another m&m

While my last M&M post was about losing life, this one is about saving it. Not so much in the bringing back a pulse kind of way, or even the complete eradication of pain, but in the way that good turns all else into sources of gratitude. This M&M is called medicine & music.

"Medical school" has too many syllables, but really, it's more accurate than "medicine," because that's where I am, and what saves me. School allows for things that medicine may not: a certain free flowing mode of learning, and complete freedom to observe. And the beginnings of anything carry a peculiar poignancy that makes you very aware of them in the moment. Working in the emergency department is humbling, as the best parts of medical school have been. Crammed in a small space are little clips of people and problems, and as a student you can appreciate that you are in the middle of it. At this point in our lives, the weight of things still correlates with how they heavy they feel. A man with vertigo finds it's due to a stroke--the dizzy you feel that should just go away cause it's just in your head, but it won't go away because it is in your head. A man whose nephew passed away at 21 from a heart attack waits as we track his chest pain with labs and tests, his eyes wet as he talks about living in the southeastern tip of a small island. A woman finds the hard back of a trauma board more painful than the floor she's been lying on for twelve hours after a fall that fractured her arm in two places. A man writhes with tremors from an overdose, who is so thin you can't help but feel he might be right that things are too much.

Medical school is also more apt than medicine, because with school comes the family of friends I've had here. Early into my first year, a time that coincided with personal difficulties, I realized how much better I function in a small community. And more importantly, how much this small group of people offered. In this past week, small acts of kindness respond to my need for them, without knowing the nature of why I needed them but not questioning why. Dinners out with honest conversation about silly things and things most important to me. Someone who makes me believe in trying for genuine good, regardless of stumbles. The Wonderful Story of Henry Sugar in hand, and a mini avocado cheesecake in my fridge. Complete, sincere, effortless, unconditional acceptance of my faults from someone too hard on himself; he takes my mess and throws back simplicity. Company at the gym and the library. Encouragement disguised as a rap, both funny and sweet, and a typed smile from someone who has never before given one. Each person offers things in their own way, and the parallel care in individual qualities is such love.

While these things often take me beyond myself, music lets me be. I've returned to sounds that I loved years ago (Flaming Lips: Yoshimi Battles the Pink Robots), or to sounds from years back that I didn't listen to properly back then (Linkin Park & Jay-Z: Collision Course, and lots of Linkin Park in general). I'm as addicted as everyone to The XX, whose atmospheric beats have both flash and depth, and I don't think I've loved this hard since Bon Iver. Besides catching up to the distant past, I'm catching up on 2009 with the timeliness of The Antlers' Hospice, and the new Muse, which has different parts all that I love through & through. A splash of Beirut's strange ache (Realpeople), all of Sigur Ros & Phoenix piling up on me, and so on and so on and it's all so filling. It's why I love commutes, the walks and train rides and road trips, the time I can take for music and myself and it's hard to describe in any other way except to say that it saves me.

I was walking around New Haven a little past four in the afternoon today, while it was still light. New Haven isn't thought to be pretty, but sometimes it is. The sky was filled in with gray but the top halves of all the brown-gray buildings were made golden by a sun you would have to turn around to see, but you wouldn't because you wouldn't move your eyes from the unearthly glow. Looking up at one point one such building merged its frame with quietly sprawling branches also alight with a mysterious sun, and my breath was sharp as I drew it in.

m&m

Within most fields there are a lot of conferences. One of ours is M&M: morbidity and mortality, where cases are discussed where life was lost or damaged, and the process is examined in order to determine what went wrong. During an M&M a couple weeks ago, I found myself wondering how I traversed from the M&M of happy chocolate to the M&M of this. I even found myself in a remote elementary school memory. I'm sitting on the carpet of my parents' bathroom with a phone, voting repeatedly for the next M&M color. The choices were pink, blue, and purple. I wanted purple. My brother said no color was going to beat out blue. As you know from M&M packages these days, he was right.

