound status. With my attending’s blessings, I titrated their blood pressure drips to protect their blood vessels, kept them sedated and paralyzed if they were mechanically ventilated, fed them benzodiazepines if they were alcoholics, and added or subtracted tubes and lines as needed. Eager for a post-rounds lull, I sank into a chair in the cardiac care unit and opened my email. Because I was still around, a nurse asked me to renew some orders for electronic housekeeping. Then the pager rang with a consult, and my lull was over.
The consult was for Roy, a gentleman with a history of a recent 4-vessel CABG who needed to be on anticoagulation. He was being followed regularly at his coumadin clinic, where his INR was checked biweekly and blood thinner dose adjusted accordingly. According to the primary team, the lab called him at home and instructed him to come to the hospital immediately for an INR level of 17. On questioning him, they found that he had been taking twice the prescribed dose of coumadin.
I went to the patient’s room to do a full history and physical exam. Roy was an 78-year-old gentleman with scraggly hair and pockmarked skin. He was probably about 5 foot 7 but his stoop cut him 3 inches. The only part of his body that suggested any reserve was a small round belly. He was the kind of person I would pass on Broad Street without noticing. But just like the CABG patients I looked over so meticulously each morning in the unit, this man was once equally carefully looked after in his immediate postoperative period. Now he was back at home with a chronic pericardial effusion, failed kidneys, and an INR that could cause him to spontaneously bleed from any vessel or orifice at any moment. I asked him why he doubled up on his coumadin dose. The question made him suddenly energized, and he angrily replied that he takes all his medications twice daily, so why should coumadin be any different?
After my assessment, I called my attending and we reviewed his echocardiogram. He had a loculated pericardial effusion, stable in size over the past few months. The fluid around his heart was sticky, which meant that effective drainage would be extremely risky. We revisited him at dialysis that same afternoon to complete the consult. He was sleeping restfully in the corner, paying no attention to the whir of the dialysis machine or the Married…With Children rerun playing on his mini television.
My attending put his hand gently on Roy’s shoulder to say hello. After several nudges the patient awoke, grunting. His breathing was labored. His blood pressure and oxygen saturation were borderline acceptable—his heart could barely tolerate the fluid being drawn off. My attending knew the patient well, and other than the INR, was not fathomed by his current state. “Doc, I can’t go on like this,” Roy said. “My lady, she’s 70, she can’t keep running after me. She’s tired. I can’t put her through this. And we got a 6-year-old to get to school every morning. You gotta do something.”
In that moment, Roy was transformed in my eyes from an old man on the street to some kind of selfless hero. With all his health problems, he wasn’t thinking of himself. In his mind, he was running on empty not because the sticky fluid in his heart bag was preventing it from pumping, but because he was a burden on his family. He was sick of tiring his wife, not sick of his heart or his kidneys tiring him. In that moment, the senselessness of his coumadin overdose melted away, and he was wise and kind. Ignorant of things that I knew all about—coumadin dosing, target INR, how to correct a supratherapeutic INR, simple and loculated effusions—but far beyond me in things that matter in life's bigger picture. Nurturing relationships, fulfilling duties, making personal sacrifices, and that too in the face of extreme physical limitations—those are things I knew very little about.
Life as a doctor is selfless and selfish at the same time. You are selfless for your patients and your surgical team, but you are selfish in the face of life outside the hospital. Every effort requires a sacrifice, and by definition, the act of giving to one cause means taking away from another. The taking away is always from outside the hospital, including sleep, sunshine, recreation, and, most importantly, loved ones.
What gives me hope in the face of sacrifice is the knowledge that even when we think our hearts cannot possibly expand to encompass everyone and everything in front of us, it can. Yes, there may be fluid around it. The fluid might even be sticky, too sticky to get rid of. The heart can accept this and make room to expand.
It can make room, if we let it.
Morning rounds passed without incident. All our CABG patients were more or less stable. I collected each patient’s overnight events, vital signs, laboratory values, daily chest xray, ekg, fluid balance and wound status. With my attending’s blessings, I titrated their blood pressure drips to protect their blood vessels, kept them sedated and paralyzed if they were mechanically ventilated, fed them benzodiazepines if they were alcoholics, and added or subtracted tubes and lines as needed. Eager for a post-rounds lull, I sank into a chair in the cardiac care unit and opened my email. Because I was still around, a nurse asked me to renew some orders for electronic housekeeping. Then the pager rang with a consult, and my lull was over.
The consult was for Roy, a gentleman with a history of a recent 4-vessel CABG who needed to be on anticoagulation. He was being followed regularly at his coumadin clinic, where his INR was checked biweekly and blood thinner dose adjusted accordingly. According to the primary team, the lab called him at home and instructed him to come to the hospital immediately for an INR level of 17. On questioning him, they found that he had been taking twice the prescribed dose of coumadin.