The day after I was studying EKGs and abnormal heart rhythms (arrhythmias) to prepare for my rotation in the emergency medicine department, I had a patient whose heart went into a life-threatening arrhythmia. As they say, he coded. As I've learned, learning in medicine has a lot to do with hearing the same phrase tossed around and observing by association what it means. For example, Code 5 means that an alarm goes off throughout the hospital and the assigned medical staff races to the location of the code. In the emergency room, this location often encompasses the space of maybe an elevator and a half. A crammed elevator and a half. A curtain separates each patient's space from another's, and as a student it's difficult to not be in the way.

The patient was a very nice elderly man with kidney failure on dialysis, which means that three times a week he's connected to a machine that does for him what his kidneys should be doing for him every second. He also had no legs, but I'm not sure why that was. His EKG showed signs of hyperkalemia, or too much potassium in his blood, which can happen with kidney failure since the kidneys filter potassium out of the blood. This is bad for the heart, because too much potassium in the blood means the potassium will enter the cells. Since potassium has a positive charge, this makes the inside of the cell positive (depolarized). Normally it's this depolarization that sparks off the action potential that allows hearts to beat. But when the cell is continuously depolarized, certain sodium channels close and don't allow any more action potentials, so the heart can't beat normally anymore. All this damage leads to decreased blood flow and thus oxygen to the heart. It tries to compensate by sending off random beats in its ventricles, which creates the arrhythmia this patient had. Ventricular tachycardia: beats are going off rapidly in the ventricles. It's bad because the heart keeps contracting, leaving no time for it to relax and fill up with the blood it needs. (I'm pretty sure that no matter how much training I'll get in my lifetime, my poor brain can only think in these simple terms).

We'd been having a nice conversation about his children (he had a daughter with my name) when his heart when haywire. Throughout the code, he was awake and could speak to us, and would always say he was doing fine. He shouted in pain when they had to shock him to bring his heart back into a normal rhythm, but continued with his polite responses to the doctors asking him loudly if he was all right. They stabilized him to bring him to the Intensive Care Unit, but he went into an even worse heart rhythm there (I heard the alarm go off throughout the hospital calling Code 5). He was shocked again. I don't think he wanted much more help, but his family did, and there was confusion, misunderstanding, and hurt. I don't really know what happened after that, because I was still in the emergency room and he wasn't. I think I lost the M&M game again.

what we talk about

I spent a good part of the evening at Koffee Too alternating between reading EKGs (electrocardiograms that record the electrical activity of the heart) and reading What We Talk About When We Talk About Love (short stories by Raymond Carver). The EKGs are supposed to be literal translations of how the heart is beating and what its shape is. Learning the code is fun, mostly because you feel like you're in on a secret. It's nice to have on paper what something inside is doing. Though at times what I translate is just that, a translation, two phrases for the same entity. And as we're all familiar with, more often things are lost in the switch than gained, not just due to elusive nuance but also because being caught in a mere transfer makes you forget to understand, sometimes. But still, in the moments of coming in and out of focus, I remember part of why I like the stubborn elegance of science. You keep whittling away at it with more and more why's, and it ends somewhere, but how surprisingly nice it is to find mystery in your lap after so many steps of rationale. The Carver stories, as expected, are not romantic. And the title made me think that it's true, we always have to explain our words; there's always a representation for the real thing. And we're always trying to get at these real things, the beats of hearts that don't look anything like <3 and the people carrying them. Maybe this is why today I nursed a stomachache with pumpkin cake and cream cheese frosting, steamed milk with Irish cream, and milk chocolate, hoping that the saccharine would dissolve the ache--shove the stand-ins in to understand them, and then out of sight to prevent their camouflage of the actual thing. I don't know; I don't know much of what I talk about.

better

So after the rare outpouring of rant and dissatisfaction yesterday, today was infinitely better than all previous days, mostly due to being on pediatric surgery. On a concrete level, the cases are shorter with very quick turnover, especially in the ear nose throat (mostly tonsillectomies) OR I was in, which means that there was a lot more action. It was easier to keep the ventilation mask on children, with their smaller mouths (I didn't realize how hard that is to do on adults until I failed, every time) and was also able to successfully intubate for the first time. In general there are fewer bells and whistles (cords and needles), which meant that after minimal observation I could help and be of use.

Underneath that (or really, overwhelming that) things were more real and honest. Kids are allowed to be expressive and vulnerable, and they show themselves whether through silence or through noise. Silence in adults goes unnoticed and noise underestimated. Having these things, that were present all of last week without anyone paying much attention, out in the open was a relief. It gives you, as a student, more room too. No one questions if you take extra time to comfort children, pat them, talk to them. Instead of patients being wheeled in on beds, the anesthesiologists carried them into the OR in their arms. Little ones make things less serious. Even as there is of course the same level of care and concern, the weight of The Things We Do is lighter; there is less self-importance and more outward generosity, such that protecting their fragility doesn't require forgetting your own.

At one point I placed my hand on top of the blanket, over where I thought the knee might be and felt a foot instead. When I applied to med school I thought I'd want to work with kids, and now I want to work with the elderly. I suppose that since then I've moved from wanting connection with innocence to connection with experience. But moments like those remind me of how much smallness exists, and how much it's worth.

surgery / pain

Coming back from break this past week, I started on my three month surgery rotation in the hospital. The first month is actually two weeks of anesthesia and two weeks of emergency medicine, before the actual surgery part begins. But anesthesia requires being in the operating room (OR), as they prep all the patients for their surgeries. And because most of the action happens in the beginning and ending of the procedures, I spend most of the day standing and watching the anesthesiologist monitor the monitors in said OR. In the simplest of terms an anesthesiologist keeps patients pain-free and alive during surgery. Which is a very worthy occupation. We spent much of the past six months thinking about people's pain; a lot of what influenced my experience and what I want my future experience to be, was about that.

This time around, literally taking away the capability for pain has me thinking about our own pain as medical students. This is not to compare at all to our patients, but maintaining relativity doesn't have to take away from personal subjective experience. Keep in mind that anesthesia is perceived as the easiest part of the surgery rotation, in terms of hours and exhaustion, and it has been. But it gives a glimpse of what's to come, and during the hours of standing, I can't help but consider the suffering we go through for this profession.

We wake up when it's still black outside, and at the height of freezing. I normally like short walks in the cold; your face warms up after a few minutes and the sharpness makes me glad for senses. But that early in the morning, destination matters and I don't look forward to going to the hospital, where the ORs feel as cold as outside. I hate wearing scrubs and how I have to layer up underneath. I hate the face masks and the fuzzy blue shower caps they call hats. An hour into surgery my shoulders ache, my lower back aches, my feet hurt. On surgery proper on most days the days are twelve hours long and you go home when it's as black as when you woke up. On surgery proper surgeries can be up to seven hours long, and there are no breaks for food or bathroom. Your sole purpose might be to hold an instrument in the same position throughout the surgery so that the surgeon can do his thing, and to answer questions I'm pretty sure I don't know. I feel inadequate in all ways, which is immeasurably worse than feeling inadequate in only a majority of ways. I can't pay attention for that long, I process things slowly, my fingers aren't nimble, I liked anatomy but am bad at it because I'm bad at spatial visualization, and I'm not good at learning motion from watching others. In surgery one of the few things we might be allowed to do is tie knots, and it took me about ten times as long as my classmates to learn this. Once I try on my own terms, it's fine, but as a med student your presence seeps away from you with each step to the OR. The one thing I felt decent at was talking to my patients, and I've spent a total of ten minutes doing that all week. I spend some time each day imagining how I'm going to do this.

And more so, why. Why do we do this? Besides from the learning, which I know there will be. But while this is a wide open avenue for education, to be melodramatic it is also elements of torture--slow, long, physical and emotional at once. Over break I read Murakami's memoirs as seen through his marathon running, and he talks about the pain of running too, and how the most important things are learned through physical pain. Sometimes I think of the process of becoming a doctor as a marathon. People talk about the uselessness of some of the long years of medical training--the requirements, the studying, the politics, the busywork, all the things that necessitate a type A personality and that physically exhaust us. No one thinks of a marathon that way, but really when you think about it, the purpose of both is to accomplish something, and it's really crazy when you consider what you're doing in the meantime. You just keep going for the sake of it. Sometimes people patronize that. But it's not mindless. For me it's a conscious decision each day.