I went to the patient’s room to do a full history and physical exam. Roy was an 78-year-old gentleman with scraggly hair and pockmarked skin. He was probably about 5 foot 7 but his stoop cut him 3 inches. The only part of his body that suggested any reserve was a small round belly. He was the kind of person I would pass on Broad Street without noticing. But just like the CABG patients I looked over so meticulously each morning in the unit, this man was once equally carefully looked after in his immediate postoperative period. Now he was back at home with a chronic pericardial effusion, failed kidneys, and an INR that could cause him to spontaneously bleed from any vessel or orifice at any moment. I asked him why he doubled up on his coumadin dose. The question made him suddenly energized, and he angrily replied that he takes all his medications twice daily, so why should coumadin be any different?
After my assessment, I called my attending and we reviewed his echocardiogram. He had a loculated pericardial effusion, stable in size over the past few months. The fluid around his heart was sticky, which meant that effective drainage would be extremely risky. We revisited him at dialysis that same afternoon to complete the consult. He was sleeping restfully in the corner, paying no attention to the whir of the dialysis machine or the Married…With Children rerun playing on his mini television.
My attending put his hand gently on Roy’s shoulder to say hello. After several nudges the patient awoke, grunting. His breathing was labored. His blood pressure and oxygen saturation were borderline acceptable—his heart could barely tolerate the fluid being drawn off. My attending knew the patient well, and other than the INR, was not fathomed by his current state. “Doc, I can’t go on like this,” Roy said. “My lady, she’s 70, she can’t keep running after me. She’s tired. I can’t put her through this. And we got a 6-year-old to get to school every morning. You gotta do something.”
In that moment, Roy was transformed in my eyes from an old man on the street to some kind of selfless hero. With all his health problems, he wasn’t thinking of himself. In his mind, he was running on empty not because the sticky fluid in his heart bag was preventing it from pumping, but because he was a burden on his family. He was sick of tiring his wife, not sick of his heart or his kidneys tiring him. In that moment, the senselessness of his coumadin overdose melted away, and he was wise and kind. Ignorant of things that I knew all about—coumadin dosing, target INR, how to correct a supratherapeutic INR, simple and loculated effusions—but far beyond me in things that matter in life's bigger picture. Nurturing relationships, fulfilling duties, making personal sacrifices, and that too in the face of extreme physical limitations—those are things I knew very little about.
Life as a doctor is selfless and selfish at the same time. You are selfless for your patients and your surgical team, but you are selfish in the face of life outside the hospital. Every effort requires a sacrifice, and by definition, the act of giving to one cause means taking away from another. The taking away is always from outside the hospital, including sleep, sunshine, recreation, and, most importantly, loved ones.
What gives me hope in the face of sacrifice is the knowledge that even when we think our hearts cannot possibly expand to encompass everyone and everything in front of us, it can. Yes, there may be fluid around it. The fluid might even be sticky, too sticky to get rid of. The heart can accept this and make room to expand.
It can make room, if we let it.
Sunday, January 22, 2012
In memory of Gai Anyuon
I just received an email from John Alier, the pharmacist at Malek Clinic , that Gai Anyuon, former UU student and nursing school graduate, passed away from tuberculosis. We had hired him to be the nurse at the clinic, but when he discovered he was suffering from TB he left to Kampala for treatment. We were all hoping he would eventually return in good health. He is second from the right in the above photo, which was taken in a truck lot right before he escorted all our cllnic building materials from Kampala to Sudan last May.
Like most Sudanese, Gai was reserved and quiet. But he had an inner strength in him I will likely never fully understand. We met up with Gai in Kampala after landing in Nairobi, our home base. He helped us with our shopping for building materials and participated in our endless evening meetings to discuss how the clinic would be run. He was painfully thin and frail, and had a hacking cough that in retrospect I should have considered might be TB. I thought he had pneumonia but he vehemently denied being sick. He probably desperately needed the job.
We sent frail Gai with all of our wares in a 20 ton truck on the 10 hour drive from Kampala to Malek. He didn't complain once about his health or comfort. He asked for a reasonable sum of money to eat food on the way. He went without basic needs for 2 days while the rest of us traveled far more comfortably to Sudan. He dealt with treacherous border officials, keeping the goods safe and fending off thieves and bandits. He didn't have an inch of flesh on his bones, but he never complained.
Gai was a knowledgeable nurse. I never saw him in action but through our conversations about how to provide health services to the people of Malek, it was clear that he was an intelligent clinician. He anticipated challenges that we would face and brought them up early, so that we could conquer potential roadblocks. My mom and I were definitely outside our element providing health care in a Sudanese village, so Gai's practicality was important (of course, along with Deng and John Alier, too). But again, even though Gai often brought up needs that we could not address due to the rural setting or financial constraints, he was accepting of the limitations and ready to improvise.
I don't know much about his personal life, but I know he was a husband to an "educated" wife, as he described her. I pray his family is safe and well. His quiet perseverance in the face of significant personal and professional challenges is a humbling example to me that I won't forget.
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