But I haven't decided whether the will and strength that you develop makes the level of bullshit valid. Having hours at the hospital for mind wanderings is not that good for me. There are so many things I'd rather be doing--writing, talking to patients and friends, sleeping. I don't even spend this idle time the way I'd like to spend nothing time, time that I often pine for. I think about stupid things. Like how I would like really long hair again so that I could chop it off. And how awkward it is to be in an elevator with a group of pretty swimsuit clad girls and a college guy ogling them. I think about self-detrimental things. Like how I keep having vivid dreams with cameos from people I don't want to think about anymore. I think about things I want to do that I couldn't do even if I weren't in the OR, like travel and spend time with my family. And I think too much about how much I don't like this.

It all gets so mixed up that it's impossible for me to write coherently about it. I resisted using this reason not to write, because this is how it is.

I met with my surgery advisor today, who gave me the good advice to always look and see. And there is a lot valuable to be seen. I think one of the hardest things for patients is not understanding what's going on inside their bodies--how something so intimately close feels impalpable. I know that developing a view of this, and being able to describe it for someone, is valuable. The problem is that I don't see the nuanced differences between the tangled monitors tracking their blood pressure and temperature, or the differences in the tones of the multiple steady beeps in the background (or foreground) telling us how they're breathing. A sweet 87 year old undergoing a heart bypass said that at his age everything scares him. As I stood in the back of the OR, I thought about how at age twenty five, I sometimes feel the same way. As med students, we see a lot in the OR. We see a system of tools that are purely functional. We see the wall between us and the people whose bodies we see more closely than they ever can. What I see is foreign, and we're supposed to familiarize such that that goes away, but honestly, I'd rather not. I'll work for skills and knowledge, but not to wear away the foreign, because how then would we really know pain, ours or theirs.

in 2010...

...I will take more care.

1) Family: take care with my tone of voice when I get bothered, be more mindful of the consequences of temper, and remember that 99% of annoyances aren't worth the argument and hurt when it comes to people who love wholly.

2) Learning: ask questions, look up the answers to questions when they first come to mind, follow through with intentions, know what's going on terms of logistics, review at night important things from the day, factual and personal.

3) Writing: write more, and with more thought to what I want from it, and what I want to give with it.

4) People: offer outwardly only what I'm sure I can give, offer inwardly what I want to try to give and then try to give it, and be open.

5) Budget: keep a strict one and take care with each large expenditure. Despite living solely on personal funds since mid-college, and traveling quite a bit, my needs have been so basic that these funds have always exceeded my expenses enough that I don't give much thought to each expense. This is still the case, and carries me through the present well, but several things now make the future a consideration.

6) Belongings: be less haphazard with my possessions (computer, camera, clothing, earphones), as often reminded by my friends that I don't care much about these things. It's always been about priorities, as I can only concentrate on so many things at once and material things tend to pile up on the sidelines. New earphones from a month ago? Already broken. But I feel a general philosophy of taking care of things would be healthy, such that I get used to approaching all things with care, and when my surroundings aren't out of sorts, my mind is also less so.

7) Running: continue to do what I can, without getting caught up in rigid goals; I don't want to give this too much thought because part of its appeal is about pure motion. But with this year keep better track of what I can do and thus have a sense of what I can strive for, so that both mentally and physically I'm moving forward.

8) Eating: eat more fruits and vegetables (we tend not to buy as many since they go bad quickly and I hate grocery shopping, but the good ones are worth the extra trips), drink more water and milk.

9) Multitasking: don't disguise lack of focus as multitasking. If I multitask, do each task completely and well; if I can't do this, focus on one thing at a time.

That last one may go for all of the above, except that daily life (or any sort) doesn't quite function that way. Hence the attempt for a philosophy rather than a checklist. For the new, and the old newly experienced.